Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 National City Post Acute during CMS and state inspections, most recent first.
The facility failed to provide and document required bed-hold notifications and ombudsman transfer notices for two residents who experienced unplanned hospital transfers due to respiratory issues, including shortness of breath and hypoxia. One resident with DM and moderate cognitive deficits was sent to the hospital after a decline in respiratory status, but the 24-hour bed-hold notification was not signed and there was no documented ombudsman notification. Another resident with CHF and severe cognitive deficits was transferred to the hospital for hypoxia, yet the record lacked evidence of bed-hold notification and ombudsman transfer notice. Staff interviews confirmed that, despite established roles for nursing, Social Services, and Medical Records in providing bed-hold information and faxing transfer notices, these notifications were not completed or documented as required.
Failure to Document Advance Directive Information and Right to Refuse Treatment: The facility did not document that written advance directive information and the right to accept or refuse treatment were provided to multiple residents. Advance Directive Acknowledgement forms for several residents had blank resident initials, and the record lacked evidence that the resident or representative received the required information. The SSD and DON confirmed the missing documentation, and the facility policy stated residents are to be given advance directive information upon admission.
Homelike Environment Not Maintained: Surveyors observed multiple resident bathrooms and rooms with visible cosmetic damage and poor upkeep, including different paint colors, white spackle and patches on walls, a cemented patch under a sink, brown spots on a ceiling, and uncovered ceiling fans with loud motor noise. CNAs, a resident, a family member, and the ADM all described the areas as not homelike, with one resident stating the room and bathroom had looked that way since admission.
Failure to Develop and Implement Resident-Centered Care Plans: A resident with mental health diagnoses kept perishable food at bedside without a care plan, another resident had severe weight loss that was not care planned timely, a resident with a heel protector order was repeatedly observed without the device in place, and a resident with LUE swelling had no care plan or documented monitoring. Staff interviews and record review confirmed the missing or unimplemented care planning for these identified needs.
Medication administration and controlled substance handling were not carried out as ordered. A nurse gave a resident the wrong cough syrup, a resident received PRN oxycodone when pain scores were below the ordered range, controlled drug records did not match MAR documentation for two residents, emergency medication kits were left unsealed and missing items, and an LPN left medications at a resident’s bedside even though there was no self-administration order.
Refrigerated meds were found stored in two medication room refrigerators that were wet inside and had temperature inconsistencies. An ADON confirmed wet packaging, water on shelves, and readings that ranged from 36 F to 51.4 F, while a MAIN’s thermogun showed higher temps than the built-in thermometers. Meds stored included insulin products, Epogen, Veltassa, Dupixent, Trulicity, and an emergency med kit, and the ADON stated the integrity of the meds could not be guaranteed.
Infection control failures were observed involving a dirty shower room and shower chair, improper hand hygiene during medication administration, and missed annual TB surveillance for a resident with vascular dementia and DM2. CNA staff reported rinsing shower stalls with water and using bleach wipes only at the end of the shift, while housekeeping logs showed missed deep-cleaning documentation for shower rooms and shower chairs. An LPN/LN was observed handling meds and entering and exiting a resident's room without hand hygiene, and the IP and DON confirmed a resident was overdue for annual TB testing.
Failure to designate a resident representative: A cognitively impaired resident with vascular dementia and bipolar disorder had no RP listed in the record, despite being unable to understand or make decisions. The admission record’s contacts section was blank, staff could not confirm the cousin named on the POLST was involved in decision making, and the resident and RP were not invited to the care conference; the DON and ADM acknowledged the issue should have been addressed long ago.
Call Light Not Within Reach: A resident with hemiplegia and hemiparesis after a stroke was found in bed unable to locate the call light while requesting a diaper change. The call light was tucked behind the head of the bed and nightstand, and a CNA later found it behind belongings on the nightstand. The MDSC, ADON, DON, and ADM stated the call light should have been within the resident's reach, and facility policy required it to be accessible when the resident was in bed.
A resident with CKD and a hx of stroke had severe, unplanned wt loss, dropping 13 lbs. in 30 days. Staff identified the change in condition but did not notify the MD in a timely manner; interviews confirmed the COC should have been reported right away and the notification documented later was not timely.
Unnecessary PRN psychotropic medication order: A resident was prescribed lorazepam 0.5 mg PO q6h PRN for anxiety/restlessness for 30 days, exceeding the facility’s 14-day limit for PRN psychotropics. The DON acknowledged the requirement for a documented rationale for extending PRN psychotropic use, but the prescriber’s treatment justification was signed after the order and was stated by the DON to be not appropriate.
Failure to provide required transfer notice. A resident was transferred to the hospital after an acute change in level of consciousness, but the facility did not send written notice of transfer to the resident's RP or the LTC Ombudsman. The SSD and DON both acknowledged the notice was not completed, and the facility policy reviewed did not state that a copy must be sent to the Ombudsman representative.
A resident was newly diagnosed with schizophrenia after admission, but the facility did not complete a PASARR or make the related referral. The admission record and prior PASARR I did not identify schizophrenia, while a psychiatry referral later documented the new diagnosis and Seroquel use. The MDSC, DON, and ADM all acknowledged that the diagnosis should have triggered PASARR screening, and the facility policy referenced following state-specific PASRR guidelines.
A resident with hemiplegia, left ankle contracture, and muscle wasting had a physician order and care plan intervention for a heel protector on the left foot while in bed for offloading, but staff repeatedly left the device on the nightstand instead of applying it. Observations showed the resident in bed without the heel protector, and CNA documentation was inconsistent; one CNA said she documented incorrectly, another said she did not know the resident required the device, and the DON and DSD gave conflicting expectations about how CNAs should receive resident care information.
