Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Murrieta Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with DM, morbid obesity, and dementia complained of left foot pain, and CNAs observed a blister and dry, flaky skin on the left great toe and reported it to the Treatment Nurse, but there was no documented assessment, physician notification, or care plan at that time. Days later, after a family member raised concerns, an LVN noted green and red discoloration, skin tear, skin debris, and a concerning toenail and lateral foot wound, and only then was the physician contacted and the resident sent to the ER. The record lacked earlier documentation of the wound or treatment, despite facility policies requiring skin assessment and prompt MD notification for changes in condition.
Unsanitary food storage and kitchen equipment were observed in the kitchen. An opened bag of frozen ground meat was unlabeled and undated, an opened container of Italian seasoning was past its use-by date, and multiple items including bowls, baking trays, and food storage containers were stacked while still wet. The walk-in refrigerator racks had dust, and a can opener and pizza cutter had visible soil and debris. The DA and DDS verified the findings.
A facility failed to ensure foods brought by visitors for residents were properly labeled and stored in the unit refrigerator. During observation with the ADON, multiple items were found unlabeled and undated, including a jar of Mango Thokku, a dough-like food item, a frozen Starbucks drink, frozen tamales, and two beverage containers with brown liquid. The ADON stated resident foods should be labeled and dated before storage, and the facility policy requires residents' foods to include the resident's name, item, and use-by date.
Uncovered Outdoor Garbage Dumpsters: Four of five outdoor garbage dumpsters were observed uncovered during an observation with a Dietary Aide. The DDS stated dumpsters should be kept covered to prevent attracting pests, and the 2022 U.S. Food Code requires outside refuse receptacles to be kept covered with tight fitting lids or doors.
Medication administration errors exceeded the acceptable rate when an LVN crushed ER potassium and mixed delayed-release aspirin into pudding for one resident, crushed ER potassium for another resident, failed to ensure mouth rinsing after Pulmicort inhalation for a resident with COPD, and gave oxycodone-acetaminophen to a resident whose pain score did not meet the ordered parameters. The DON and LVNs acknowledged the orders were not followed, including improper dosage forms, technique, and administration outside prescribed pain criteria.
Staff failed to follow infection control practices when hand hygiene was not performed before entering and after leaving rooms on EBP, and a PTA did not wear the required gown while assisting a resident with high-contact care. Respiratory supplies for two residents were left unlabeled, despite orders requiring weekly changes with name and date labels. A LVN also reused shared equipment, including a BP cuff, stethoscope, and pulse oximeter, for multiple residents without cleaning or disinfecting between uses.
Failure to Provide Advance Directive Information: The facility did not provide written information about the right to formulate an Advance Directive for three residents whose records showed no Advance Directive on POLST and no Advanced Healthcare Directive Acknowledgment Form in the chart. The SSD confirmed the forms were not provided to the residents or their representatives, and the DON stated the form should be completed upon admission for all residents.
A resident with schizophrenia and orders for olanzapine had PASRR Level 1 Screenings that incorrectly answered “No” to questions about serious mental illness, psychosis, and psychotropic medication. The MDS Supervisor confirmed the screenings were inaccurate and verified the resident had a serious mental illness and was on psychotropic medication, while the DON stated PASRR Level 1 screening should be completed on admission and updated as needed.
A resident was observed using a plate guard and adaptive eating utensils while being assisted with lunch, but the medical record did not show a physician order for either item. The DON verified the missing order and stated hospice typically communicates new and current orders to staff for entry into the system.
IV therapy was not consistently documented or performed as ordered for two residents with PICC lines. One resident had missing documentation for IV antibiotic administration and PICC flushes, and the PICC dressing was unlabeled. Another resident’s PICC dressing was overdue for change and remained labeled with an older date. RN, ADON, and DON reviews confirmed the missing documentation and overdue dressing change, and the facility’s policy required labeled dressings and dressing changes at set intervals.
Failure to Obtain Oxygen Administration Order: A resident was observed receiving oxygen at 4 L/min via nasal cannula, but the active order was only for 2 L/min at bedtime, with no daytime or PRN order. An LVN verified the order, and an RN and the DON stated that oxygen administration requires a physician order. The resident had diagnoses including asthma and obstructive sleep apnea, and the facility policy required verification of a physician order before oxygen administration.
A resident’s oxycodone-acetaminophen CS record did not match the MAR. Nursing staff signed out the medication on the CDR on two occasions, but there was no corresponding MAR documentation of administration or pain assessment. An LVN and the DON both confirmed the discrepancy, and the facility policy required documentation of the date and time given, symptoms, results, and the administering staff member’s signature and title.
Dietary staff failed to ensure a DA had the competency to verify quaternary sanitizer concentration for food-contact surface sanitation. During observation, the DA could not explain how to test the sanitizer, and the DDS stated staff should dip the test strip for 10 seconds and match the color chart to confirm the solution was within 200-400 ppm. The DDS could not locate the DA’s competency check, which should have been completed within 3 months of hire.
A resident’s PICC line dressing was documented as changed in the MAR/IV record even though the DON confirmed there was no evidence the dressing had been changed since admission, and the dressing on the arm remained dated from the hospital. In a separate issue, another resident’s activity record had missing entries for several days despite the AD stating the resident was visited daily and that room visits and activities should be documented with the date, activity provided, and resident response.
Nonfunctioning Resident Call Light Systems: Two residents had call light systems in their rooms that did not light up or sound at the nursing station when tested by a CNA. The systems remained nonfunctional on repeat testing later that day, and staff reported using a bedside call bell while maintenance was notified of the issue.
A resident with hypertension and impaired cognition experienced dizziness and shakiness with a markedly elevated BP and later a low BP with tachycardia. An RN notified the physician once in the morning and received orders to monitor and provide oxygen, which the resident refused, but did not recheck the BP or closely monitor the resident for several hours. The next BP check showed hypotension and tachycardia, at which point the physician ordered transfer to the ER. The DON reported that nursing staff were expected to notify the physician for symptomatic high BP, obtain PRN medication, and monitor BP at least hourly, consistent with facility policies on BP measurement and change in condition.
A resident with an unstageable right heel DFU receiving daily Betadine and dressing changes was discharged to an ALF that could not manage this level of wound care. The physician’s 602 form, emailed to the ALF, documented the heel as "without" pressure injury, and the Discharge Instruction/Recapitulation form omitted the wound and listed discharge to a private residence, despite concurrent orders detailing daily wound care for the right heel. The ALF, relying on the inaccurate documentation and staff reports that the wound was healing, admitted the resident, then immediately identified an unstageable heel wound and transferred the resident to a GACH because it could not provide the required care.
A resident with multiple chronic conditions developed a bruise on the right arm that was observed by CNAs, who reported it to an LVN. The LVN acknowledged being informed but did not assess or document the bruise at that time, believing it to be old. Facility records showed no assessment or documentation of the bruise on the day it was first reported, with the first note describing a purplish discoloration and notification of the treatment nurse entered the following day. The DON later confirmed that the nurse who was notified did not follow facility policy for evaluating and reporting a change in condition.
Two residents experienced abuse and neglect when a CNA refused to provide care to one, making a derogatory statement, and handled another resident with dementia and Parkinson's disease in a rough, aggressive manner, causing the resident to scream in pain. Staff witnessed and reported the incidents, which involved both verbal and physical abuse, as well as neglect.
A facility did not report an allegation of abuse by a CNA against a frail, cognitively impaired resident to CDPH within the required timeframe. Although the incident was observed and reported internally, the mandated notification to state authorities was delayed until the following day, contrary to policy and regulatory requirements.
The facility failed to respond to call lights in a timely manner for three residents, impacting their well-being and care. One resident reported waiting 20 to 30 minutes for assistance, while another was left in a soiled diaper due to unanswered calls. Observations showed call lights left unanswered for over 10 minutes, despite staff presence. Facility policies require prompt responses to maintain resident dignity, which were not followed.
