Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monterey Palms Health Care Center during CMS and state inspections, most recent first.
Nursing staff failed to notify the MD of a resident’s abnormal VS and did not administer ordered Milk of Magnesia despite repeated lack of BM documentation. In a separate event, the facility did not arrange transportation for another resident’s scheduled chemotherapy appointment, and the resident did not attend. The DON and LVNs stated the facility process for reporting changes in condition, bowel care, and coordinating appointments was not followed.
A resident with cancer diagnoses had a critical low Hgb of 6.7 and later became dizzy, weak, light headed, and pale during PT with symptomatic anemia. Nursing notes stated the provider was aware and the resident was sent to the ER, but the chart did not contain documentation of the physician notification or orders related to the critical lab. The DON later showed a nurse-physician text exchange about the low Hgb, but it had not been entered into the resident’s medical record.
A resident with liver and colon cancer had a physician order for a regular diet, but the RN’s communication slip sent to dietary indicated a clear liquid diet, and the resident was served clear liquids instead of the ordered diet. The tray card also did not include the resident’s preferred or disliked foods, and the DS and DON verified the mismatch between the order and what was provided.
Medication storage and labeling deficiencies were identified when the med room temperature was 80 F with emergency med kits stored inside, two Rx meds in a med cart lacked pharmacy labels, an open expired vial of Humulin R remained in the cart, and two boxes of Trulicity for a resident were stored at room temp despite refrigeration instructions. The LVN and consultant pharmacist confirmed the labeling and storage issues, and facility policy required meds to be stored per pharmacy/manufacturer directions.
Dietary staff were not competent to safely carry out food service duties. An aide demonstrated cleaning a soil meal cart with sanitizer only instead of the full wash-rinse-sanitize process, and a cook was unable to demonstrate spoon testing for pureed diets or fork testing for minced and moist diets. During lunch, the cook served running pureed cauliflower and minced and moist items that were not in the correct texture. The RD and DS stated staff should know and apply IDDSI testing for texture-modified diets, and job descriptions required proper sanitation and preparation of modified and therapeutic diets.
Therapeutic diet service was not followed as ordered. A cook used the wrong scoop for minced and moist meat, another used the wrong scoop for pureed dessert, and beef stroganoff was portioned with a smaller scoop than the Therapeutic Diet Spreadsheet required for residents on Regular, easy to chew, soft and bite sized, and minced and moist diets. A cook also prepared pureed cauliflower without following the recipe, resulting in a running puree that did not hold its shape.
Incorrect Dysphagia Food Textures Served: A review of meal service and test meals found that pureed foods were not smooth and contained lumps or excess liquid, Minced and Moist items were served in pieces larger than fork-tine size, and Soft and Bite Sized noodles exceeded the required size. During dining observations, two residents on MM5 were served broccoli and pear pieces that were too large, and the DS and RD acknowledged the texture errors.
Failure to honor resident food preferences during observed meals. Several residents had meal tickets listing preferred items such as ice cream, Jello, or fortified soup, but those items were not served. The DON, LVNs, and CNAs confirmed the omissions, and one resident stated dietary staff had listed ice cream on the meal ticket and it should have been honored. The RD stated residents should have their food preferences honored, and the facility policy said residents have the right to be served food per their individual preferences.
Therapeutic diets were not followed during meal service. A resident on CKD 5 was served processed ham and potatoes even though those items were restricted on the diet guidance, another resident ordered for large portions received regular portions on two meals, a resident on NAS diet was given a salt packet, and a resident ordered high calories/high protein/high fiber received a regular sandwich without the ordered enhancements. The RD confirmed the physician orders and stated dietary staff missed following the meal ticket and Therapeutic Diet Spreadsheet.
Kitchen sanitation and food handling deficiencies were observed when the ice machine had grime buildup, multiple kitchen surfaces and equipment had dust or grime, and a CK was seen preparing food with uncovered facial hair. The RD confirmed the findings and stated the ice maker needed deep cleaning, the kitchen areas should be kept clean, and beard restraints should be worn to prevent hair from falling into food.
Kitchen equipment and freezer maintenance deficiencies were observed when ice condensation and ice buildup were found in the walk-in freezer, along with rust on several shelves and a drying board, two worn cooking pans with missing nonstick coating, and chipped paint on multiple pieces of equipment. The RD confirmed the findings and stated the conditions were unacceptable, noting that the freezer buildup could affect food quality and that damaged or unsmooth surfaces could trap bacteria.
A resident with dementia with psychotic disturbance, MDD, and anxiety disorder was given ramelteon for sleep without documentation that the resident or RP was fully informed before the medication was started. The chart showed no informed consent, no care plan entry for ramelteon, and no behavior monitoring documentation, while the DON said she believed the drug was a supplement and the CP identified it as a psychotropic medication requiring informed consent and monitoring.
Improper Psychotropic Medication Order for Sleep Aid: A resident with dementia, MDD, and anxiety received ramelteon without a proper diagnosis or indication documented. The eMAR showed the resident received the prescription hypnotic daily, while the DON believed it was a supplement similar to melatonin and the CP stated it was a psychotropic medication that should not be ordered as a supplement.
Unmonitored Toe Wound: A resident’s right second toe injury was observed open to air with no dressing, and staff interviews and record review showed the wound was not documented or monitored for an extended period. The resident said the injury occurred during transport by paramedics, while the MDS nurse, LVNs, and DON confirmed there were no weekly skin checks or timely wound documentation before the issue was finally entered in the chart.
A resident receiving O2 via NC was observed with the NC unlabeled, and the resident did not know when it had last been changed. An LVN confirmed there was no date on the NC and stated it should be labeled and changed every seven days; the DON also stated it should have been labeled with the last change date per facility policy.
An audit found that a pharmacy-labeled bottle of hydromorphone for a resident had an actual remaining volume that did not match the CS dispense log. An LVN confirmed the bottle contained about 100 ml, while the log showed 52 ml remaining after the last 2-ml dose, and the CP stated the CS count log and actual volume should match.
A resident with intense hand tremors and an order for a closed cup (sippy cup) at all meals was observed using a regular cup instead of the ordered adaptive equipment. Staff confirmed the resident did not receive the sippy cup with juice and coffee, while OT and the RHD stated the cup was ordered to help prevent spilled beverages and noted the resident had nearly spilled hot liquid on herself. The RD stated dietary staff were expected to follow the meal ticket and provide the ordered cup.