Respiratory care was not provided according to acceptable standards for two residents receiving oxygen therapy. One resident with pneumonia had oxygen tubing and a nasal cannula with crusted buildup, and staff confirmed the tubing had not been changed weekly per facility protocol. Another resident with COPD and hemiplegia had a nasal cannula on the floor, and the DBD picked it up and placed it in the resident's nostrils even though it was dirty and should not have been used; the IP and DON stated only clinical staff should have provided clean oxygen equipment.
Incompetent Preparation of Pureed Diets: A cook was observed preparing pureed foods and repeatedly needed help from the KM to mix thickener correctly for blended vegetables, chicken stroganoff, and bread. The KM stated the cook should have known how to use the thickener, and the ADM said cooks were expected to be competent when making pureed foods for residents on a pureed diet. The facility policy states pureed diets are for people with severe chewing and/or swallowing problems and all foods are pureed to simulate a soft food bolus.
A resident with DM and hyperglycemia received a meal tray that included sausage patties despite the tray card listing sausage patties as a dislike. The resident stated the tray often did not match the tray card and felt frustrated when unwanted items were served. A CNA and the Kitchen Manager both confirmed the sausage patties should not have been plated, and the ADM stated staff were expected to follow residents' meal preferences.
Expired tomatoes were observed stored in a refrigerator, and the KM and ADM stated the food should have been discarded. In a separate tray line observation, CK 1 changed gloves multiple times while prepping and plating food without washing hands before putting on new gloves. Facility policy required food items not be past expiration dates and required handwashing before gloves are worn and whenever gloves are changed.
Incomplete and inaccurate documentation was found for two residents. One resident with CKD and stroke had a Megace order tied to weight loss and a dietitian recommendation, but there was no nursing note showing the resident’s condition was communicated to the provider or that the new order was documented when received. Another resident’s levothyroxine order included unrelated extra directions about insulin pens, and staff said the wording was odd and needed correction because it was not applicable to the medication order.
Failure to Offer Annual Influenza Vaccine: A resident with vascular dementia and type II DM had no documentation that the annual flu vaccine was offered or declined for two flu seasons, and the last recorded influenza vaccine was over a year earlier. The IP and DON both stated the resident should have been offered the vaccine annually, consistent with facility policy and CDC guidance that everyone 6 months and older get vaccinated every flu season.
A resident with a history of Paroxysmal Atrial Fibrillation experienced an unwitnessed fall that was documented in clinical notes but not coded on the quarterly MDS assessment. The MDSN and DON confirmed the fall should have been coded according to RAI guidelines, resulting in inaccurate reporting of the resident's fall history and health status.
A resident with a history of cervical disc disorder was found to have head lice and received appropriate treatment, but staff did not initiate contact precautions or monitor the resident’s former or new roommates for lice during a room change. Both LNs and the DON confirmed that required infection control procedures, including roommate assessment and isolation, were not followed according to CDC guidelines and facility policy.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on multiple occasions because LNs failed to administer the medication and did not notify the DON or ADM about the pharmacy delivery delay, resulting in missed doses and lack of documentation.
Multiple residents and staff reported significant delays in call light response and personal care due to insufficient CNA staffing, particularly when CNAs were assigned to 1:1 monitoring. Family members and private caregivers sometimes had to provide care themselves. Staff interviews and resident council minutes confirmed ongoing issues with unmet care needs, especially during periods of short staffing and lack of a dedicated shower aide. Facility leadership was not fully aware of the extent of these problems.
Surveyors found that two residents' room had insects present and a sliding door screen in disrepair, with one resident using an insect trap due to concern about insects entering. The maintenance supervisor confirmed the insect presence and noted the sliding door was open, which could allow insects inside. These conditions did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with limited mobility and recent surgical wounds developed a stage 2 pressure injury on the coccyx that was not identified until it was already open, and did not consistently receive prescribed wound care treatments. Multiple CNAs and LNs confirmed the resident required assistance with repositioning and that wound care duties were performed by medication nurses without formal wound management training, leading to missed treatments and worsening of the resident's condition.
A resident who preferred a vegan diet and specifically requested tofu did not receive it during her stay, as the CDM failed to obtain the item despite being aware of the request. The facility's policy requires accommodation of resident dietary preferences, but the resident was only provided with some vegan food and not the requested tofu.
A resident with chronic pain conditions did not receive prescribed pain medication for several days because the prescription expired and was not renewed in time. Staff interviews and record reviews confirmed that the resident, who was cognitively intact, repeatedly requested pain relief but was told the medication was unavailable. The process for reordering and renewing the prescription was not followed, and the issue was compounded by the timing over a weekend, resulting in unmanaged pain.
A resident was discharged with opioid medication that was not part of the Nurse Practitioner's plan, due to a failure by the Licensed Nurse to verify the discharge plan. The resident, admitted with a lumbar fracture, was supposed to receive pain management with Gabapentin and acetaminophen. However, the resident was given 12 tablets of hydrocodone/acetaminophen upon discharge, contrary to the NP's instructions. The facility's policy did not require verification of opioid medications with the provider, leading to this oversight.
A resident with End Stage Renal Disease sustained a fracture to the left humerus during a transfer from bed to wheelchair due to the failure of facility staff to use a gait belt, as required by the resident's care plan and facility policy. The incident led to severe pain and the need for hospitalization to place a new dialysis access site. Interviews revealed that the CNAs involved did not adhere to the proper transfer protocol, compromising the resident's safety.
A facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19. Upon returning from the hospital, the resident was placed in a room with two roommates without wearing a face mask, and the room was not set up for contact droplet isolation. The Manager of Staff Development and the Director of Infection Prevention acknowledged the oversight, which was contrary to the facility's policy requiring N95 respirators, gloves, gowns, and eye protection. This delay in implementing precautions placed others at risk of exposure.