The facility failed to assess three residents for safe self-administration of medications, leading to potential risks of misuse. A resident had Allergy Calm tablets, another had Afrin nasal spray, and a third had Alevex lotion at their bedsides without proper assessments or physician orders. Staff confirmed these medications should not be self-administered without supervision, and the facility's policy required an interdisciplinary team assessment, which was not conducted.
The facility failed to change respiratory tubings for three residents according to its policy, which requires changes every seven days. A resident's nebulizer tubing was dated several months prior, while two other residents had oxygen and humidifier tubings dated weeks earlier. Staff interviews confirmed the tubing should be changed weekly, and failure to do so could lead to respiratory illness or infection.
The facility failed to provide proper pharmaceutical services by storing expired medications with active ones and not documenting the administration of controlled substances for several residents. Expired medications for two residents were found in a medication cart, and controlled substances for three residents were signed out but not recorded on the MAR. The DON confirmed these discrepancies, which violated the facility's policies.
Two residents were administered quetiapine without appropriate clinical justification or the implementation of non-pharmacological interventions prior to its use. Resident 34 received quetiapine without an annual GDR attempt, and there was no documentation of the nature of hallucinations or any indication of harm. Resident 5 was given quetiapine following extreme behavior, but non-pharmacological interventions were not documented before or during the first two months of medication use. The facility's policy required non-pharmacological approaches to minimize the need for psychotropic medications, which was not followed in these cases.
The facility failed to properly store and label medications and medical supplies, leading to deficiencies. Expired medications and supplies were found in medication and treatment carts, and several opened inhalers and vials lacked open dates. Staff interviews confirmed these items should have been removed, highlighting a failure to adhere to facility policies on medication labeling and storage.
The facility's kitchen had several sanitation and storage deficiencies, including a brown-black substance in the walk-in refrigerator, ice buildup in the reach-in freezer, and improperly stored food items. The RD and DM acknowledged these issues could lead to cross-contamination and resident illness.
The facility failed to implement proper infection control practices, including inadequate disinfection of shared medical equipment, improper handling of oxygen cannula tubing, and failure to use PPE. Nursing staff did not adhere to specified contact times for disinfecting equipment, and a vendor entered a resident's room without PPE. Additionally, an IV tubing was unlabeled, and a sterile dressing kit was compromised. These lapses increased the potential for infection spread among residents.
A resident with moderate cognitive impairment and a urinary condition felt embarrassed due to her urinary bag being left uncovered, contrary to facility policy. An LVN and the DON acknowledged the oversight, which could affect the resident's psychosocial well-being.
A facility failed to maintain a copy of a resident's Advance Directive (AD) in the medical record, despite the resident having end-stage renal disease and the capacity to make decisions. The Social Services team did not follow up with the family member to obtain the AD, and the Director of Nursing expected the document to be readily available. The facility's policy requires ADs to be prominently displayed and retrievable, but this was not followed.
A resident's room had multiple damaged window blinds, disrupting her sleep due to excessive brightness. The ADON acknowledged the issue, but the Maintenance Supervisor and Administrator were unaware of the problem. Facility policies emphasize maintaining a homelike environment and reducing glare, which was not upheld in this case.
A facility failed to follow its antibiotic stewardship policy for a resident, resulting in a delay in obtaining a urinalysis specimen and a lack of evaluation for an antibiotic time out. The resident was prescribed Keflex for leukocytosis without other infection symptoms, and the urinalysis was delayed by five days, showing no bacteria. The Infection Preventionist and Director of Nursing acknowledged the oversight, which could lead to antibiotic resistance.
A resident with Alzheimer's and muscle weakness was not offered the pneumococcal (PCV20) vaccine as per CDC guidelines, despite receiving the initial PCV13 dose in 2015. The facility's policy requires offering vaccines unless contraindicated, but there was no documentation of the resident being offered the subsequent dose, as confirmed by the IP and DON.
A facility failed to document medication administration times accurately in the EMAR for a resident with multiple diagnoses, including heart failure and dementia. Medications scheduled for 9 a.m. were documented as administered at 3:55 p.m. and 3:56 p.m. An LVN admitted to administering the medications on time but delayed documentation. The DON highlighted the importance of timely documentation for resident safety.
A resident at moderate risk for pressure injuries developed a blood blister and skin discoloration, but the facility failed to conduct a thorough wound assessment and notify the physician as required by policy. Interviews with staff confirmed the lack of documentation and assessment, despite the facility's protocol mandating such actions.
The facility failed to ensure proper infection control measures for COVID-19. A CNA did not wear a face shield or change the N95 mask after caring for a COVID-19 positive resident. Multiple staff members were unable to verbalize proper PPE use and disposal. Observations showed PPE carts were not adequately stocked with N95 masks and face shields. The DON, ADON, and IP confirmed that all PPE should be discarded after exiting isolation rooms.
A resident refused lactulose three times, and the facility failed to notify the physician or document the refusals in the medical record. The resident had multiple diagnoses, including COPD and severe protein-calorie malnutrition. The DON confirmed the lack of documentation and notification, which was against the facility's policy.
A resident with multiple diagnoses had stat laboratory tests ordered by a physician, which were not completed before the resident was transferred to the hospital. Interviews with staff confirmed that the stat orders should have been drawn within four to six hours, but this did not occur.
The facility failed to document the reasons for medication orders for a resident with multiple diagnoses, including effusion, osteoporosis, COPD, and severe malnutrition. Medications lactulose and dicyclomine were ordered without documented reasons or correlation to the resident's condition, and the resident's refusal of lactulose was not communicated to the physician or recorded.
The facility failed to follow physician orders for two residents, leading to delayed care and potential complications. One resident did not receive consistent Foley catheter care, resulting in urinary sediment and infection. Another resident experienced inconsistencies in insulin dosing and delays in receiving other medications, leading to self-advocacy for timely care.
Failure to Timely Assess and Notify Physician of Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s left great toe skin condition was promptly evaluated and referred to a physician after it was first identified. On February 10, 2026, a CNA reported that while assisting the resident in bed, the resident complained of foot pain. Upon removing the sock, the CNA observed a blister on the left great toe with slightly lifted skin and pink tissue underneath, without bleeding or drainage. The CNA stated she notified the Treatment Nurse, who replied she was doing rounds anyway, but when the CNA returned to work two days later, she had received no report or update that anything had been done about the blister. The resident’s medical record showed she had been admitted with diagnoses including diabetes mellitus, morbid obesity, and dementia, and her MDS indicated memory problems and cognitive difficulty in new situations. The record contained a physician’s order dated February 14, 2026, to send the resident to the ER for evaluation of the left foot due to green and red discoloration, a skin tear, and buildup of skin debris, and an eINTERACT Change in Condition Evaluation documented a change in condition related to a skin wound or ulcer, with lack of treatment noted as a factor keeping the condition unchanged. The narrative in that evaluation described the family approaching the nursing station about skin concerns to the left foot, and staff then observing green and red discoloration to the left great toe and top of the left foot, a skin tear, and skin debris buildup. There was no indication in the record that the wound on the left great toe was assessed and referred to the physician when first identified by the CNA on February 10, 2026, and no care plan was developed to address the left foot wound. Further interviews supported that the skin condition was present and unaddressed before the physician was notified. A second CNA confirmed assisting with repositioning the resident in early February, hearing the resident complain of left foot pain, and seeing that the sock was removed, revealing a dry, flaky wound that was not yet open; she stated CNA 1 said she would notify the Treatment Nurse and left the sock off because it was hurting the foot. An LVN later reported that in the evening of February 14, 2026, a family member was upset about the foot wound, and the LVN then observed three areas of excess green skin debris, flaky skin on the top of the foot, a concerning toenail with a reddened nail bed, a lateral foot area that looked like a wound with a blackened area, and extension of the condition between the great and second toes. The LVN stated there had been no prior communication or documentation about the skin condition in the chart before that time. Facility policies required examination and assessment of skin, notification of the physician of abnormalities such as wounds or rashes, and prompt notification of the physician and resident representative of changes in condition, but the documentation and interviews showed these steps were not carried out when the skin issue was first identified.