Improper Dumpster Waste Disposal: Surveyors observed trash on the ground around the dumpster area and two trash dumpsters that were overflowing so their lids could not fully close, along with a recycle dumpster lid left widely open. The DS stated trash should not be around the dumpsters and the lids should close properly to prevent pests, and the RD identified the condition as an infection control and environmental hazard issue.
A resident with post-stroke hemiplegia and moderate cognitive deficit alleged that a CNA hit his elbow away while providing perineal care and became upset when the CNA responded by calling him a liar and challenging his accusation. The CNA later admitted becoming angry and telling the resident he was lying about being hit. This interaction conflicted with facility policy and training that direct staff not to argue with residents, to use professional de-escalation techniques, and to walk away and give residents space when they become angry or accusatory.
Two residents did not receive their prescribed IV antibiotics as ordered, with doses being missed, given late, or not documented, and there was no evidence that the physician or pharmacy were notified when medications were unavailable. Nursing staff and the DON confirmed that medication administration and documentation did not follow facility policy.
Three residents with complex medical conditions did not have their medication administrations accurately documented, with multiple instances of late intravenous antibiotic and antifungal doses recorded in the MAR. Nursing staff and the DON confirmed that documentation did not always reflect the actual time of administration, contrary to facility policy requiring timely and accurate charting.
The facility failed to ensure proper food safety and sanitation practices. A dietary aide did not follow guidelines for testing sanitizer concentration, risking improper sanitization. A cook inadequately cleaned a prep counter after handling raw chicken, and another cook failed to monitor the cooling process of roast meat, risking foodborne illness. These deficiencies affected all residents receiving food from the kitchen.
The facility failed to adhere to dietary guidelines and portion control, impacting residents' nutritional needs. Dietary staff did not follow the Cooks spreadsheet for portion sizes, leading to incorrect servings of pureed foods. Additionally, recipes were not followed, affecting the consistency and flavor of meals. Residents on specific diets received inappropriate food items, and salad dressing was served without measuring, potentially affecting calorie and nutrient intake.
The facility failed to provide appetizing and properly tempered food, affecting seven residents. Multiple residents reported cold and unappetizing meals, with staff confirming issues such as lack of seasoning and delayed meal service. The facility's policy required tasting and quality checks, which were not adhered to, leading to this deficiency.
The facility failed to maintain a sanitary environment and adhere to food safety standards. Wet kitchen equipment, dust accumulation, and build-up on equipment were observed, posing contamination risks. Improper food storage and labeling practices were noted, along with unsanitary conditions such as a worn cutting board and cracked tiles. Personal items were stored inappropriately, and a staff member did not follow proper cleaning procedures after handling raw chicken, increasing the risk of foodborne illnesses.
A facility failed to create a care plan for a resident with a new diagnosis of pulmonary emboli on anticoagulant therapy. The resident, with moderate cognitive impairment, was readmitted with a prescription for Eliquis, but no care plan was documented to address the condition or medication management. The DON acknowledged the oversight, which was contrary to the facility's policy requiring an acute condition care plan.
A resident with cerebral infarction and end-stage renal disease was found with dirty fingernails, indicating a failure in maintaining proper hygiene. The facility's policy required daily nail care, but the routine was limited to Sundays. The infection preventionist and CNA acknowledged the oversight, and the DON confirmed the established routine, highlighting a deficiency in adhering to the care plan for maintaining resident dignity and comfort.
A resident was found with an outside pharmacy's Simvastatin medication at her bedside without a self-administration assessment, and expired Daptomycin IVPB bags were stored in the medication room refrigerator for another resident. The facility's policies on medication storage and self-administration were not followed, leading to potential risks for residents.
A resident was served a turkey sandwich despite documented preferences for cottage cheese and a dislike for turkey. The meal ticket indicated these preferences, but the resident did not receive the preferred food. The Dietary Manager confirmed the importance of honoring food preferences to prevent nutritional deficiencies. This incident reflects a failure to adhere to the facility's policies on serving foods and nutrition care.
The facility failed to properly dispose of garbage and refuse, as observed when dumpster lids were not closed and trash was found on the ground. The Dietary Services Supervisor and Registered Dietitian acknowledged the issue, which could attract pests and cause infection control problems. The facility's policy requires dumpster areas to be clean and lids closed.
A facility failed to follow infection control measures for a resident with contact isolation precautions. Staff members entered the resident's room without wearing appropriate PPE, and one CNA used non-disposable equipment without proper disinfection. Interviews revealed a lack of understanding of infection control policies among staff, despite the resident's need for contact isolation due to an ESBL infection.
A resident with a history of stroke and Parkinson's disease was found unable to reach her call light, which was wrapped around the siderail, during a complaint investigation. The CNA confirmed the call light was not within reach, contrary to the resident's care plan and facility policy, which required call lights to be accessible to prevent falls.
The facility failed to ensure timely responses to call lights, as evidenced by two residents experiencing delays of up to an hour, leading to unmet care needs and feelings of embarrassment. Staff interviews and observations confirmed that call lights should be answered within 3-5 minutes, but this standard was not consistently met.
The facility failed to ensure that two out of three trash dumpster lids were securely closed, potentially attracting pests and creating an unsanitary environment. Staff acknowledged the importance of keeping lids closed, but the lids were sometimes left open because they were heavy and hard to close.
Failure to Report Vital Sign Changes, Administer Ordered Constipation Medication, and Arrange Chemotherapy Transportation
Penalty
Summary
Nursing staff failed to notify the physician of changes in vital signs for one resident with diagnoses including left femur fracture, hypertension, congestive heart failure, and abnormal blood findings. The resident’s physician orders included monitoring vital signs every shift and monitoring for signs and symptoms of dehydration. The record showed low blood pressure on December 6 and December 13, 2025, and elevated heart rates on December 16 and December 22, 2025. The chart contained no documented evidence that the physician was notified of these changes as required by the order. The same resident also did not receive Milk of Magnesia as ordered for constipation management. Physician orders included docusate sodium twice daily, Milk of Magnesia 30 ml by mouth as needed if no bowel movement in 2 days, and monitoring for constipation from opioid use every shift. The bowel movement record showed multiple dates with no bowel movement documented, including several dates when no bowel movement was recorded for 2 or more days. The MAR contained no documented evidence that Milk of Magnesia was administered during the month as ordered. A second resident, admitted with diagnoses including intraductal carcinoma in situ of the right breast and malignant neoplasm of the ovary, did not have transportation arranged for a scheduled chemotherapy appointment. The hospital AVS listed a chemotherapy appointment for Monday, June 22, 2026, but there was no documented evidence that the facility arranged transportation for that appointment. The physician’s office receptionist confirmed the resident did not attend the scheduled chemotherapy appointment, and the DON stated nursing staff should have worked with social services to assure the resident was at the appointment.