Failure to Provide Bed-Hold and Ombudsman Transfer Notifications for Unplanned Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required notifications related to emergent hospital transfers and bed-hold rights for two residents. For Resident 1, who had diabetes mellitus and moderate cognitive deficits with a BIMS score of 12/15, nursing staff identified a change in condition when the resident complained of shortness of breath late at night. A licensed nurse obtained orders for a STAT chest X-ray and a breathing treatment, but the resident’s condition continued to decline, and the resident requested transfer to the hospital. Emergency medical services transported the resident to the hospital in the early morning hours. Review of the medical record showed that the 24-hour bed-hold notification section was not signed, and there was no documentation that a Notice of Transfer was sent to the California Long-Term Care Ombudsman Program. Interviews with staff clarified the facility’s internal process and confirmed the lack of required notifications for Resident 1. The Medical Records Director stated that the former Social Services Director was responsible for discharge and transfer notifications, including ombudsman notification, and that Medical Records was responsible for completing and faxing the Notice of Transfer to the ombudsman for unexpected hospital transfers. The Medical Records Director acknowledged that this process was not completed for Resident 1. The Social Services Director stated that Social Services handled advance discharge notifications and obtained fax confirmations, while Medical Records was responsible for ombudsman notification for unplanned hospital transfers, and that nursing staff were responsible for notifying residents and/or responsible parties of the 24-hour bed-hold policy. For Resident 2, who had congestive heart failure and severe cognitive deficits and was rarely or never understood, a licensed nurse reported that the resident experienced hypoxia and that the physician and the resident’s conservator were notified. The resident was assessed by a nurse practitioner, labs were ordered, and the resident was later transferred to the hospital due to hypoxia. Record review for this resident showed there was no documentation of a bed-hold notification or a Notice of Transfer to the ombudsman in the requested records. Although the Medical Records Director stated that the ombudsman was notified of Resident 2’s transfers, the record lacked evidence of such notification. The facility’s transfer or discharge policy indicated that appropriate notice was to be provided to the resident and/or legal representative, but the survey findings showed that required notifications and confirmations related to bed-hold rights and ombudsman notification were not documented for these unplanned hospital transfers.
Failure to Document Advance Directive Information and Right to Refuse Treatment
Penalty
Summary
The facility failed to ensure documentation of written information regarding advance directives and the right to accept or refuse medical treatment was provided to 9 of 10 sampled residents, including Residents 6, 9, 25, 33, 34, 60, 62, 78, and 89. The deficiency involved the resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive. The report states that this failure resulted in residents not having the opportunity to express wishes for care if capacity for decision making was lost and the right to accept or refuse treatment. For Resident 6, the clinical record did not contain documentation that advance directive information was provided to the resident or the resident's representative. For Residents 9, 25, 33, 34, 60, 62, 78, and 89, the facility's Advance Directive Acknowledgement forms were reviewed and the resident initials line indicating that written materials had been given and that the resident had been informed of the right to formulate advance directives was left blank. The records also did not contain documentation that the facility provided advance directive information to the resident or the resident's representative. During interview and record review, the SSD stated that resident initials were expected on the advance directive acknowledgement form to document that written information regarding the right to accept or refuse treatment and the right to formulate an advance directive had been provided. The DON stated that written documentation was not provided to these residents regarding advance directive information and the right to accept or refuse treatment, and that there should have been documentation in the medical record that the information was given or refused by the resident, family, and/or representative. The DON also stated the witness signature should have included the first and last name of the witness. The facility policy titled Advance Directive stated that the facility will provide the resident with information related to advance directives upon admission.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for eight residents, including residents 51, 53, 92, 45, 100, 95, 34, and 31. In the shared bathroom used by residents 51, 53, and 92, surveyors observed a section of wall with different paint colors and an uncovered ceiling fan that made a loud motor sound. Resident 92 stated the fan had always been loud when turned on. CNA 2 later observed the same bathroom and stated the fan was really loud, did not look nice, should have had a cover, and was not homelike. The administrator and maintenance assistant also observed the bathroom and stated the uncovered fan was not acceptable and was not homelike. In the shared bathroom used by residents 45, 100, and 95, surveyors observed a ceiling fan with a loud motor sound and multiple splattered small brown spots on the ceiling. CNA 4 stated the bathroom was not homelike, would not have a bathroom like that in her house, and said the loud fan hurt her ears. The administrator and maintenance assistant also observed the bathroom and stated they did not know what the brown spots were and that the bathroom was not homelike. In resident 34's room, surveyors observed several white painted patches on the wall, white spackle under the paper towel dispenser, and a cemented square patch under the sink in the bathroom. Resident 34 stated the room and bathroom had been this way since admission, that it was ugly, and that he wished the facility would paint the patches and fix the bathroom. In resident 31's bathroom, surveyors observed white spackle under the paper towel dispenser, and the resident's family member and CNA 11 both stated the bathroom was not homelike and should be repaired. The administrator observed residents 31 and 34's room and bathroom and stated it was not a homelike environment.
Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered written care plans for four residents with identified needs. Resident 92, who had diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, routinely kept perishable food at her bedside. Observation showed hummus, celery sticks and dip, opened salad dressing, and sweet and sour sauce on her overbed table, and the resident stated she wanted a place to store her perishable food because the facility did not have a refrigerator for residents. Staff interviews confirmed she ordered food from outside vendors and would not allow staff to place her food in the resident refrigerator, and the ADON stated this behavior should have been care planned when first identified. Resident 95, who had chronic kidney disease and stroke, experienced severe weight loss. The monthly weight record showed a drop from 154 lbs. in October 2025 to 140.6 lbs. in December 2025, and the nutritional assessment documented a 13 lb. loss in 30 days. The MDSC stated that a weight loss of more than 3 lbs. should be reported the same day and that a change in condition form, physician notification, responsible party notification, and a written care plan were required. Review of the record showed the care plan addressing the unplanned weight loss was not developed until 12/17/25, and the MDSC and ADON stated it was not timely. Resident 5, who had hemiplegia and hemiparesis affecting the left side, left ankle contracture, and muscle wasting and atrophy, had a physician order and care plan intervention for a heel protector on the left foot while in bed for offloading. Multiple observations over several days showed the resident in bed without the heel protector applied, with the device sitting on the nightstand. Staff interviews confirmed the heel protector should have been on while the resident was in bed, and the DON stated the care plan was not implemented. Resident 60, who had hemiplegia following a stroke affecting the left non-dominant side and congestive heart failure, was observed with swelling of the left forearm and hand resting on a pillow. The physician ordered monitoring of left upper extremity swelling, but staff interviews and record review found no documentation of monitoring and no care plan for the swelling, and the DON stated a care plan should have been developed and implemented.
Medication administration and controlled substance documentation failures
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when a nurse administered Geri Tussin DM to a resident instead of the ordered Geri Tussin. The resident had an active order for Geri Tussin 15 mL by mouth three times a day for cough for 14 days. During medication administration observation, the nurse prepared and gave Geri Tussin DM from the medication cart. The nurse later confirmed the bottle used was different from the medication ordered in the resident’s clinical record, and the consultant pharmacist stated the two cough syrups were not the same and did not do the same thing. Controlled pain medication was also not administered according to the physician’s order for one resident with an oxycodone 5 mg PRN order for severe pain rated 8 to 10. The resident received oxycodone on multiple occasions when documented pain scores were below 8, including pain scores of 7, 6, 7, 7, 7, 7, 5, and 0. The consultant pharmacist stated the medication should only have been administered for pain levels of 8, 9, or 10, and the DON reviewed the MARs and acknowledged the order was not followed. Controlled medication accountability was not maintained for two residents receiving PRN oxycodone products. For one resident, the controlled drug record showed the medication was signed out, but the MAR did not document administration on one occasion. For another resident, the controlled drug record showed multiple sign-outs without corresponding MAR documentation on several dates, and the MAR also showed administrations that were not signed out on the controlled drug record. In addition, emergency medication kits were found unsealed in the medication rooms, with one kit missing a Humalog vial that had been removed days earlier and another IV kit missing items listed on its contents sheet. A nurse also left medications at another resident’s bedside, including tramadol, vitamin B complex, and Miralax, even though the resident did not have an order for self-administration and the nurse acknowledged the medications should not have been left there.
Refrigerated medications stored in wet refrigerators with temperature excursions
Penalty
Summary
The facility failed to ensure refrigerated medications were stored under proper temperature controls in two medication rooms. During observation and interview, the medication refrigerator in the Back Medication Room was found to be wet inside, with two boxes of acetaminophen suppositories wet and a basket of medications visibly wet. Icicles were observed under a mini-freezer area, and the Assistant Director of Nursing confirmed the wet condition and stated the suppositories would be discarded. In the Front Station Medication Room, the medication refrigerator was also observed to be wet, with medications stored in plastic bags and the exterior bags and labeling wet. A temperature log from that morning showed the refrigerator at 40 F, and after the refrigerator was reopened later, the internal thermometer read 48 F, which the Assistant Director of Nursing confirmed. On the following day, the Front Station Medication Room refrigerator was again inspected and found to have a puddle of water leaking onto the countertop and water on the bottom shelf. The Assistant Director of Nursing confirmed the shelf was wet, and the Maintenance Director stated it was not normal for a refrigerator to be wet. The refrigerator thermometer read 36 F while the Maintenance Director's thermogun read 44.2 F, and a second thermogun reading was 46.8 F. The Back Medication Room refrigerator was also rechecked and found wet on the top shelf under the mini-freezer area, with the Maintenance Director's thermogun reading 51.4 F while the internal thermometer read 40 F. Medications stored in these refrigerators included emergency medication kits, insulin products, Epogen, Veltassa, Dupixent, Trulicity, Basaglar, Humalog, Novolog, and acetaminophen suppositories. The Assistant Director of Nursing stated the refrigerator temperature should be 36-46 F and that temperature excursions could decrease medication potency, and stated the integrity of medications stored in either refrigerator could not be guaranteed.
Infection Control Failures in Shower Room Cleaning, Hand Hygiene, and TB Surveillance
Penalty
Summary
The facility failed to follow infection prevention and control practices in the back shower room and with shower chair cleaning. On 12/16/25, a joint observation and interview with CNA 6 found the back shower room had a wet musty smell, dark scattered black residue in grout and tiles on the walls and floor, and a shower chair with torn tape and scattered black spots on the handle. CNA 6 stated she rinsed the shower stall with water after each resident use and used bleach wipes only at the end of the shift, and she said she would not want her own mother to use areas that had mold on them. She also stated it was the housekeeper's duty to maintain the shower rooms. The housekeeping director later reviewed the shower room condition and the facility logs. The HD stated the shower room should not have been in that condition and said friction and brushing were needed to remove the dirt. She stated housekeeping was responsible for deep cleaning the shower rooms on Sundays and Wednesdays and deep cleaning shower chairs at the end of each month, with staff expected to sign the Cleaning Log. The HD reviewed the Wheelchairs and Shower Chairs Cleaning Log for November 2025 and found blank entries for the back and front station shower chairs, stating they were not deep cleaned that month. She also reviewed the December 2025 Janitor Calendar and noted the shower rooms were not documented as cleaned on 12/3/25, 12/10/25, and 12/14/25, and stated the deep cleaning did not appear to have been done. The facility also failed to ensure hand hygiene during medication administration and failed to maintain annual TB testing for a resident. During observation of medication pass, LN 9 exited a resident's room with gloves on, did not remove the gloves or perform hand hygiene, touched the medication cart garbage can, removed medications from the cart, handled a computer mouse, and entered the resident's room again without hand hygiene. LN 9 stated he should have performed hand hygiene when coming out of and going into the resident's room. In addition, Resident 5, who had vascular dementia and type II diabetes mellitus with hyperglycemia, had a last documented TB test on 1/29/24 with no documentation of a subsequent annual TB test or chest x-ray. The IP and DON stated the resident was due for an annual TB test on 1/29/25 and should have had one done.