Unsanitary Food Storage and Kitchen Equipment
Penalty
Summary
The facility failed to ensure sanitary food storage and equipment cleanliness in the kitchen during observation and interview. An opened, unlabeled, and undated bag of frozen ground meat was found in a box labeled Casa Solana Carne de Chorizo Sausage Bulk with an open date of 7/11/24 in the walk-in freezer, and an opened container of Italian seasoning had a use-by date of 2/25/26. The Dietary Aide verified these findings and stated the food items should have been thrown away to prevent food borne illness and cross-contamination. The facility policy titled Food Receiving and Storage stated that foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date, and refrigerated food are to be monitored so they are used by their use-by date, frozen, or discarded. The facility also failed to keep food-contact and nonfood-contact surfaces clean and failed to ensure items were fully dried before storage. Five clear plastic bowls, five metal baking trays, and three plastic food storage containers were observed stacked while still wet. The wire racks in the walk-in refrigerator had dust, a table-mounted can opener had a brown sticky substance, and a pizza cutter had crusty debris. The Director of Dietary Services verified these findings and stated the equipment should have been properly cleaned, sanitized, and completely dried before storing to prevent cross-contamination and food related illnesses. The 2022 U.S. Food Code cited in the report states that food-contact surfaces and nonfood-contact surfaces must be kept free of soil and debris, and items must be allowed to drain and air-dry before being stacked or stored.
Unlabeled and Undated Resident Foods Stored in Refrigerator
Penalty
Summary
The facility failed to ensure that foods brought by visitors for residents were properly labeled and stored in the unit refrigerator. During a concurrent observation and interview with the ADON, several items in the resident refrigerators were found unlabeled and undated, including a jar of Mango Thokku, a Ziplock bag containing a dough-like food item with brown chunks on top, a frozen Starbucks drink, a bag of frozen tamales, and two beverage containers with brown liquid. The ADON stated that all foods placed in resident refrigerators should be labeled and dated before storage to prevent food-borne illnesses. The facility policy titled Food Receiving and Storage, revised November 2022, states that residents' foods are labeled with the resident's name, item, and use-by date, beverages are dated when opened and discarded after 24 hours, and other opened containers are dated and sealed or covered during storage.
Uncovered Outdoor Garbage Dumpsters
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner when, during a concurrent observation and interview on 3/2/26 at 3:24 PM, four of the five outdoor garbage dumpsters were observed uncovered. A Dietary Aide stated the dumpsters should be kept closed. During a follow-up interview on 3/2/26 at 3:50 PM, the Director of Dietary Services stated the garbage dumpsters should be kept covered to prevent attracting pests, which may spread illness and disease. A review of the 2022 United States Food Code, Section 5-501.113, indicated that receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered, with tight fitting lids or doors if kept outside the food establishment.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and professional standards of practice, and surveyors identified a medication error rate of 8.62% with five errors out of 58 medication administration opportunities during observations of four residents. The errors involved inappropriate dosage forms, improper administration technique, and administration outside ordered parameters during medication passes for residents receiving oral medications, inhaled medications, and pain medications. For one resident, an LVN crushed potassium chloride ER tablets and mixed them with chocolate pudding, and also placed an aspirin delayed-release tablet into the pudding mixture. The resident chewed the spoonfuls before swallowing. The physician orders called for potassium chloride ER 20 mEq daily and aspirin delayed-release 81 mg daily. During interview, the LVN acknowledged the potassium chloride ER tablet should not have been crushed and stated the aspirin EC tablet should have been administered separately or changed to a chewable formulation. The DON stated staff should have contacted the pharmacy and physician for alternative formulations rather than crushing the ER potassium tablet and mixing the aspirin EC tablet with pudding. For another resident, an LVN crushed potassium chloride ER 20 mEq and mixed it with chocolate pudding before administering it. The resident’s order directed potassium to be given by mouth daily with 8 oz of water. The LVN confirmed the tablet was crushed and acknowledged it should not have been crushed. The manufacturer’s instructions reviewed by surveyors stated the tablet should be taken without crushing, chewing, or sucking, and provided alternate methods for administration if swallowing whole tablets was difficult. For a third resident, after self-administering Anoro Ellipta and Pulmicort Flexhaler, the resident did not rinse and spit after the Pulmicort inhalation and then swallowed oral medications with water. The physician ordered Pulmicort Flexhaler 90 mcg, 1 puff every 12 hours for COPD. The LVN acknowledged the resident did not rinse and spit after inhalation and stated this step helps prevent oral thrush, but she did not document the refusal or notify the physician. The DON stated the manufacturer’s instructions should be followed and that a resident refusal required further administration steps. For a fourth resident, an LVN administered oxycodone-acetaminophen 5-325 mg when the resident’s documented pain level was 3. The physician orders allowed oxycodone-acetaminophen only for moderate pain rated 4-6 and acetaminophen 325 mg for mild pain rated 1-3. The resident requested stronger medication before physical therapy and refused acetaminophen. The LVN acknowledged the physician’s order was not followed and stated she should have reassessed the pain and notified the physician for clarification. The DON confirmed the medication was given when the resident’s pain level was 3 and stated staff should follow the ordered pain parameters or contact the physician for clarification.
Infection control lapses with hand hygiene, PPE, unlabeled respiratory supplies, and shared equipment
Penalty
Summary
The facility failed to ensure infection control practices were followed when staff did not perform hand hygiene and did not use the required PPE while entering and leaving resident rooms on Enhanced Barrier Precautions (EBP). In one observation, a Maintenance Assistant entered and exited a room on EBP without performing hand hygiene. In another observation, an Activity Assistant entered and exited a room on EBP without performing hand hygiene while distributing The Daily Chronicles to residents in the room. Both staff members acknowledged the observations and stated they were expected to follow EBP and hand hygiene practices. A Physical Therapy Assistant was observed entering a room on EBP, donning gloves without performing hand hygiene, assisting a resident with socks, a gait belt, and a transfer from bed to walker without wearing a gown, and then leaving the room after removing gloves without performing hand hygiene. The PTA acknowledged that hand hygiene should have been performed and that a gown should have been worn while providing care. The resident involved, Resident 46, had diagnoses including CHF, pneumonia, and resistance to multiple antimicrobial drugs, and was on EBP with signage posted outside the room indicating hand hygiene and gown-and-glove use for high-contact care activities. The facility also failed to maintain respiratory supplies in a labeled condition for two residents. In one room, a respiratory bag containing nasal cannula tubing, a nebulizer mask, and nebulizer tubing was observed at the bedside with no label, and staff confirmed the supplies were unlabeled and undated. Resident 46 had orders for weekly changes of oxygen nasal cannula and nebulizer-related supplies with name and date labeling. In another room, a resident's nasal cannula and humidifier solution container were observed without labels or dates, and the resident had orders for weekly changes of the humidifier and nasal cannula with name and date labeling. In addition, a LVN used the same BP cuff, stethoscope, and pulse oximeter for three residents without cleaning or disinfecting the equipment between uses. The equipment was used for one resident, then placed on the medication cart or in cart storage without disinfection, and then reused for two additional residents. The LVN acknowledged the equipment was not cleaned or disinfected between residents and stated it should have been disinfected with wipes kept in the medication cart. The DON confirmed that shared medical equipment such as BP cuffs, stethoscopes, and pulse oximeters must be cleaned and disinfected between each use.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information concerning the right to formulate an Advance Directive for three sampled residents. Resident 3 was readmitted to the facility and had a POLST dated 12/7/23 indicating no Advance Directive, but the medical record did not contain an Advanced Healthcare Directive Acknowledgment Form. Resident 7 was readmitted to the facility and had a POLST dated 1/12/23 indicating no Advance Directive, and there was no Advanced Healthcare Directive Acknowledgment Form in the record. Resident 88 was readmitted to the facility and had a POLST dated 10/2/24 indicating no Advance Directive, and there was no Advanced Healthcare Directive Acknowledgment Form completed. During a concurrent interview and record review on 3/3/26, the Social Services Director reviewed the records for Residents 3, 7, and 88 and confirmed that no Advanced Healthcare Directive Acknowledgment Form had been provided to the residents or their representatives concerning their rights to formulate an Advance Directive. The SSD stated that the form should be completed and discussed with residents or family members upon admission. During an interview on 3/4/26, the DON stated that an Advanced Healthcare Directive Acknowledgment Form should be completed upon admission for all residents and noted the importance of formulating an Advance Directive to honor resident rights and wishes. The facility policy titled Advance Directives, revised September 2022, states that residents have the right to formulate an advance directive and that, prior to or upon admission, the social services director or designee inquires about the existence of any written advance directives.