Failure to Document Physician Communication for Critical Low Hgb
Penalty
Summary
The facility failed to ensure that communication with the physician was entered into the resident’s chart for one of six residents reviewed. Resident 2 was admitted with diagnoses including intraductal carcinoma in situ of the right breast and malignant neoplasm of the unspecified ovary, and the physician’s history and physical indicated the resident had capacity to make decisions. A laboratory result dated June 15, 2026 showed a critical low Hgb of 6.7, and the nursing progress note dated June 16, 2026 at 12:29 p.m. documented that the resident became dizzy, light headed, weak, and pale during physical therapy, with a heart rate of 120 and BP of 95/53. The note also stated the provider was aware and that the resident had symptomatic anemia, with new orders to send the resident to the ER for further evaluation and management. There was no documented evidence in the resident’s medical record that nursing staff communicated with the physician regarding the critical low Hgb result or that physician orders were received in response to that result. During interview and record review, an LVN stated the facility process for critical labs was to notify the physician and family and complete an SBAR, and stated there was no documented SBAR or progress note for the critical lab value and no documented evidence the physician was notified. The DON stated nursing staff were expected to notify the physician of critical labs and document the notifications and any new orders in the resident’s chart, and stated there was no documented evidence that the physician was notified of the Hgb 6.7. The DON later presented a nurse-physician text message showing nursing staff had texted the physician about the low Hgb and the physician responded to inform oncology the next day for orders to repeat Hgb or transfusion, but this communication was never documented in the resident’s chart.
Diet Order Not Followed and Food Preferences Omitted
Penalty
Summary
The facility failed to provide one resident with the diet ordered by the physician and did not include the resident’s preferences and dislikes on the dietary tray card. The resident was admitted with diagnoses of liver and colon cancer and had a physician order for a regular diet to be served three times per day. However, the nursing communication slip completed by the RN indicated a no added salt, controlled carbohydrate, clear liquid diet, advance as tolerated, and the dietary tray card later reflected no added salt and controlled carbohydrate without identifying the diet type or texture or listing the resident’s preferred and disliked foods. During interview and record review, the Dietary Supervisor verified the resident was served a clear liquid diet throughout the stay instead of the ordered regular diet. The Dietary Supervisor stated the nurse was responsible for communicating the diet order to dietary staff and that the tray card should include the resident’s preferences and dislikes, but she did not verify the diet order against the communication slip and relied on the nurse’s information. The Director of Nursing also verified the resident had orders for a regular diet and received a clear liquid diet during the stay, and stated she was not sure why the communication slip indicated a clear liquid diet. The facility policy stated residents will have a written diet order on admission and diets will be served as ordered by the physician.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled according to accepted professional principles, manufacturer instructions, and facility policy. During an inspection of the F Court medication room, the thermometer showed 80 F while emergency medication kits were stored there, including IV, oral, and IM kits containing multiple medications. The consultant pharmacist stated the medication room temperature should be below 78 F, and the facility policy required medications to be stored according to manufacturer or pharmacy recommendations, including controlled room temperature ranges. During inspection of F Court Medication Cart 2, two prescription medications in the cart drawer did not have pharmacy labels: a lidocaine and prilocaine cream tube and a manufacturer box containing lidocaine 5% topical patches. The LVN confirmed there was no pharmacy label and stated she did not know who the lidocaine patches belonged to without it. The consultant pharmacist agreed that all prescription medications from the pharmacy should have a pharmacy label, and the facility policy required each prescription medication to include the resident's name, directions for use, prescriber's name, date dispensed, and expiration or end-of-use date. The same cart inspection found an open 10-ml vial of Humulin R with an open date of 4-9-26, which the LVN confirmed was expired. In addition, E Court Medication Cart 1 contained one partial box and one full box of Trulicity 3 mg/0.5 ml pens for Resident 31 stored in the cart drawer at room temperature, even though each box was labeled to refrigerate at 36 to 46 F. The consultant pharmacist stated refrigerated Trulicity boxes stored at room temperature would be a big issue, and the facility policy required refrigerated medications to be kept in a refrigerator with temperature monitoring.
Dietary Staff Not Competent in Cart Sanitizing and IDDSI Texture Testing
Penalty
Summary
Dietary staff were not trained and competent to carry out food and nutrition service functions safely and effectively. During observation and interview at the dishwashing area, Diet Aide 1 demonstrated cleaning a soil meal cart by using sanitizer only. The Registered Dietitian stated the standard practice was to wash the cart with detergent, rinse off the detergent, sanitize it, and then air dry it, and explained that using only sanitizer would not clean and sanitize the cart properly and effectively. The facility’s staffing inservice and orientation job description also stated that food preparation staff were responsible for following proper sanitation and cleaning procedures and for cleaning and sanitizing equipment using recommended cleaning agents and established procedures. The facility also failed to ensure [NAME] 3 could perform texture-modified diet checks. When asked to demonstrate spoon testing for pureed diet and fork testing for minced and moist diet, [NAME] 3 was unable to do so. During lunch, [NAME] 3 served running pureed cauliflower, and the minced and moist beef, noodle, and cauliflower were not in the correct modified texture. The RD stated that dietary staff should know and fully apply spoon and fork testing for IDDSI diets to ensure residents received the correct texture to prevent choking and aspiration, and the Dietary Supervisor stated that dietary staff and she needed more guidance from the menu company, RD, and Speech Therapy for preparing IDDSI modified diet texture. The facility’s cook job description stated that the cook prepares and serves food including texture modified and therapeutic diets according to the facility menu.
Therapeutic diet portions and puree consistency not followed
Penalty
Summary
The facility failed to ensure therapeutic diet portions were served using the correct scoops and that standardized recipes were followed. During a concurrent observation at the trayline on May 11, 2026, a cook used a 2 oz scoop to plate minced and moist meat even though the Therapeutic Diet Spreadsheet indicated a 6 oz scoop. The Registered Dietitian later stated this resulted in residents on the minced and moist diet receiving less protein and calories than planned and not meeting nutritional needs in accordance with the physician’s diet order. Also on May 11, 2026, a cook portioned pureed fruit using a green #12 scoop measuring 2.5 oz, while the Therapeutic Diet Spreadsheet indicated a #10 scoop measuring 3 oz. The Registered Dietitian stated this underserved the pureed dessert by 0.5 oz. The facility’s Diet Type Report showed residents on the pureed diet were affected by this portioning error, and the facility policy stated menus and portion sizes were to meet residents’ nutritional needs and correspond to prescribed diets. On May 12, 2026, a cook used a 4 oz scoop to serve beef stroganoff intended for residents on Regular, Easy to Chew, Soft and Bite Sized, and Minced and Moist diets, although the Therapeutic Diet Spreadsheet indicated a 6 oz scoop. The Registered Dietitian stated this resulted in residents receiving less calories and nutrients than planned. Also that day, a cook prepared pureed cauliflower without referring to the recipe and added liquid to the blender, producing a puree that was running and unable to hold its shape. The RD and Dietary Supervisor verified the consistency was not correct, and the facility’s recipe and IDDSI guidance indicated pureed food should hold its shape.