Failure to Designate a Resident Representative
Penalty
Summary
The facility failed to ensure that Resident 5, who was cognitively impaired, had a designated resident representative or responsible party to exercise the resident's rights. Resident 5's record showed diagnoses including vascular dementia and bipolar disorder, and the admission MDS dated 1/29/21 documented a BIMS score of 5 out of 15. A later history and physical stated the resident had no capacity to understand and make decisions, and a quarterly MDS dated 11/4/25 indicated the resident was rarely or never understood. Review of the admission record showed the section for resident contacts was blank. During interview, the ADON acknowledged the record did not list a representative or RP and stated the cousin named on the POLST form would be the RP, but she had not seen the cousin and did not know whether the cousin participated in decision making. The CM stated the resident or RP should be invited to care conferences, yet the 10/24/25 interdisciplinary care conference showed only facility staff attended and that Resident 5 and the RP were not invited. The SSD stated the facility did not know what became of the cousin/RP or whether that person wanted to be involved, and noted the resident had been in the facility for almost five years without the issue being resolved. The DON and ADM both stated representation should have been addressed long ago, and the ADM stated the facility should have reached out in a timely manner to the Department of Aging for assistance.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light for one resident was within reach. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left side of the body. The resident's MDS assessment indicated dependence for toileting and substantial to maximal assistance for upper body tasks and sit-to-stand activities. During an observation in the resident's room, the resident was lying in bed, stated a need for a diaper change, appeared upset, and said he could not find his call light to ask for help after waiting a long time. The call light was observed behind the head of the bed and tucked behind the nightstand. A CNA later searched for the call light and found it on the nightstand behind belongings, acknowledging that it was not within the resident's reach. The CNA stated the call light should be attached to the bed where the resident could use it. The MDSC, ADON, DON, and administrator all stated the call light should be within the resident's reach at all times, and that this resident could not get to it when it was placed behind objects on the nightstand. Facility policy stated the call light should be accessible to the resident when in bed, and personal items should be arranged so they are in easy reach.
Delayed Physician Notification of Severe Weight Loss
Penalty
Summary
The facility failed to ensure the physician was notified in a timely manner of a resident’s change in condition related to severe weight loss for Resident 95. The resident was admitted with diagnoses including chronic kidney disease and stroke. The monthly weight record showed the resident weighed 154 lbs. in October 2025, 153.6 lbs. in November 2025, and 140.6 lbs. in December 2025, with the 140.6 lb. weight recorded on 12/6/25. The nutritional assessment documented a 13 lb. loss, or 8% in 30 days, which was identified as severe weight loss under the State Operations Manual. During interviews, the MDS coordinator stated that weight loss of more than 3 lbs. had to be reported to the LN the same day, and the LN was then expected to assess the resident, complete the COC form, notify the physician and responsible party, and develop a written care plan. The MDS coordinator stated the resident’s 13 lb. loss was a COC and that physician notification was not timely because the record did not show notification until 12/17/25. The ADON also reviewed the record and stated the severe weight loss identified on 12/6/25 should have been reported right away. The DON acknowledged the weight loss was severe and a COC, and stated the physician notification was not timely.
Unnecessary PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 6, was free from unnecessary psychotropic medication when she was prescribed lorazepam 0.5 mg by mouth every six hours as needed for anxiety evidenced by restlessness for 30 days. The order was dated 12/2/25 and exceeded the 14-day limit for PRN psychotropic medications described in the facility policy. During interview and record review, the DON confirmed awareness that PRN psychotropic orders extending beyond 14 days required a specified duration and a rationale for the extended use. When asked to provide documentation supporting the 30-day lorazepam order, the DON reviewed the prescriber's treatment justification, which stated that ongoing follow-up was medically necessary to monitor efficacy, tolerability, and adherence of current psychopharmacological interventions. The prescriber electronically signed that justification on 12/4/25, two days after the lorazepam order was written, and the DON stated that the justification was not appropriate.
Failure to Provide Required Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer to Resident 97's responsible party and the Long-Term Care Ombudsman when the resident was transferred to the hospital for evaluation after an acute change in level of consciousness. Resident 97 was admitted to the facility and, according to alert charting, was assessed on 9/17/25 to have an acute change in level of consciousness and was sent to the hospital. During record review and interviews, the Social Services Director and the Director of Nursing both stated that Resident 97 was discharged to the hospital on 9/17/25 and acknowledged that the written notice of transfer to the resident's RP and the Ombudsman was not completed, although it should have been. Review of the facility's Transfer or Discharge Documentation policy showed it did not indicate that a copy of the notice of transfer or discharge must be sent to the representative of the Office of the State LTC Ombudsman.
Failure to Complete PASARR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a PASARR and appropriately refer one of two residents reviewed for PASARR after the resident was newly diagnosed with schizophrenia while residing in the facility. Resident 8 was admitted without schizophrenia documented on the admission record, and the PASARR I level screening completed at the hospital before admission indicated the question about a serious mental disorder such as schizophrenia was marked “No.” A psychiatry referral dated 1/7/25 later documented that the resident was newly diagnosed with schizophrenia and was to receive Seroquel at bedtime. During interview and record review, the MDS coordinator stated the resident was newly diagnosed with schizophrenia while at the facility, had no mental disorder diagnosis prior to admission, and that schizophrenia would prompt a PASARR evaluation/screening. The MDS coordinator stated the facility should have completed a PASARR I upon receipt of the new diagnosis so it would prompt a PASARR II evaluation. The DON and administrator also stated the facility should have started a PASARR for the resident when he was newly diagnosed with schizophrenia. The facility policy titled PASRR Completion Policy indicated the facility would follow state-specific guidelines for completion.