Inaccurate PASRR Screening for Resident With Schizophrenia
Penalty
Summary
The facility failed to ensure an accurate PASRR Level 1 Screening for one resident with schizophrenia. The resident’s admission record showed a diagnosis of schizophrenia, and the custodial care re-admission record stated the resident was being treated for an unspecified psychiatric condition with Zyprexa (olanzapine) and had unspecified schizophrenia managed with medication. The order summary also listed olanzapine 20 mg by mouth at bedtime for schizophrenia manifested by paranoid delusions and monitoring for psychosis every shift for olanzapine use. Despite this information, the resident’s PASRR Level 1 Screenings dated 7/10/24, 6/26/23, and 5/31/23 answered “No” to questions asking whether the resident had a diagnosed serious mental illness such as schizophrenia/schizoaffective disorder or symptoms of psychosis and psychotropic medication. During interview and record review, the MDS Supervisor confirmed the screenings were not accurately completed and verified the resident had a serious mental illness and was on psychotropic medication. The DON stated residents should be screened for PASRR Level 1 upon admission and updated as needed by the MDS nurse, and confirmed the screening should be accurate to trigger Level 2 Screening when needed.
Missing Physician Order for Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure that Resident 73 had a physician's order for the use of a plate guard and adaptive eating utensils. During an observation in the dining room, Resident 73 was seen sitting in a wheelchair and being assisted with lunch while using a plate guard and adaptive utensils. The resident's admission record showed diagnoses including displaced fracture of the sixth cervical vertebra, muscle wasting and atrophy, and Alzheimer's disease. A review of Resident 73's order summary report did not show a physician's order for the plate guard or adaptive eating utensils. During a concurrent interview and record review, the DON verified that the resident did not have a physician's order for these items. The DON stated that hospice usually communicates new and current orders to facility staff, who then update the resident's orders in the system, and stated that obtaining a physician's order was important to ensure the resident receives appropriate services and to allow staff to reassess the need for adaptive equipment in the future.
IV Therapy Documentation and PICC Dressing Deficiencies
Penalty
Summary
IV therapy was not consistently provided in accordance with physician orders and the facility’s care plans for two residents. Resident 2 was admitted with diagnoses including streptococcal sepsis and liver abscess and had an order for Piperacillin-Tazobactam 3.375 grams IV every 12 hours through 2/5/26, along with orders to flush the PICC line with normal saline every 12 hours and before and after IV medications. Review of the IV Administration Record showed no documented evidence that the antibiotic was administered on 2/4/26 and 2/5/26 at 9:00 PM, and no documented evidence that the PICC line was flushed on those dates. RN 2, the ADON, and the DON each reviewed the record and confirmed the missing documentation. During observation of Resident 2, the IV antibiotic was infusing through the PICC line in the right upper arm, and the PICC dressing had no label. RN 2 confirmed the dressing was unlabeled and stated staff were expected to label the dressing with the date, time, and initials for tracking and infection control. Resident 2’s orders included use of an antimicrobial disc and PICC dressing changes on a weekly schedule, and the care plan included IV antibiotic therapy for the abdominal abscess and septicemia. Resident 59 also had a PICC line and IV-related orders. The resident’s diagnoses included abdominal wall abscess, prostate cancer, and acute osteomyelitis. The order summary required an antimicrobial disc and PICC line dressing changes every 7 days. During observation, RN 2 read the dressing label and confirmed the date written was 2/16/26, stating the dressing was normally changed every seven days and was seven days overdue. The DON reviewed the record and stated the dressing dated 2/16/26 was from the hospital and there was no documented evidence it had been changed on 2/23/26, adding that the PICC line dressing had not been changed since admission. The facility’s policy for central venous catheter dressing changes required dressing changes at established intervals and labeling with initials, date, and time.
Failure to Obtain Oxygen Administration Order
Penalty
Summary
The facility failed to ensure an oxygen administration order was obtained for one of five sampled residents, Resident 166, who was observed in bed, alert, and verbally responsive while receiving oxygen at 4 liters per minute via nasal cannula. During the observation and interview, the resident stated that the previous oxygen rate had been 2 liters per minute and believed staff may have received an order to increase it. Record review and staff interviews showed that Resident 166’s active order was for oxygen at 2 liters per minute at bedtime only, with no order for daytime or as-needed oxygen. LVN 3 verified the order and stated the attending physician should be notified to obtain an oxygen administration order for daytime and/or as needed and to adjust the parameters accordingly. RN 1 and the DON both stated that oxygen administration requires a physician’s order and should be followed within scope of practice. Resident 166’s admission record showed diagnoses including asthma and obstructive sleep apnea, and the facility’s Oxygen Administration policy stated that a physician’s order must be verified before oxygen is administered.
Controlled substance documentation did not reconcile with MAR
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances when the Controlled Drug Records for one resident did not reconcile with the Medication Administration Record. During review of Medication Cart 2A at Nursing Station 200, a blister card for oxycodone-acetaminophen 5-325 mg labeled for the resident was checked with an LVN. The resident had a physician order for oxycodone-acetaminophen 5-325 mg, 1 tablet by mouth every 4 hours as needed for severe pain 7-10. Review of the resident’s CDR and January 2026 MAR showed that nursing staff removed and signed out one tablet on two occasions, but there was no corresponding documentation of administration or pain assessment on the MAR. During interview, the LVN confirmed the discrepancy and stated that CS administration was required to be documented on both the CDR and the MAR. The DON also confirmed the discrepancies and stated the expectation was to document CS removal on the CDR and medication administration on the MAR. The facility policy for administering medications stated that the person administering the medication records the date and time administered, symptoms for which the drug was given, results achieved, and the signature and title of the person administering the drug.
Dietary Staff Lacked Competency to Verify Sanitizer Concentration
Penalty
Summary
The facility failed to ensure kitchen staff had the appropriate skill set to safely perform daily Food and Nutrition Services operations. During an observation and interview on 3/2/26 at 3:30 PM, Dietary Aide 2 was asked to demonstrate how to check the sanitizing solution and stated she was not sure how to do it. The aide had been hired on 3/18/25, and the Director of Dietary Services later stated that staff were supposed to dip the test strip into the sanitizing solution for ten seconds and then match the color to the chart. During the same interview and record review, the Director of Dietary Services stated the quaternary sanitizer should be between 200-400 ppm and that the competency skills check for Dietary Aide 2 should have been completed within three months after hire. The Director was unable to locate the aide’s competency skills check. The facility policy titled Sanitization, dated November 2022, stated that service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration.
Incomplete and Inaccurate Documentation for PICC Line Care and Activity Records
Penalty
Summary
Resident 59’s medical record did not accurately reflect the status of the resident’s PICC line dressing. During observation, the resident was awake, verbally responsive, and lying comfortably in bed, and the PICC line dressing on the right upper arm was dated 2/16/26. RN 2 confirmed the date on the dressing and stated the dressing was normally changed every seven days, making the dressing change seven days overdue at the time of observation. Record review showed Resident 59 had diagnoses including cutaneous abscess of the abdominal wall, prostate cancer, and acute osteomyelitis. The order summary included instructions for an antimicrobial disc to be changed every seven days with the dressing change and for the PICC line dressing and Stat-lock to be changed every seven days. The IV Administration Record showed these items were signed off as completed on 2/18/26 and 2/25/26, but the progress notes stated the dressing dated 2/16/26 was due on 2/23/26. During interview, the DON reviewed the record and stated the 2/16/26 dressing was from the hospital, there was no documented evidence it had been changed on 2/23/26, and the IV Administration Record showing a change on 2/25/26 was inaccurate because the PICC line dressing had not been changed since admission. Resident 60’s activity documentation was also incomplete and inconsistent. The resident was observed resting in bed with the television on, and the care plan identified daily activity preferences, including daily room visits with sensory motor stimuli and small conversation, as well as a preference to choose bedtime. The Activities Director reviewed the February 2026 Event Calendar Report and found no activities documented on 2/18, 2/24, and 2/25/26. The AD stated the resident was visited daily, verified the dates lacked entries showing activities were provided, and noted that documenting activities was important to track what residents received and what they liked and preferred. The facility’s room visit program policy stated room visit records should include the date of the visit, the activity provided, and the resident’s response.