Incorrect Dysphagia Food Textures Served
Penalty
Summary
The facility failed to provide food in the correct texture for residents on prescribed dysphagia diets during lunch observations and meal reviews. On May 12, 2026, a test meal review with the Registered Dietitian and Dietary Supervisor found pureed beef that was grainy, pureed bread with lumps, and pureed cauliflower that was too runny after approximately 2 cups of liquid were added while preparing 4 servings. The RD and DS stated pureed foods should be smooth, hold their shape, and be free of lumps or grainy particles, and they identified that the cauliflower had been made too thin. The same review found that foods served for the Minced and Moist diet did not meet the required texture. The RD used a fork to test beef, noodles, and cauliflower and found the items were larger than the tines of a fork. The RD and DS admitted the texture was incorrect for the Minced and Moist diet. The facility’s diet type report showed residents were ordered this diet, including residents 11, 17, 34, 88, and 114. A separate review found that Soft and Bite Sized noodles were larger than the required 1.5 cm by 1.5 cm size, and the RD stated there was potential for choking if noodles were served in pieces that large. During dining observations on May 11, 2026, resident 88 and resident 20, both ordered Minced and Moist, were served broccoli pieces that were too large, and resident 20 was also served pear pieces that did not fit between the tines of a fork. The DS used a fork to check the broccoli and pear and stated the pieces were too large and that resident 20 could choke on the pear.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that food preferences were honored for seven of 30 sampled residents during lunch observations on 5/11/2026 and 5/12/2026. During concurrent observation, interview, and meal ticket review, Resident 104’s meal ticket listed a preference for ice cream, but no ice cream was served with lunch; Resident 104 stated, “I want ice cream for my lunch and dinner,” and the SSA confirmed it was not provided. Similar observations were made for Resident 46, Resident 41, Resident 101, and Resident 66, whose meal tickets also listed ice cream as a preference, but none received it during the observed meals. Resident 88’s meal ticket listed a preference for Jello, but none was served, and Resident 12’s meal ticket listed fortified soup, but no soup was provided; LVN 1 confirmed Resident 12 did not receive any soup. During the observations, staff members including the DON, LVN 1, CNA 1, CNA 2, and CNA 3 confirmed that the residents did not receive the food items listed on their meal tickets. Resident 66 stated that dietary staff had put ice cream on the meal ticket and that the preference should be honored. On 5/13/2026, the RD stated that the facility is the residents’ home and that residents should have their food preferences honored. The facility policy titled NUTRITION CARE, dated 11/25/2025, stated that residents have the right to be served food per their individual preferences.
Therapeutic diets were not followed during meal service
Penalty
Summary
The facility failed to ensure physician-ordered therapeutic diets were followed during meal service. During trayline observation on May 11, 2026, only one meat item, processed ham, and one starch item, mashed potatoes, were available, and residents on CKD 5 were served those items even though the facility’s CKD 5 diet guidance identified high-potassium foods such as potatoes and high-sodium, high-phosphorus foods such as processed meats as restricted. The Registered Dietitian stated that residents on CKD 5 were not supposed to receive potatoes or processed ham, and also stated the CKD 5 diet was missing from the Therapeutic Diet Spreadsheet used by dietary staff. Resident 104’s ordered large portion diet was not followed at lunch on two separate days. On May 11, 2026, the resident’s meal ticket indicated large portion, but the resident was served the same portions as the regular diet, including 6 oz ham, 1/2 cup mashed potatoes, 1 wheat roll, and 1 margarine. On May 12, 2026, the resident again had a large portion meal ticket, but was served regular portions of beef stroganoff and noodles, along with 1 slice of wheat bread and 1 margarine. After reviewing the EMR, the RD confirmed the physician had prescribed large portion and stated dietary staff missed serving it as ordered. Resident 104 also had a no added salt diet, but on May 12, 2026, the resident was observed receiving a salt package with lunch. The LVN reviewing the meal ticket stated the resident was not supposed to get the salt package, and the RD confirmed the resident’s NAS diet was part of medical nutrition therapy and that the salt package should not have been served. In addition, Resident 55, whose meal ticket indicated high fiber and high protein, was served a regular sandwich entree without extra fiber items or a large portion. The RD later stated the physician had prescribed high calories, high protein, high fiber for Resident 55 and that cooks should have followed the large portion guidance on the Therapeutic Diet Spreadsheet, but the RD could not provide in-service documentation showing dietary staff were instructed to serve large portions for that diet.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
Safe and sanitary food preparation and storage practices were not maintained in the kitchen during survey observations and interviews. The ice machine in the kitchen had black, brown, and yellowish grime buildup on the ice maker. During interview, the RD stated the ice maker needed a deep clean, that the inside of the ice machine should be free of grime buildup, and that germs could grow on the grime and cross contaminate the ice. The RD also stated the facility had only one ice machine, located in the kitchen, and that the ice produced was used for resident consumption and food production. Additional kitchen observations identified dust and grime buildup on multiple pieces of equipment and areas. Brown debris, identified by the RD as dust, was observed on the door frame leading out of the kitchen, the door frame leading to the dining room, the walk-in freezer fan guard covers, the walk-in refrigerator fan guard covers, and a black pipe behind the ventilator in the walk-in refrigerator. Other observations found grime buildup on the walk-in freezer green storage shelves, splash inside the top of the microwave, grime on the microwave door, and black sticky grime on the can opener base. In a separate observation, CK 1 was seen preparing food with facial hair not covered. The RD stated CK 1 should wear a beard restraint to prevent hair from falling into food.