Failure to Apply Ordered Heel Protector
Penalty
Summary
The facility failed to implement the use of a heel protector that had been ordered by the physician and included on the care plan for Resident 5, who had diagnoses including hemiplegia and hemiparesis affecting the left side, contracture of the left ankle, and muscle wasting and atrophy. The resident’s care plan for higher risk/potential for pressure ulcer development related to impaired mobility and fragile skin condition included applying a heel protector to the left foot when in bed for off loading, and the physician’s order also directed that the heel protector be applied on the left foot when in bed for offloading. During multiple observations, Resident 5 was seen in bed or sitting up in bed without the heel protector on the left foot, and the device was observed on top of the nightstand. A restorative nursing assistant stated the heel protector should have been on while the resident was in bed and that the resident was cognitively impaired and never gets up. CNA documentation for 12/17/25 and 12/18/25 indicated the heel protector was on during day shifts, but one CNA stated she documented incorrectly and did not apply it, and another CNA stated she did not put it on during the entire shift and did not know the resident required it. Both CNAs stated they did not receive needed information about the resident’s care needs from the licensed nurse before their shifts. The DSD stated CNAs were expected to look on the computer at the start of their shift for resident care information, while the DON stated CNAs should have received information from licensed nurses during daily report, acknowledging conflicting expectations. The facility policy titled Pressure Ulcers/Injuries Overview, revised March 2020, did not provide guidance related to preventing pressure injuries.
Respiratory Care Not Provided According to Standards
Penalty
Summary
Respiratory care was not provided according to acceptable standards of practice for two residents receiving oxygen therapy. One resident, admitted with pneumonia and ordered oxygen at 2 L/min via nasal cannula for shortness of breath every shift, was observed with oxygen tubing hanging over the siderail of the bed while the oxygen remained running. The nasal cannula had crusted brown buildup, and the tubing had a handwritten label dated 11/24/25. The Minimum Data Set Coordinator observed the same condition and stated the tubing and humidifier should be changed weekly and as needed if soiled, and that the resident's tubing had not been changed since 11/24/25. The ADON, who was also the infection prevention nurse, stated oxygen tubing had to be changed once a week by the licensed nurse on the night shift every Sunday to prevent infections like pneumonia and irritation to the nasal passages. A second resident, admitted with hemiplegia following a stroke and COPD, was observed lying in bed with the call light ringing and stating she needed her oxygen because she could not reach the nasal cannula, which was on the floor next to the oxygen concentrator. The DBD entered the room, and after the resident said she was having trouble breathing, picked up the nasal cannula from the floor and placed it into the resident's nostrils. The DBD stated she should not have done that because the cannula was dirty and could cause infection. The Infection Preventionist stated a nasal cannula should be stored in a plastic bag on the concentrator when not in use, that one lying on the floor should not be used because it was dirty and could have caused an infection, and that only clinical personnel should have provided a clean nasal cannula because the DBD was not qualified to administer oxygen.
Incompetent Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure the cook was competent to carry out dietary functions according to standards of practice when pureed foods were not prepared according to the recipe. A review of the therapeutic diet menu dated 12/16/25 showed 12 residents were on a pureed diet. During an observation on 12/18/25 at 11:00 A.M., the cook prepared mixed vegetables by blending them and placing them in a metal container, then attempted to prepare thickener by putting water in a pitcher and adding thickener without following the recipe. The cook asked the Kitchen Manager if it was correct, and the Kitchen Manager stated it was not, took the pitcher away, dumped the mixture, rinsed the pitcher, and then measured hot water and thickener, stirred it, and added it to the blended vegetables. The cook then blended chicken stroganoff and bread and placed each in metal containers, but again asked the Kitchen Manager for help to make sure the thickener was being mixed correctly. The Kitchen Manager assisted with the chicken stroganoff and again with the bread. On 12/19/25, the Kitchen Manager stated the cook should have known how to use the thickener for pureed foods and that the correct consistency was important to prevent choking. The Administrator stated his expectation was that cooks be competent when making pureed foods for residents on a pureed diet. The facility policy stated pureed diets are used for people with severe chewing and/or swallowing problems and all foods are pureed to simulate a soft food bolus, eliminating the chewing phase.
Meal Tray Did Not Match Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preference for one of 19 sampled residents, Resident 34. Resident 34 was admitted with a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. During an observation in the resident's room, the meal tray included milk, juice, fruit cup, dry cereal, toast, and two sausage patties, even though the resident's tray card listed dislikes of egg, sausage patties, pancakes, and sweet bread. Resident 34 stated the tray often did not match the tray card and pointed out that sausage patties were served despite being listed as disliked. The resident stated this caused frustration and made the resident feel the facility did not care what was placed on the tray. A CNA reviewed the tray card with the meal tray and stated the sausage patties should not have been put on the plate. The Kitchen Manager stated the sausage patties should not have been plated for Resident 34 and that kitchen staff were expected to read meal tickets and honor residents' dislikes. The Administrator, with the DON present, stated the expectation was for kitchen staff to read meal tickets and follow residents' choices and preferences. The facility policy titled Resident Food Preferences stated the Dietary Department would provide residents with meals consistent with their preferences as indicated on their tray card.