Nonfunctioning Resident Call Light Systems
Penalty
Summary
The facility failed to keep the resident call light system in working order for two sampled residents, Resident 13 and Resident 171. During a concurrent observation and interview on 3/2/26 at 8:59 AM, CNA 1 tested the call light systems in both residents’ rooms and found that neither system showed a light or was audible at the nursing station. CNA 1 verified that both call light systems were not working. During a follow-up observation and interview later that morning on 3/2/26 at 11:59 AM, CNA 1 tested both call light systems again and found that they still did not show a light or sound at the nursing station. During an interview on 3/2/26 at 12:12 PM, CNA 1 stated that the facility placed a call bell at the bedside table so the residents could alert staff if needed, and said she had already placed a request to notify maintenance of the issue. On 3/4/26 at 10:54 AM, the Maintenance Assistant confirmed he was aware of the nonfunctioning call lights and stated he had fixed the issue by replacing the wall call light systems and testing them.
Failure to Monitor and Manage Symptomatic Hypertension and Hypotension
Penalty
Summary
The deficiency involved the facility’s failure to provide appropriate treatment and monitoring for a resident with hypertension when the resident experienced significantly elevated blood pressure and related symptoms. The resident, admitted with a diagnosis including hypertension and having an impaired cognitive status (BIMS score of 9), had a physician’s order for Terazosin 1 mg at bedtime for systolic BP greater than 140. On the day in question, an eINTERACT Change in Condition Evaluation documented that the resident complained of dizziness and shakiness, with vital signs at 9:43 a.m. showing BP 157/122 mmHg. The RN reported that while passing morning medications, the resident complained of dizziness and shakiness and had a high BP of about 150/120. The RN stated she notified the physician around 9:40 a.m. and received orders to monitor the resident, provide supplemental oxygen, and obtain medical history, but the resident refused oxygen. Despite the elevated BP and ongoing symptoms, the RN acknowledged she did not monitor or recheck the resident’s BP between approximately 9 a.m. and 1 p.m. At around 1 p.m., the RN notified the physician that the resident continued to complain of dizziness and shakiness, had a BP of 78/59 mmHg and a heart rate of 120, and had a history of stroke; the physician then ordered the resident sent to the ER. The DON stated she was notified after 10 a.m. of the high BP and advised the RN to call the physician, and further stated that she expected the licensed nurse to call the physician for high BP with symptoms, obtain PRN medication, monitor BP at least hourly, follow up with the physician, and send the resident to the hospital if appropriate. Facility policies on blood pressure and change in condition required hypertensive and hypotensive readings and significant changes in condition to be reported to the physician, with multiple BP readings recorded at different times of day and prompt notification of the physician when treatment needed to be altered significantly.
Failure to Ensure Appropriate Discharge and Accurate Wound Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was discharged to a setting capable of meeting the resident’s wound care needs and to accurately communicate the presence and status of a significant pressure injury at discharge. The resident was admitted with an unstageable right heel pressure ulcer/diabetic foot ulcer and had ongoing daily wound care with povidone-iodine and dressings. A wound assessment completed six days prior to discharge documented a non-healable right heel diabetic ulcer with 100% eschar, negative progression, additional devitalized tissue, and daily Betadine treatment. Despite this, the physician’s 602 form completed earlier indicated “R heel w/o pressure injury,” and the nurse practitioner later confirmed that “w/o” meant “without,” while being unable to recall why the heel was documented as without a pressure injury. The case manager confirmed that the 602 form, which indicated no pressure injury, was emailed to the assisted living facility (ALF) prior to discharge. The ALF’s Resident Service Director reported that their Executive Director had visited the SNF and saw the resident’s heel covered with a dressing; SNF staff reported the wound was healing, and the 602 form signed by the nurse practitioner indicated no pressure injury. The ALF typically relies on such information to determine whether a resident is appropriate for admission and generally can accept only simple wounds, not unstageable wounds. The social services director stated that usually the ALF determines if a resident is appropriate and that ALFs typically do not take unstageable wounds. On the day of discharge, the order summary documented that the resident requested discharge to the ALF with home health nursing, PT, and wound care, and included specific wound care orders for the right heel diabetic foot ulcer, including Betadine application and dressing instructions. However, the registered nurse confirmed that the Discharge Instruction Form/Recapitulation of Stay listed discharge to a private residence and did not document the right heel wound. Upon admission to the ALF, staff assessed the right heel wound as unstageable and, due to their inability to care for it, transferred the resident to a general acute care hospital the same day. These actions and documentation discrepancies show the facility did not ensure the discharge destination could meet the resident’s care needs and did not provide accurate, complete wound information in the discharge documentation sent to the receiving facility.
Failure to Timely Assess and Document Reported Arm Bruise
Penalty
Summary
The deficiency involves the facility’s failure to assess and document a newly observed bruise on a resident’s right arm in a timely manner after it was reported to nursing staff. The resident had been admitted with diagnoses including heart failure, hypertension, and type 2 diabetes mellitus. During an unannounced visit on December 2, 2025, surveyors reviewed records and conducted interviews. CNA 1, who worked the evening shift on November 17, 2025, reported that she observed a bruise on the resident’s right forearm and notified a licensed nurse, but she did not know what occurred afterward. CNA 2 also reported that she notified LVN 1 of an olive-toned bruise on the resident’s right arm on November 17, 2025, and stated she did not see LVN 1 assess the resident’s arm. LVN 1 confirmed that a CNA had informed her on November 17, at about 7 a.m., that the resident had a bruise, but she did not assess or document the bruise, stating she believed it was old and related to a previous fall. A review of the resident’s progress notes showed no documentation of an assessment of the right arm bruise on November 17, 2025, despite it being observed and reported that day. The first documented assessment appeared in a progress note dated November 18, 2025, at 9:53 a.m., which stated that the writer noticed the resident’s right arm had a purplish discoloration and notified the treatment nurse. The DON stated that the licensed nurse who was notified of the bruise did not follow the facility’s policy and procedure for evaluation and notification of a change in condition.