Kitchen Equipment and Freezer Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure timely maintenance of kitchen equipment and food storage areas when ice condensation and ice buildup were observed in the walk-in freezer. During a concurrent observation and interview with the Registered Dietitian, ice condensation was seen on the ceiling, on a black pipe behind the ventilator, and on storage shelves below the ventilator, with ice buildup on top of food boxes stored under the ventilator. The Registered Dietitian stated it was unacceptable to have ice condensation and ice buildup in the walk-in freezer and explained that ice buildup on food boxes could affect food quality. During a general kitchen tour, several pieces of equipment were observed with brown grime identified by the Registered Dietitian as rust, including silver storage shelves in the walk-in freezer, silver storage shelves used for onions and potatoes, and a drying board. Two worn cooking pans with missing nonstick coating were also found on the drying board, and the Registered Dietitian stated they were not appropriate to use for resident safety. In addition, several pieces of equipment had chipped paint, including storage shelves in the walk-in freezer and a drain in the dish washing area, and the Registered Dietitian stated these items needed to be painted or replaced because the unsmooth surface could trap bacteria.
Failure to Document Informed Consent Before Starting Ramelteon
Penalty
Summary
The facility failed to ensure there was documentation in the medical record that the resident or responsible party was fully informed with material information provided by the prescriber before ramelteon was started for Resident 114. Resident 114 was admitted with diagnoses including dementia with psychotic disturbance, major depressive disorder, and anxiety disorder. The record showed a physician order on May 4, 2026 for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, which was discontinued on May 7, 2026, and then a new order on May 7, 2026 for ramelteon 8 mg by mouth daily at bedtime for supplement. The resident's care plan did not indicate ramelteon use for sleep, and the behavior monitoring record did not show documentation of behavior monitoring for ramelteon. The record also did not show informed consent from the resident or responsible party prior to use of ramelteon, while the eMAR showed the resident received one dose daily from May 4, 2026 to May 12, 2026. During interview, the DON stated she thought ramelteon was a supplement similar to melatonin and was not aware it was a prescription drug, and the CP stated ramelteon was a psychotropic medication and should not be given as a supplement.
Improper Psychotropic Medication Order for Sleep Aid
Penalty
Summary
The facility failed to ensure there was a proper diagnosis and indication associated with the use of one psychotropic medication for one resident. Resident 114, who was admitted with diagnoses including dementia with psychotic disturbance, major depressive disorder, and anxiety disorder, had a physician order on May 4, 2026 for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, and that order was discontinued on May 7, 2026. A new physician order was entered on May 7, 2026 for ramelteon 8 mg by mouth daily at bedtime for supplement. The eMAR showed Resident 114 received ramelteon 8 mg daily from May 4, 2026 through May 12, 2026. The manufacturer’s prescribing information identified ramelteon as a prescription hypnotic indicated for the treatment of insomnia characterized by difficulty with sleep onset. During interview, the DON stated she thought the medication was a supplement because it was similar to melatonin and was not aware it was a prescription drug. The DON also stated that because it was for sleep, it would need informed consent and monitoring of sleep. The CP stated ramelteon was a psychotropic medication and should not be given as a supplement, and that informed consent and behavior monitoring were needed for ramelteon. The facility policy for physician orders required the diagnosis for medication to be received with the order.
Unmonitored Toe Wound
Penalty
Summary
The facility failed to provide necessary care and treatment for a right second toe injury for one resident, resulting in the wound going unmonitored. On May 11, 2026, the resident was observed resting in bed without socks, and the right second toe had a discolored area below the nailbed with an open wound/injury present and no dressing in place. The resident stated the injury occurred when his foot hit the door in his room a few days earlier, possibly a week ago, and also stated it happened during transport to the ER by paramedics. He was alert, oriented, denied pain, and said staff were already aware of the injury. Record review and staff interviews showed the most recent skin assessment was dated April 9, 2026, and documented no open skin areas, with no weekly skin assessments documented after that date until the wound was identified. The shower record dated May 11, 2026, documented the toe wound and was signed by a CNA and LVN, but the first wound documentation in the chart was entered on May 12, 2026, at 9:58 p.m. Staff stated there was no documentation of a skin assessment when the resident returned from transport, and the nurse who was present when the resident was picked up by paramedics did not document or report the injury to the next nurse. The DON stated there was no documentation regarding the wound prior to May 12, 2026, and that the failure to identify, assess, and treat the wound placed the resident at risk for possible infection.
Unlabeled nasal cannula for resident receiving oxygen
Penalty
Summary
The facility failed to provide respiratory care and treatment for one resident who was using oxygen via nasal cannula. During observation, the resident was in bed, awake and alert, and the nasal cannula did not have a label showing the date it was last changed. In a concurrent interview, the resident stated she did not know when the nasal cannula had last been changed. A concurrent observation and interview with an LVN confirmed the nasal cannula was unlabeled and that there was no way to know when it had last been changed. The LVN stated the cannula should have had a date label and should be changed every seven days. The DON later stated the nasal cannula should have been labeled with the date it was last changed and should be changed every seven days per facility policy. The resident’s record showed a physician order for oxygen at 2 liters per minute, and the facility policy stated respiratory equipment should be handled to prevent contamination and the cannula changed within every seven days.
Controlled Substance Count Discrepancy for Hydromorphone
Penalty
Summary
The facility failed to ensure an accurate and complete record of controlled substances when the remaining volume in a pharmacy-labeled bottle of hydromorphone 5 mg/5 ml oral solution for Resident 10 did not match the corresponding controlled substance dispense log. During a controlled substance audit in E Court Medication Cart 1 with LVN 1, surveyors observed a bottle dispensed on April 1, 2026 that contained approximately 100 ml of hydromorphone solution. The dispense log for Resident 10 showed 2-ml doses being logged out beginning April 12, 2026, with the last 2-ml dose logged on May 13, 2026 at 5:13 a.m., and the log indicated 52 ml remaining after that dose. During the audit, LVN 1 confirmed that the bottle contained about 100 ml, which was more than the amount reflected on the dispense log. On May 14, 2026, the CP stated that the CS count log and the actual volume of the bottle should match. The facility policy titled Controlled Medication Administration and Declining Sheet Verification stated that controlled medication administration required accurate narcotic count verification, prevention of diversion, prevention of missed or duplicate doses, immediate identification of discrepancies, and verification before administration that the remaining count matches the declining sheet balance.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure that Resident 57 was provided with the adaptive eating equipment ordered for meals. On May 11, 2026, during a concurrent observation and meal ticket review in the Assisted Feeding dining room, Resident 57’s meal ticket indicated a 2-handled cup (sippy cup), but the resident was observed using a regular cup for a beverage. On May 12, 2026, Resident 57 was again observed in the Assisted Feeding dining room, and both hands were noted to be shaking intensely. During a concurrent observation, interview, and meal ticket review on May 12, 2026, CNA 2 reviewed Resident 57’s meal ticket and stated the resident did not receive a sippy cup with juice and coffee. On May 13, 2026, OT stated Resident 57 was able to eat independently but had intense tremors in both hands, and that the physician ordered a sippy cup with each meal to help prevent spilled beverages. The RHD stated Resident 57 had almost had an accident spilling hot beverage on herself, and the RHD and OT stated the sippy cup was important for the resident’s safety when drinking, especially hot beverages. The RD stated dietary staff should follow the meal ticket and provide the sippy cup as ordered. The physician order report dated 5/01/2026 through 5/12/2026 indicated a feeding/mealtime order for a closed cup (sippy cup) for all meals, and the facility policy stated adaptive equipment recommended by OT and other feeding equipment, including cups, could be obtained through OT.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when surveyors observed trash outside the surrounding dumpsters and found the lids of the trash dumpsters unable to fully close because they were overflowing. During a concurrent observation and interview at the back kitchen dumpster area, three dumpsters were seen, including two trash dumpsters with trash overflowing and trash on the floor around the dumpster area, and one recycle dumpster with its lid widely opened. The Dietary Supervisor stated that trash should not be surrounding the dumpsters and that the lids should close properly to prevent pests. The Registered Dietitian also stated that the trash surrounding the dumpsters and the lids not closing properly were an infection control and environmental hazard issue that could attract pests. The facility policy titled Pest Control, dated November 25, 2025, stated to keep facility grounds free of trash and keep the dumpster area clean with the lids closed.