Expired Food Storage and Improper Hand Hygiene in Kitchen
Penalty
Summary
Food was found stored and handled in a manner that did not follow infection prevention and control practices in the kitchen. During an initial kitchen tour, a small box of tomatoes was observed in refrigerator number two with a used-by date of 12/14/25 written on the box. The Kitchen Manager stated the box should have been thrown away and that expired food could cause residents to become ill. The Administrator later stated there should never be expired food in the kitchen and that staff should have discarded the expired box of tomatoes. The facility policy titled Refrigerator and Freezers, revised November 2022, stated supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use-by or expiration dates. A kitchen tray line observation also showed CK 1 changing gloves several times while prepping and plating food without washing hands before putting on a new pair of gloves. CK 2 stated hands must be washed every time a new pair of gloves is put on. The Kitchen Manager stated CK 1 should have washed his hands every time gloves were changed and that proper hand hygiene was important to prevent the spread of germs. The Administrator, with the DON present, stated all staff including kitchen staff were expected to follow proper hand hygiene protocols. The facility policy titled Proper Wearing of Gloves in Healthcare, revised 12/15/2022, stated handwashing must occur prior to putting on gloves and whenever gloves are changed.
Incomplete and inaccurate medication documentation
Penalty
Summary
The facility failed to ensure medical record documentation was complete and accurate for 2 of 19 residents. For one resident with chronic kidney disease and stroke, the record showed a physician order for Megace and a nutritional assessment noting an 8% weight loss in 30 days with a recommendation to add Megace daily. However, there was no documentation that the nurse communicated the resident’s weight loss and condition to the provider or documented the discussion and receipt of the new order in the clinical record. During interviews, the MDS coordinator, an LN, and the ADON stated that provider communication and new orders should have been documented as a nursing progress note, and the ADON stated she was the nurse who took the order but could not recall whether the discussion occurred in person or by phone. For another resident, the clinical record listed levothyroxine with additional directions that were unrelated and not applicable to the medication order, including a warning about insulin pens. The MDS coordinator and an LN both stated the added directions did not make sense or were odd, and the DON stated additional directions should be applicable to the order and that the levothyroxine order needed to be corrected to avoid confusing nursing staff. The facility policy required physician orders to be complete and accurate, and the nursing documentation policy required a complete, comprehensive, and accessible accounting of care and monitoring provided.
Failure to Offer Annual Influenza Vaccine
Penalty
Summary
The facility failed to ensure that Resident 5 received the influenza vaccine in accordance with CDC recommendations and facility policy. Resident 5 was admitted with diagnoses of vascular dementia and type II diabetes mellitus with hyperglycemia. Review of the immunization record showed the last influenza vaccine was given on 11/21/23, and there was no documentation that the vaccine was offered or declined for 2024 or 2025. During interview and record review, the Infection Preventionist Nurse stated that Resident 5 should have been offered the flu vaccine annually and that it was important to offer the vaccine to all residents during flu season. The DON also stated that Resident 5 should have been offered the influenza vaccine. The facility policy titled Influenza Prevention and Control of Seasonal, revised March 2022, stated that the infection preventionist organizes and oversees an annual influenza vaccine campaign and that all residents and staff are offered the vaccine prior to the onset of influenza season.
Failure to Accurately Code Resident Fall on MDS Assessment
Penalty
Summary
The facility failed to accurately code a fall incident on the Minimum Data Set (MDS) for one resident. The resident, who had a history of Paroxysmal Atrial Fibrillation, experienced an unwitnessed fall in her room, as documented in both the Intradisciplinary (IDT) note and a progress note. The fall was not coded on the resident's quarterly MDS assessment, which instead indicated that no fall had occurred since admission or the prior assessment. This omission was confirmed during interviews with the MDS Nurse (MDSN) and the Director of Nursing (DON), both of whom acknowledged that the fall should have been coded according to the Resident Assessment Instrument (RAI) guidelines. The inaccurate coding resulted in the resident's fall not being reflected in the federal database, which is used for care planning and monitoring of fall risks. The resident's care plan had previously identified a risk for falls, but the failure to code the incident on the MDS meant that the assessment did not accurately represent the resident's health status or fall history at the time of the deficiency.
Failure to Implement Infection Control Measures for Lice Infestation
Penalty
Summary
The facility failed to follow proper infection control procedures for a resident who was identified with pediculosis (lice). Upon admission, the resident complained of an itchy scalp and was found to have head lice, for which treatment with permethrin 1% shampoo was ordered and administered. Despite this, the facility did not initiate contact precautions or isolation measures as required by CDC guidelines, and there was no documentation that the resident’s former or new roommates were assessed, screened, or monitored for lice during or after the room change. Both licensed nurses involved confirmed that contact precautions were not implemented and that there was no evidence of monitoring or assessment of the roommates for lice. The Director of Nursing acknowledged that the facility did not follow its own policy or CDC recommendations, which require contact precautions for at least 24 hours after initiation of effective therapy for lice. The DON also confirmed that no monitoring of roommates occurred during the resident’s room transfer and that a sign for precautions was not placed on the door. The facility’s policy indicated that the interdisciplinary team should implement measures to eliminate infestation and prevent spread, but these steps were not documented or carried out in this instance.
Failure to Administer Prescribed Ophthalmic Medication Due to Pharmacy Delay and Lack of Notification
Penalty
Summary
Licensed Nurses (LNs) failed to consistently administer prescribed eye drop medication to a resident diagnosed with glaucoma, as ordered by the physician. The resident was readmitted with a diagnosis that included glaucoma, and the physician's order specified the use of Latanoprost ophthalmic solution for both eyes. A review of the medication administration record (MAR) revealed that the resident did not receive the prescribed eye drops on several dates, and there was no documentation of administration for those days. During a joint review and interview, it was confirmed that the missed doses were due to a delay in the delivery of the medication from the pharmacy. The nurses' notes indicated the medication was not available, but the LNs did not notify the Director of Nursing (DON) or the Administrator (ADM) to expedite the delivery. The facility's policy provided did not address the requirement to follow physician's orders, contributing to the failure to ensure the resident received treatment and care in accordance with professional standards of practice.