Failure to Protect Residents from Abuse and Neglect by CNA
Penalty
Summary
The facility failed to protect two residents from abuse by a Certified Nursing Assistant (CNA). For one resident, the CNA refused to provide care and made a derogatory statement, saying, "I am not your slave." This refusal and verbal abuse were witnessed by staff and reported by the resident, who expressed being taken aback by the CNA's attitude and comments. The resident required significant assistance due to multiple medical conditions, including multiple sclerosis, COPD, and congestive heart failure, and was dependent on staff for care. For another resident, the CNA provided care in a rough and aggressive manner. Multiple staff members, including two LVNs, observed the CNA forcefully moving the resident, pulling a sheet out from under him, and not addressing the resident while he was screaming in pain. The resident, who had diagnoses of Parkinson's disease and dementia, was described as frail, confused, and requiring moderate to maximum assistance for bed mobility. The incident was witnessed by staff who reported that the resident was not being combative at the time, contrary to the CNA's claims. The resident's roommate was also visibly upset by the incident. Interviews and record reviews confirmed that the CNA's actions and statements constituted both physical and verbal abuse, as well as neglect by refusing care. The facility's policies prohibit such conduct and require staff to provide compassionate care, report abuse, and use appropriate techniques when caring for residents with behavioral challenges. The events described led to the residents experiencing or being at risk for physical and emotional distress.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse by a Certified Nursing Assistant (CNA) towards a resident was reported to the California Department of Public Health (CDPH) within the required timeframe. On the morning of May 26, a Licensed Vocational Nurse (LVN) observed the CNA providing care to a resident in an aggressive and forceful manner, with the resident screaming in pain and stating he was hurt. The LVN reported the incident to the Administrator and the Assistant Director of Nursing (ADON), and the CNA was suspended from duty. However, the LVN did not complete the required abuse documentation or notify CDPH as mandated by facility policy and state regulations. The Administrator became aware the following morning that the abuse allegation had not been reported to CDPH within the required two-hour window. The Administrator then notified CDPH about the incident on May 27, which was outside the mandated reporting timeframe. The facility's policy and state and federal guidelines require that all allegations of abuse be reported to the appropriate authorities immediately or within two hours if serious bodily injury is suspected, or within 24 hours otherwise. The resident involved was described as frail, confused, and suffering from dementia and Parkinson's disease, requiring significant assistance with mobility. Documentation and interviews confirmed that the resident was subjected to rough handling by the CNA, and that the mandated reporting process was not followed in a timely manner, as required by both facility policy and regulatory guidelines.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for three of five sampled residents, which could negatively impact their psychosocial well-being and overall health condition. During an unannounced visit, Resident 3 reported that call lights were typically answered within 20 to 30 minutes from 6 p.m. to early morning, and sometimes not at all, requiring her to wheel herself to the nursing station. Resident 3, who was admitted with muscle weakness, required assistance with activities of daily living (ADLs) and was cognitively intact. Resident 5 also experienced delays, stating that 60 percent of the time, he waited over 10 minutes for a response, and on one occasion, his call light was never answered, leaving him in a soiled diaper. Resident 5, who was admitted with multiple health issues including gangrene and multiple sclerosis, required assistance with personal care and was also cognitively intact. Resident 1 reported that call lights were not answered timely during the night shift, often taking over 30 minutes to an hour, resulting in her being left soiled multiple times. Resident 1, admitted with conditions such as seizure disorder and muscle weakness, required substantial assistance for toileting. Observations during the visit revealed that call lights were left unanswered for over 10 minutes, even with a licensed nurse present at the nurse's station. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the expectation was for call lights to be answered within 3 to 5 minutes, and any staff member could respond. The facility's policies emphasized the importance of timely responses to maintain residents' dignity and meet their needs, which were not adhered to in these instances.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to conduct assessments for safe self-administration of medications for three residents, leading to potential risks of medication misuse. Resident 382 was found with an opened box of Allergy Calm tablets on her over bed table, which she stated she used for allergy relief, taking it twice a day or more as needed. Licensed Vocational Nurse (LVN) 3 confirmed that Resident 382 should not have the medication at her bedside and should not self-administer without an assessment. The Assistant Director of Nursing (ADON) confirmed there was no assessment or physician order for self-administration, and the resident's medical record lacked documentation of such an assessment. Resident 388 had an opened bottle of Afrin nasal spray on her over bed table, which she used for nasal congestion relief, applying it intermittently. LVN 3 stated that the nasal spray should not be at the resident's bedside and that Resident 388 should not self-administer without supervision. The ADON confirmed the absence of a self-administration assessment and physician order, and the resident's medical record did not contain evidence of an assessment. Resident 388 was noted to be mentally capable of understanding, with a BIMS score indicating cognitive intactness. Resident 389 was observed with an opened tube of Alevex lotion on her over bed table, which she used for mild pain relief, applying it multiple times daily. LVN 3 indicated that the lotion should not be at the bedside and should not be self-applied without supervision. The ADON confirmed the lack of a self-administration assessment and physician order, and the resident's medical record did not document such an assessment. The facility's policy required an interdisciplinary team assessment to determine if self-administration was safe and appropriate, which was not conducted for these residents.
Failure to Change Respiratory Tubing as Per Policy
Penalty
Summary
The facility failed to ensure that respiratory tubings were changed according to its policy and procedure, which requires changes every seven days or as needed. For Resident 17, the nebulizer tubing was observed with a label dated June 23, 2024, indicating it had not been changed for an extended period. Licensed Vocational Nurse (LVN) 4 confirmed that the tubing should have been changed long ago. Resident 17 had a history of transient ischemic attack and asthma, conditions that necessitate proper respiratory care. For Resident 19, the oxygen tubing, nebulizer tubing, and tubing to the humidifier bottle were all labeled with the date November 21, 2024, indicating they had not been changed in a timely manner. LVN 5 acknowledged the tubing should be changed at least once a week. Resident 19 was diagnosed with chronic respiratory failure and chronic obstructive pulmonary disease. Similarly, Resident 80's oxygen tubing and humidifier bottle were labeled with the date November 11, 2024. The Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that the facility's practice was to change the tubing weekly, and failure to do so could lead to respiratory illness or infection.
Pharmaceutical Services and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by storing discontinued and expired medications alongside active medications in a medication cart. During an inspection, it was found that Resident 88's meclizine and Resident 101's trazodone were expired and still stored in the cart. The Licensed Vocational Nurse (LVN) confirmed that these medications should have been removed and discarded according to the facility's policy. The Director of Nursing (DON) also stated that the expectation was for nursing staff to remove any discontinued or expired medications from the cart. Additionally, the facility did not maintain accurate documentation for the administration of controlled substances (CS) for Residents 90, 76, and 55. The CS medications were signed out on the count sheet but were not documented on the Medication Administration Records (MAR) to indicate they were administered. This discrepancy was acknowledged by the LVNs and the DON, who confirmed that the medication administrations should have been documented on the MAR to ensure accountability and prevent diversion. The facility's policies and procedures for administering medications and handling controlled substances were not followed, leading to unaccounted medications and missing documentation. The DON confirmed the discrepancies and acknowledged the missing documentation in the MAR for the residents involved. The facility's policy required that the individual administering the medication record the administration details in the resident's medical record, which was not adhered to in these instances.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents, Resident 34 and Resident 5, were free from unnecessary psychotropic medications, specifically quetiapine, which was administered without appropriate indication or clinical justification. Resident 34 was given quetiapine without an annual gradual dose reduction (GDR) attempt in 2024, and no non-pharmacological interventions were implemented prior to or during the use of the medication. The resident's medical record lacked documentation of the nature of hallucinations or any indication that the behavior was dangerous or harmful. Despite being on quetiapine since April 2021, there was no evidence of a GDR attempt in 2024, and the facility's psychiatric nurse practitioner was unaware of the long-term use of the medication. Resident 5 was also administered quetiapine without the implementation of non-pharmacological interventions prior to its initiation. The resident's medical record indicated extreme behavior, such as refusing medications and fighting with staff, which led to the prescription of quetiapine. However, there was no documentation of non-pharmacological interventions being tried before starting the medication or during the first two months of its use. The facility's policy required that non-pharmacological approaches be used to minimize the need for psychotropic medications, but this was not adhered to in Resident 5's case. The facility's policy on psychotropic medication use emphasized that residents should not receive medications that are not clinically indicated and that non-pharmacological interventions should be attempted first. Both residents' cases showed a lack of adherence to this policy, as there was no documented evidence of non-pharmacological interventions being implemented before or during the administration of quetiapine. This oversight increased the potential for medication interactions, adverse reactions, and other risks associated with the use of psychotropic medications.