Failure to Treat Resident with Dignity During Dispute Over Alleged Hitting During Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a CNA verbally responded inappropriately after the resident alleged being hit during care. The resident, who had hemiplegia/hemiparesis following a stroke and a BIMS score of 12 indicating moderate cognitive deficit, reported that while receiving perineal care he asked the CNA for a wipe and, when he reached for it, the CNA hit his elbow out of the way. The resident stated it was more than a push and that when he told the CNA, "You hit my elbow," the CNA yelled, "You're a liar." The resident reported that the CNA became mad at him, which upset and angered the resident. Progress notes indicated hospice staff reported the resident’s statement that the CNA hit his elbow while providing care. In a subsequent interview, the CNA acknowledged that during perineal care, when the resident asked, "Why did you hit me?" he became "a little angry" and told the resident, "You're lying," and further stated that he went out of his way for the resident and accused the resident of lying about being hit. The administrator, who serves as the abuse coordinator, stated that staff receive abuse training and that when a resident becomes angry or accusatory, staff are expected to walk away, give the resident space to calm down, and report to the charge nurse, and that the CNA should not have engaged with the resident by calling him a liar. Facility policy on Mood and Behavior Management Techniques directs staff not to argue with residents, to detach from resident agitation, and, if unsuccessful, to walk away and wait before re-approaching, which was not followed in this interaction.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of residents by not administering medications in accordance with physician orders for two residents. One resident, who was alert and oriented and had diagnoses including bacteremia, diabetes, and hypertension, reported receiving his antibiotic at inconsistent times. Review of his records showed that a scheduled dose of cefazolin was administered late and another dose was not documented as given. The Medication Administration Record (MAR) confirmed these discrepancies, and there was no evidence that the missed or late doses were communicated to the physician as required. Another resident, admitted with diagnoses including pneumonia, congestive heart failure, stroke, and end stage renal disease, had a physician order for vancomycin to be administered on specific days. The MAR indicated that two scheduled doses were not administered, with one dose noted as unavailable. Interviews with nursing staff and the Director of Nursing confirmed that medications were not given on time, not properly documented, and that neither the physician nor the pharmacy were notified when medication was unavailable. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for administration to be recorded immediately, which was not followed in these cases.
Failure to Accurately Document Medication Administration Times
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, specifically regarding the accurate documentation of medication administration for three residents. For one resident with bacteremia, diabetes, and hypertension, the Medication Administration Record (MAR) showed multiple instances where the scheduled 7 a.m. dose of intravenous cefazolin was administered late, with times ranging from over an hour to more than three hours past the scheduled time. Despite these delays, the MAR sometimes included comments indicating the medication was given on time, while other entries noted the late administration. The resident reported receiving antibiotics late or early at times. Another resident with septicemia, congestive heart failure, and a history of stroke had a physician's order for daily intravenous ceftriaxone at 9:00 a.m. The MAR indicated that on two occasions, the medication was administered more than an hour late. Similarly, a third resident with Crohn's disease, ileocecal resection, and an ileostomy had a physician's order for daily intravenous fluconazole at 9:00 p.m., but the MAR showed the medication was administered over an hour late on one occasion. Interviews with the RN and DON confirmed that the MARs reflected late administration times, and both acknowledged that medication administration should be documented accurately and timely, with the MAR reflecting the actual time of administration. Facility policies reviewed stated that charting should be factual, accurate, and timely, and that medications should be administered within 60 minutes of the scheduled time, with immediate documentation following administration.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services, as evidenced by several observations and interviews. Dietary Aide 2 did not adhere to the manufacturer's guidelines for testing the Quaternary sanitizer, which is crucial for sanitizing food contact surfaces. Instead of dipping the test strip for the required 10 seconds, DA 2 only dipped it for 1 second, potentially leading to a false reading of the sanitizer concentration. This deviation from protocol was confirmed by the Registered Dietitian, who emphasized the importance of following the manufacturer's guidelines to ensure proper sanitization. Additionally, Cook 2 did not follow the proper cleaning procedures after preparing raw chicken. The prep counter was observed with pink chicken juice, and CK 2 only used sanitizing wipes to clean the surface, rather than following the necessary steps of washing, rinsing, air drying, and sanitizing. This improper cleaning method was identified as a hazard for foodborne pathogens by the Registered Dietitian, who reiterated the importance of adhering to the facility's cleaning procedures to prevent contamination. Furthermore, Cook 1 demonstrated a lack of understanding of the proper cooling process for food. CK 1 began cooling roast meat from 140 degrees F and stored it in the refrigerator, checking the temperature only after 14 hours. The Registered Dietitian explained that the cooling process should involve monitoring the temperature every 2 hours to ensure it reaches 70 degrees F within 2 hours and 40 degrees F within an additional 4 hours. The failure to monitor the cooling process properly posed a food safety risk, as it could allow bacteria or viruses to grow on the roast meat, potentially leading to foodborne illness for the residents.
Failure to Follow Dietary Guidelines and Portion Control
Penalty
Summary
The facility failed to ensure that the menus, recipes, and Cooks spreadsheet were followed, resulting in deficiencies in meeting the nutritional needs of residents. On two separate occasions, dietary staff did not adhere to the specified portion sizes for pureed food items as outlined in the Cooks spreadsheet. Specifically, on January 27, 2025, CK 1 used incorrect scoop sizes for pureed beef pot pie and cauliflower, and on January 28, 2025, CK 2 used incorrect scoop sizes for pureed chicken and white rice. This led to residents on pureed diets receiving incorrect amounts of food, potentially affecting their nutritional intake. Additionally, the preparation of pureed cauliflower on January 27, 2025, did not follow the standardized recipe, resulting in a runny consistency that was not appealing or appetizing. CK 1 added unmeasured hot water to the cauliflower, which diluted its nutritional value. The facility's policy emphasized the importance of using standardized recipes to ensure meals are attractive and provide necessary nutritive value, which was not adhered to in this instance. Further deficiencies were observed when CK 2 failed to add margarine and seasoning to buttered corn, affecting the flavor and potentially decreasing residents' meal intake. Moreover, dietary staff served ice cream instead of chilled pears to residents on low fat, low cholesterol, and cardiac diets, contrary to the Cooks spreadsheet instructions. Lastly, the Dietary Services Supervisor served salad dressing without measuring, which could lead to incorrect calorie and nutrient intake. These actions demonstrate a lack of adherence to established procedures and policies, potentially impacting the nutritional well-being of the residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing appetizing and palatable food at appropriate temperatures according to residents' preferences. This deficiency was identified for seven out of 89 sample residents. Multiple residents reported that the food was often cold and unappetizing. Specific instances included Resident 96 stating the food was cold most of the time, Resident 43 expressing the need for warm and timely dinner service, and Resident 82 describing the food as terrible and cold. Additionally, Resident 84 mentioned cold eggs, and Resident 23 noted that the food was often cold and did not taste well. Resident 99 also expressed dissatisfaction with the food. Observations and interviews with staff further confirmed these issues. During a test tray evaluation, the Registered Dietician (RD) confirmed that the Buttered Corn and Lemon Pepper Chicken lacked flavor and seasoning. The Dietary Service Supervisor (DSS) acknowledged that scrambled and pureed eggs were served cold, with temperatures recorded at 101 F and 100 F, respectively. The DSS attributed the cold food to delays in passing meal trays. The facility's policy required cooks to taste all food before serving to ensure adequate seasoning and quality, and for the DSS and RD to routinely check prepared food for portion control, seasoning, quality, and correct consistency. However, these procedures were not followed, leading to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to professional standards for food service and safety. Observations revealed that kitchen equipment was improperly stored while still wet, which could lead to the transmission of microorganisms. Dust accumulation was noted on several surfaces, including door frames and vents in the walk-in refrigerator, posing a risk of food contamination. Additionally, there was a significant build-up on various kitchen equipment, such as the blender, ice machine, and storage shelves, which were not cleaned and sanitized as required. Food storage practices were also found to be inadequate. Two opened tortillas were left exposed to the air in the walk-in refrigerator, and ground beef was placed for defrosting without proper labeling. These practices could compromise food quality and safety, increasing the risk of foodborne illnesses. Furthermore, a strainer with brown spots, possibly rust, was observed, and cracked tiles in the dishwashing area presented potential hazards for contamination and pest attraction. Personal items were improperly stored in the kitchen's storage area, and a cutting board was found to be worn and unsanitary. Additionally, a staff member failed to follow proper cleaning procedures after preparing raw chicken, using only sanitary wipes instead of the required wash, rinse, and sanitize steps. These deficiencies collectively posed a significant risk of foodborne illnesses to the facility's residents, who are a medically vulnerable population.
Failure to Develop Care Plan for Resident with Pulmonary Emboli
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a new diagnosis of pulmonary emboli who was on anticoagulant treatment. The resident, identified as having moderate cognitive impairment and lacking the capacity to make medical decisions, was readmitted to the facility with a diagnosis of pulmonary emboli and a new prescription for Eliquis, an anticoagulant medication. Despite the resident's condition and treatment requirements, there was no documented evidence of a care plan addressing the signs and symptoms of pulmonary emboli or the management of the anticoagulant therapy. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing (DON) and the MDS Coordinator. The DON acknowledged that a care plan specific to the resident's new diagnosis and medication was not developed, despite the facility's policy requiring an acute condition plan of care to be created when an acute condition is identified. This oversight had the potential to delay necessary care and services, placing the resident at risk for further complications related to their condition and treatment.
Failure to Maintain Resident's Fingernail Hygiene
Penalty
Summary
The facility failed to maintain the cleanliness and proper hygiene of a resident's fingernails, which was observed during a survey. The resident, who had a history of cerebral infarction with left-sided weakness, osteomyelitis, and end-stage renal disease requiring hemodialysis, was found with blackish material under the fingernails of the right hand. The resident expressed a desire to have the nails cleaned, indicating that they had been in this condition for some time. The facility's infection preventionist and a CNA acknowledged the need for nail cleaning, noting that the resident's nails should have been cleaned before hemodialysis treatment. The facility's policy indicated that nail care should include daily cleaning and regular trimming to prevent infections and promote circulation. However, the facility had established a routine where nail cleaning and shaving were scheduled only on Sundays. This routine was confirmed by the Director of Nursing, who stated that CNAs were responsible for checking and maintaining the cleanliness of all residents' nails. The deficiency in providing necessary care and services for the resident's fingernail hygiene was identified as a failure to adhere to the facility's policy and the resident's care plan, which aimed to provide assistance in activities of daily living to maintain comfort and dignity.