Deficiencies in Medication and Supply Management
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and medical supplies, leading to several deficiencies. During an inspection of Medication Cart 3 in Nursing Station 3A, an expired medication blister card containing meclizine tablets was found. The Licensed Vocational Nurse (LVN) confirmed the medication was expired and should have been removed and discarded. Additionally, several opened medication inhalers were found without open dates, which is necessary to determine their expiration. The Assistant Director of Nursing (ADON) confirmed that opened vials of Tuberculin PPD in the medication room also lacked open dates, which is crucial for ensuring their effectiveness. Further inspections revealed that IV Cart 3 contained expired IV supplies, including IV Filter 1.2-micron extension sets, which were readily available for use. The ADON acknowledged that these expired items should have been removed from the cart. Similarly, the Station 4 Treatment Cart contained multiple expired wound care supplies, such as Sharp Debridement Trays, sponges, and dressings. The Treatment Nurse confirmed these items were expired and should not have been in the cart, indicating a failure in monitoring and removing outdated supplies. Interviews with the Director of Nursing (DON) and other staff members highlighted the expectation for nursing staff to remove expired medications and supplies from active stock. The facility's policies on medication labeling and storage were not adhered to, as evidenced by the presence of expired and undated items. The lack of proper labeling and removal of expired items posed a risk of administering ineffective or unsafe medications and supplies to residents.
Sanitation and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. In the walk-in refrigerator, a brown-black substance was found along the seams where the walls and ceiling meet, which the Registered Dietician (RD) identified as dirt that should not be present, as it could lead to cross-contamination of food. Additionally, the six-door reach-in freezer had significant ice buildup on the inside doors and seals, which the cook acknowledged could damage food and lead to potential illness. Open packages of food, including hamburger patties with freezer burn and discolored cookie dough, were also found in the freezer, indicating improper storage practices. Further observations revealed that the air vents in the dry goods storeroom were coated with brown dust, which the RD agreed could contaminate food products if the dust fell. The Dietary Manager (DM) and Administrator (ADM) confirmed the presence of peeling caulking and brown substance in the walk-in refrigerator, which could lead to contamination. The DM also noted that the ice buildup in the freezer could prevent it from maintaining a steady temperature, risking food safety. The facility's policy on food storage was not adhered to, as evidenced by the improper storage and handling of food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during several instances involving shared medical equipment and resident care. Nursing staff did not adhere to the manufacturer's specified contact time for disinfecting shared blood pressure cuffs and glucometers with bleach wipes, nor did they properly disinfect stethoscopes. Additionally, a prefilled insulin pen was used without cleaning the rubber seal with alcohol, contrary to the manufacturer's instructions. These lapses were confirmed by the Infection Prevention nurse and the Director of Nursing, who acknowledged that staff training did not include instructions on achieving the necessary contact time for disinfection. Further deficiencies were noted in the handling of oxygen cannula tubing and the use of personal protective equipment (PPE). An oxygen cannula was observed hanging unbagged on an oxygen concentrator, which could lead to bacterial growth and respiratory illness. A CNA failed to perform hand hygiene, wear appropriate PPE, and disinfect equipment when providing care to a resident on Enhanced Barrier Precautions. Additionally, a vendor entered a resident's room without PPE and was not educated by staff on the necessary precautions, despite the resident being on Enhanced Barrier Precautions due to an indwelling catheter. Other issues included unlabeled IV tubing and compromised sterile supplies. An IV tubing was found unlabeled, making it impossible to determine when it was last changed, which is against facility protocol. An opened and exposed dressing change kit was found in the IV cart, which should have been removed to maintain sterility. These failures in infection control practices increased the potential for the spread of infection among the facility's medically compromised resident population.
Failure to Cover Urinary Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not covering the resident's urinary bag with a dignity bag. This incident involved a resident with moderate cognitive impairment and a diagnosis of obstructive and reflux uropathy, who expressed feeling embarrassed when her urinary bag was visible to others. The observation was made on December 9, 2024, when the urinary bag was seen hanging uncovered at the side of the bed. During an interview, the resident confirmed that the bag was not covered when she walked outside her room, leading to her embarrassment. A Licensed Vocational Nurse (LVN) acknowledged that the urinary bag was exposed and should have been covered, expressing that she would feel embarrassed if it were her bag. The Director of Nursing (DON) also confirmed that residents should always be treated with respect and dignity, and leaving the urinary bag uncovered could have psychosocial effects on the resident. The facility's policies on resident rights and dignity emphasize treating residents with respect and covering urinary catheter bags to promote dignity, which was not adhered to in this case.
Failure to Maintain Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a copy of the Advance Directive (AD) for a resident with end-stage renal disease was available in the medical record. The resident was admitted with the capacity to understand and make decisions, and it was noted in a Social Service Review that an AD existed and a copy was requested from the resident and his family member. However, the medical record did not contain a copy of the AD, and there was no documented evidence that the facility followed up with the family member to obtain it. Interviews with the resident, Social Service Director, Social Services Assistant, and Director of Nursing revealed that there was no follow-up conducted to obtain the AD from the family member. The Social Services Assistant admitted to not asking for a copy of the AD, and the Social Service Director acknowledged that the team should have followed up sooner. The Director of Nursing expected the AD to be readily available in the chart and indicated that social services should have ensured the document was uploaded. The facility's policy requires that information about advance directives be prominently displayed and retrievable in the medical record, but this was not adhered to in this case.
Failure to Maintain Homelike Environment Due to Damaged Blinds
Penalty
Summary
The facility failed to provide a comfortable homelike environment for a resident when multiple damaged window blinds were observed in her room. During an observation and interview, the resident expressed that the brightness from the window in the morning disturbed her sleep. The blinds were noted to be broken on two separate occasions, and the Assistant Director of Nursing acknowledged that the damaged blinds would not contribute to a homelike environment and should be repaired. The Maintenance Supervisor and the Administrator were both unaware of the damaged blinds in the resident's room. The Maintenance Supervisor stated that the blinds needed replacement, while the Administrator agreed that the blinds should have been repaired or replaced to maintain a homelike environment. The facility's policies on providing a homelike environment and maintenance services emphasize the importance of maintaining the building in good repair and reducing glare to ensure comfort for residents.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy for a resident, leading to a delay in obtaining a urinalysis specimen and a lack of evaluation for an antibiotic time out within 72 hours. The resident, who was admitted with dysuria, was prescribed Keflex for leukocytosis without documented evidence of other infection symptoms. The urinalysis, which was supposed to be collected promptly, was delayed by five days, and the results showed no presence of bacteria. The Infection Preventionist (IP) acknowledged that the resident's use of Keflex should have been reevaluated, and the physician should have been notified about the delay in specimen collection. The IP also stated that the facility had a 3-day antibiotic time out policy, which was not followed in this case. The Director of Nursing (DON) expected licensed nurses to use McGeer's criteria to determine the appropriate use of antibiotics and confirmed that the IP should have performed the antibiotic time out and notified the physician about the specimen delay. The facility's policy on specimen collection and antibiotic stewardship was not followed, as the urinalysis was not collected in a timely manner, and the antibiotic time out was not conducted. This oversight had the potential to contribute to the development of antibiotic-resistant organisms, as the resident continued to receive antibiotics without proper evaluation of their necessity.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine as per the guidelines. Resident 31, who was admitted with diagnoses including muscle weakness and Alzheimer's disease with late onset, had received one dose of the pneumococcal (PCV13) vaccine in 2015. However, there was no documentation indicating that the resident was offered the subsequent dose of the pneumococcal (PCV20) vaccine after one year, as recommended by the CDC guidelines. This oversight was identified during a review of the resident's medical records and an interview with the Infection Preventionist (IP), who acknowledged the lapse in following the facility's vaccination policy. The Director of Nursing (DON) confirmed that the facility's policy required all licensed nurses to adhere to the guidelines for pneumococcal immunization, which includes offering the vaccine to residents unless contraindicated. The facility's policy, updated in October 2023, mandates that all residents be assessed for vaccination eligibility upon admission and offered the vaccine series within thirty days if indicated. Despite these policies, the facility did not ensure that Resident 31 was offered the necessary pneumococcal vaccine, potentially leaving the resident unprotected against pneumonia.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the scheduled time of medication administration in the Electronic Medication Administration Record (EMAR) for one resident. This issue was identified during an unannounced visit to investigate a complaint related to quality of care and other issues. The resident involved had multiple diagnoses, including rhabdomyolysis, heart failure, hypertension, and dementia. The physician orders for this resident included medications such as Clopidogrel, Colace, Famotidine, and Losartan, all scheduled to be administered at 9 a.m. However, the Medication Administration Audit Report showed that these medications were documented as administered at 3:55 p.m. and 3:56 p.m., indicating a significant delay in documentation. During interviews, a Licensed Vocational Nurse (LVN) admitted to administering the medications at the scheduled time but failing to document them immediately. The LVN later returned to the EMAR to document the administration. The Director of Nursing (DON) confirmed that the medications were documented as administered much later than the scheduled time and emphasized the importance of timely documentation for resident safety. The facility's policy on administering medications requires that medications be administered according to prescriber orders and documented immediately after administration.