Improper Medication Storage and Expired Antibiotics Found
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, as evidenced by two separate incidents involving residents. In the first incident, a resident was found with a bottle of Simvastatin medication from an outside pharmacy at her bedside. The resident, who was alert but with some confusion, stated she intended to take the medication in the evening. The medication was not part of the facility's supply, and there was no record of a medication self-administration assessment for the resident prior to the discovery. Interviews with the LVN and QA nurse confirmed that the medication should not have been at the resident's bedside, as it was not dispensed by the facility's pharmacy. In the second incident, three expired Daptomycin antibiotic IVPB bags were found in the medication room refrigerator for another resident. The bags had expired several days prior to the observation, and the RN acknowledged that the expired medications should have been discarded. The IP nurse and DON confirmed that licensed nurses were responsible for ensuring expired medications were not stored and that administering expired antibiotics could result in ineffective treatment. The facility's policies on medication storage and self-administration were reviewed, indicating that medications should be stored properly and that assessments should be conducted to determine a resident's capability for self-administration. However, these policies were not followed, leading to the potential for residents to self-administer medication without monitoring and to receive expired or ineffective medications.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, as evidenced by an incident involving a resident who was served a turkey sandwich despite having a documented dislike for turkey and a preference for cottage cheese. During an observation, it was noted that the resident's meal ticket clearly indicated these preferences, yet the resident was observed eating a turkey sandwich. The resident expressed that she did not like turkey sandwiches but chose not to mention it to the staff. The Restorative Nurse Assistant confirmed that the resident did not receive cottage cheese as preferred and did not like the turkey sandwich. The Dietary Manager acknowledged the importance of honoring residents' food preferences and offering alternatives, noting that failure to do so could lead to decreased food intake, weight loss, and nutritional deficiency. The facility's policy on serving foods requires the use of meal tickets to ensure tray accuracy and adherence to resident preferences. Additionally, the facility's nutrition care policy mandates that resident food preferences be documented and identified on tray cards, with appropriate substitutions offered for dislikes. This incident highlights a lapse in following these established procedures, potentially compromising the resident's nutritional and medical status.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on January 27, 2025. During an inspection of the dumpster area outside the back kitchen, it was noted that the lids of a white recycle dumpster and one of the black trash dumpsters were not closed. Additionally, trash items such as used gloves, forks, napkins, and opened cut boxes were found scattered on the floor surrounding the dumpsters. The Dietary Services Supervisor confirmed the presence of trash on the ground and acknowledged that the dumpster lids needed to be closed at all times to prevent pest attraction and infection control issues. Further interviews with the Registered Dietitian reinforced the necessity of keeping dumpster lids closed to minimize odors and prevent pest attraction and infection control problems. The facility's Policy and Procedure on Pest Control, dated 2018, mandates that dumpster areas be kept clean and sanitized, with trash receptacles covered at all times and dumpster lids closed. The failure to adhere to these procedures was identified as a deficiency by the surveyors.
Inadequate Infection Control Practices for Contact Isolation
Penalty
Summary
The facility failed to adhere to infection control measures for a resident requiring contact isolation precautions. Multiple staff members were observed entering and exiting the resident's room without wearing the appropriate personal protective equipment (PPE). Specifically, a Certified Nursing Assistant (CNA) entered the room to answer a call light and provide water without wearing a gown, gloves, or mask. Another CNA entered the room to perform vital sign monitoring without using a disposable blood pressure cuff or wearing PPE, and incorrectly used bleach wipes for hand hygiene upon exiting the room. Interviews with staff revealed a lack of understanding and adherence to the facility's infection control policies. One CNA incorrectly believed that PPE was only necessary for direct patient care and not for brief interactions, and was unable to articulate the proper method for disinfecting equipment. In contrast, a Licensed Vocational Nurse (LVN) correctly stated that PPE should be worn whenever entering a room with contact precautions. The resident in question was admitted with a urinary tract infection and had a physician's order for contact isolation due to an ESBL infection in the urine. The facility's policy required the use of PPE and dedicated equipment for residents under contact precautions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that basic accommodations of needs were provided when a resident's call light was not within reach. During an unannounced visit for a complaint investigation, it was observed that a resident, who was sitting in a wheelchair at the foot of her bed, had her call light wrapped around the right siderail, making it inaccessible. The resident confirmed in an interview that she was unable to reach her call light and could not call for help. A Certified Nursing Assistant (CNA) also acknowledged that the call light was not within reach and stated that call lights should be accessible to residents in wheelchairs. The resident involved had a medical history of cerebral infarction (stroke) and Parkinson's disease, and her care plan indicated an increased susceptibility to falling, with a specific approach to keep the call light within reach. The facility's policy on call lights also required that they be placed within the resident's reach when leaving the room.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, as evidenced by the experiences of two residents who required assistance with activities of daily living (ADLs). Resident 1, who had diagnoses including glioblastoma, left-sided hemiplegia, and muscle wasting, reported that call light response times were often over 30 minutes and sometimes up to an hour, particularly during evening or night shifts. On one occasion, Resident 1 did not receive assistance in time and soiled herself, leading to feelings of embarrassment and humiliation. Resident 5, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), muscle wasting, and congestive heart disease, also reported similar delays in call light responses, sometimes up to an hour. Both residents had documented capacity to make decisions and were aware of their needs for assistance. During the survey, it was observed that call lights were not answered promptly. For instance, Resident 5 activated her call light at 2:00 p.m., and it was not answered until 2:10 p.m. by a Certified Nursing Assistant (CNA). Interviews with facility staff, including CNAs, a Physical Therapy Assistant (PTA), and a Registered Nurse (RN), confirmed that call lights should be answered within 3-5 minutes to prevent accidents and assist with resident needs. The facility's policy documents also indicated that call lights should be answered in a timely manner to meet residents' needs and uphold their dignity. However, the observed delays in response times indicated a failure to adhere to these policies, potentially compromising resident care and dignity.
Failure to Securely Close Trash Dumpster Lids
Penalty
Summary
The facility failed to ensure that two out of three trash dumpster lids were securely closed, which had the potential to attract pests, insects, and vermin, creating an unsanitary environment for the residents. During an unannounced visit, one dumpster near the kitchen was observed with its lid open and flies flying in and out, while another dumpster near the property line was also found with its lid open and filled with broken-down cardboard. The Administrator, Director of Nursing, Janitor, Dietary Supervisor, Director of Maintenance, Housekeeper, and Housekeeping Supervisor all acknowledged the importance of keeping the dumpster lids closed to prevent pests and odors. The facility's document titled 'Pest Control' indicated that dumpster lids should be kept closed to maintain cleanliness and prevent pest infestations. The 2022 FDA Food Code also mandates that refuse, recyclables, and returnables be stored in covered receptacles to be inaccessible to insects and rodents. Despite these guidelines, the dumpster lids were left open, posing a risk to the sanitary conditions of the facility. Interviews with various staff members revealed that the dumpster lids were sometimes left open because they were heavy and hard to close.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palm Desert
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rancho Mirage Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 21 | 0 |
| Desert Springs Post Acute | 2.8 mi | ★★★★★ | 40 | 0 |
| The Springs Healthcare Center At The Carlotta | 3.2 mi | ★★★★★ | 2 | 0 |
| Bayshire Rancho Mirage | 3.7 mi | ★★★★★ | 1 | 0 |
| Desert Springs Healthcare & Wellness Centre | 9.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.