Failure to Conduct Thorough Wound Assessment
Penalty
Summary
The facility failed to ensure a thorough assessment of wounds and proper notification to the physician after a change in condition was identified for a resident. The resident, who was admitted with multiple diagnoses including a fracture, glaucoma, hypertension, heart failure, COVID-19, dementia, and a urinary tract infection, was at moderate risk for developing pressure injuries as indicated by a Braden Score of 13. On August 7, 2023, a blood blister on the resident's left buttock was noted, and on August 8, 2023, new skin breakdown and discoloration were observed on the right heel. However, a complete assessment of these wounds was not conducted as per the facility's policy. Interviews with facility staff, including a CNA, LVN, and the Treatment Nurse, revealed that changes in skin condition were supposed to be reported and assessed immediately. Despite this, the Treatment Nurse confirmed that no photo or assessment was completed for the blood blister and heel discoloration. The Director of Nursing also confirmed that the required documentation, including wound description, location, and other details, was not completed following the identification of these wounds. The facility's policy, revised in April 2018, mandates a full assessment and documentation of pressure sores, which was not adhered to in this case.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to ensure proper infection control measures were implemented to prevent the spread of COVID-19. A Certified Nursing Assistant (CNA) did not wear a face shield while caring for a resident who tested positive for COVID-19 and was under isolation/droplet precautions. Additionally, the CNA did not discard the N95 mask after exiting the isolation room and used the same mask when caring for non-COVID positive residents. This practice was observed during an announced visit to the facility, where the CNA admitted to not being aware of the requirement to wear a face shield and change the N95 mask between tasks. Multiple nursing staff members were unable to verbalize the proper use and disposal of Personal Protective Equipment (PPE) when caring for residents in isolation/droplet precaution rooms. Interviews with various CNAs and a Licensed Vocational Nurse (LVN) revealed that they did not change their N95 masks after caring for COVID-19 positive residents and did not wear face shields as required. The staff members stated they were not aware of the need to change N95 masks and wear face shields, despite being trained and in-serviced on PPE protocols. Observations of the isolation rooms showed that PPE carts were not adequately stocked with N95 masks and face shields. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that staff should wear all PPE, including N95 masks, face shields, gloves, and gowns, when entering or caring for residents in isolation rooms. The Infection Preventionist (IP) also stated that all PPE should be discarded after exiting the isolation room to prevent the spread of infection. The failure to follow these protocols had the potential to result in the transmission of COVID-19 to the vulnerable population of residents in the facility.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure the physician was notified when a resident refused a medication ordered by the physician. The resident refused lactulose, a medication used to treat constipation and certain brain conditions caused by liver failure, three times after it was ordered on February 27, 2024. Despite the refusals, there was no documentation in the resident's medical record indicating that the physician was notified of the refusals, nor was there any assessment, change of condition, or progress notes recorded. This failure was identified during an unannounced visit to the facility on April 18, 2024, to investigate a quality care issue. The resident in question had multiple diagnoses, including effusion of the right knee, age-related osteoporosis, chronic obstructive pulmonary disease (COPD), and severe protein-calorie malnutrition. The Director of Nursing (DON) confirmed during interviews that the resident had refused the medication three times and acknowledged that there should have been documentation that the physician was notified. The facility's policy requires that the physician be notified if a resident refuses treatment or medication two or more consecutive times, but this protocol was not followed in this case.
Failure to Complete Stat Laboratory Tests as Ordered
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered by the physician for one resident. The physician ordered a stat laboratory workup on March 1, 2024, which included a urinalysis with culture and sensitivity, complete blood count, comprehensive metabolic panel, and C-reactive protein. However, these tests were not completed. The resident was transferred to the hospital on the same day at 6:00 p.m. without the lab results being available. Interviews with the RN, LVN, and DON confirmed that the stat laboratory orders should have been drawn within four to six hours, but this did not occur. The resident's medical records indicated multiple diagnoses, including effusion of the right knee, age-related osteoporosis, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, major depressive disorder, fall, atrial fibrillation, hypo-osmolality, and hyponatremia. Despite the urgency of the stat lab orders, the facility's staff failed to ensure the tests were completed in a timely manner. The facility's policies and procedures for lab and diagnostic test results and laboratory services were reviewed, indicating that stat orders must be called into the laboratory dispatch and marked as stat for expedited processing, which was not effectively followed in this case.
Failure to Document Reasons for Medication Orders
Penalty
Summary
The facility failed to ensure that medical records accurately reflected the reasons for medication orders for one of the three sampled residents. Specifically, the medical record for a resident who was admitted with multiple diagnoses, including effusion of the right knee, age-related osteoporosis, COPD, and severe protein-calorie malnutrition, did not document the reasons for the physician's orders for lactulose and dicyclomine on February 27, 2024. The resident's Medication Administration Record indicated that lactulose was ordered to be given twice daily and dicyclomine every six hours for seven days, but there was no documentation explaining the necessity of these medications or any change in the resident's condition that warranted these orders. Additionally, there was no record of the resident's refusal of lactulose being communicated to the physician or documented in the medical record. During an unannounced visit on April 18, 2024, it was found that the facility's policy required documentation of the reasons for starting medications and a 72-hour evaluation to assess their effectiveness. The Director of Nursing confirmed that there should have been documentation correlating the medications with the resident's condition, but none was found. The facility's policy also mandated notifying the physician and documenting any refusal of treatment or medications, which was not adhered to in this case.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to ensure physician orders were followed for two residents, Resident A and Resident B, leading to delayed care and potential complications. Resident A, who was admitted with multiple diagnoses including a fractured left femur, hypertension, hypothyroidism, and hyperlipidemia, had a physician order for Foley catheter care every shift. However, the Treatment Administration Record (TAR) indicated multiple instances where Foley care was not documented, and Resident A developed urinary sediment, leading to a request for a urine culture and antibiotic treatment. The Director of Staff Development (DSD) confirmed that blank spaces on the treatment record indicated the care was not performed, which could lead to increased pain or further infections for Resident A due to his compromised state. Resident B, admitted with heart failure, respiratory failure with hypoxia, and Diabetes Mellitus Type 2, also experienced inconsistencies in care. Resident B's Order Summary Report included orders for insulin injections, blood glucose monitoring, and medications for shortness of breath and edema. However, the Blood Glucose Monitoring and Medication Administration Record (MAR) showed multiple instances where insulin, blood glucose levels, and other medications were not documented as given. Resident B reported inconsistencies in insulin dosing and delays in receiving other medications, leading to self-advocacy for timely care. The DSD confirmed that blank spaces on the record indicated the medications were not given, which could lead to complications such as hyperglycemia, fluid overload, increased hypertension, and shortness of breath. The facility's policies on insulin administration, diabetes clinical protocol, administering medication through a metered dose inhaler, and general medication administration were reviewed. These policies emphasized the importance of following physician orders, timely administration of medications, and proper documentation. Despite these policies, the facility failed to ensure that physician orders were consistently followed for Resident A and Resident B, resulting in delayed care and potential complications for both residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 2 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Murrieta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 9 | 0 |
| Temecula Healthcare Center | 9 mi | ★★★★★ | 7 | 0 |
| Menifee Lakes Post Acute | 10.1 mi | ★★★★★ | 10 | 0 |
| Fallbrook Skilled Nursing | 13.7 mi | ★★★★★ | 2 | 0 |
| Centinela Grand Inc | 16.3 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.