Insufficient Staffing Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily care needs of residents, resulting in significant delays in responding to call lights and providing personal care. Multiple residents and their family members reported waiting 30 minutes to an hour for assistance with incontinence care and other needs. Certified Nursing Assistants (CNAs) were frequently unavailable due to being assigned to one-on-one (1:1) monitoring of other residents, leaving their assigned residents unattended for extended periods. In some cases, family members or private caregivers had to step in to provide care due to staff unavailability. Observations and interviews revealed that CNAs were responsible for both their assigned residents and those of colleagues who were on 1:1 monitoring, at times resulting in a single CNA being responsible for up to 19-20 residents. CNAs reported being unable to complete their duties, including providing showers, due to the additional burden of 1:1 monitoring and the lack of a dedicated shower aide. Licensed Nurses (LNs) did not assist with call lights or transfers, further exacerbating the delays in care. Resident council meeting minutes from recent months documented ongoing complaints from multiple residents about excessive wait times for assistance and staff not responding to their needs. The Director of Staff Development (DSD) confirmed that there were days when staffing levels were below the minimum required to provide adequate care, particularly on weekends with call-ins. The DSD and CNAs acknowledged that the current staffing practices, including the rotation of CNAs for 1:1 monitoring and the absence of a dedicated shower aide, resulted in neglect of other residents' needs. Facility leadership was unaware of the extent of the issue and the impact on resident care, despite documented complaints and staff concerns.
Insects Observed and Damaged Screen Door Compromise Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and comfortable homelike environment for residents when insects were found in a resident room and the screen of the sliding door was in disrepair. During an unannounced visit, two residents reported the presence of insects, with one resident stating she had placed an insect trap due to fear of insects entering the room. The maintenance supervisor confirmed the presence of a large black insect in the trap and noted that the sliding door was open, which could allow insects to enter. The resident was unsure if the screen door was broken, and the maintenance supervisor indicated that residents sometimes open the sliding door. The facility's policy requires providing a safe, clean, and homelike environment, but these conditions were not met in this instance.
Failure to Timely Identify and Treat Pressure Injuries and Surgical Wounds
Penalty
Summary
The facility failed to timely identify and treat the development of pressure injuries for a resident who was at moderate risk due to limited mobility and required assistance with repositioning. Upon admission, the resident had no pressure wounds on the coccyx, and skin assessments confirmed the absence of such wounds in the following weeks. However, the resident later developed an open wound on the buttocks, which was not identified or reported until it had progressed to a stage 2 pressure injury. Multiple certified nursing assistants confirmed that the resident could not reposition independently and did not refuse assistance, and one CNA reported noticing redness but could not recall to whom it was reported. The facility also failed to consistently provide prescribed treatments for the resident's existing surgical wounds on the right foot and knee. Treatment administration records showed several missed treatments for the resident's surgical sites, including post-amputation and wound vacuum therapies. Interviews with licensed nurses revealed that, due to the absence of a dedicated treatment nurse, medication nurses—who lacked formal wound management training—were responsible for wound care. These nurses reported being overwhelmed with multiple duties, making it unlikely that all treatments were administered as ordered. As a result of these lapses, the resident's surgical wounds did not heal properly, became infected, and ultimately led to further amputations. The director of nursing confirmed that the expectation was for CNAs to report skin changes promptly and for licensed nurses to ensure timely assessment and treatment, which did not occur in this case. The facility's policy emphasized the importance of structured risk assessment and individualized care planning, but these procedures were not effectively implemented for this resident.
Failure to Provide Requested Vegan Food Option
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated dietary preferences. The resident, who was admitted following surgery, informed the Certified Dietary Manager (CDM) of her preference for a vegan diet and specifically requested tofu. Despite this request, the CDM acknowledged that tofu was not available in the facility and, although some vegan food was purchased, tofu was not obtained for the resident during her stay. The CDM admitted fault for not fulfilling the resident's preference for tofu. During a review of the resident's clinical and dietary records, facility leadership, including the Administrator, confirmed that the facility is responsible for meeting residents' dietary needs and preferences, including ordering specific requested items such as tofu. The facility's own policy states that menus should be developed to meet resident choices, including religious, cultural, and ethnic needs, while ensuring nutritional adequacy. The failure to provide the requested tofu resulted in the resident not receiving her preferred diet.
Failure to Provide Timely Pain Medication Due to Lapsed Prescription
Penalty
Summary
The facility failed to ensure that a resident with chronic pain conditions, including a chronic left foot ulcer and gout, had access to prescribed pain medication. The resident, who was cognitively intact and able to make decisions, reported running out of pain medication and experiencing pain for several days, which affected his sleep. The care plan instructed staff to medicate the resident as ordered and to advise him to request pain medication before pain became severe. However, staff interviews and record reviews confirmed that the prescription for the resident's pain medication had expired and was not renewed in a timely manner, resulting in the resident not receiving pain relief as needed. Licensed nurses and a CNA confirmed that the resident regularly requested pain medication and that there was no pain medication available for several days. The process for medication reordering was not followed, as no renewal or authorization form was sent to the attending physician before the prescription expired. Staff also indicated that the lack of medication was exacerbated by the timing of the prescription running out over a weekend, making it more difficult to obtain a physician's signature for renewal. The Director of Nursing acknowledged the expectation that pain medications should be available to prevent resident suffering.
Failure to Verify Opioid Discharge Plan
Penalty
Summary
The deficiency involved a failure by Licensed Nurse (LN) 1 to verify a provider's discharge plan regarding opioid medication for Resident 1 upon discharge. Resident 1, who had been admitted with a lumbar fracture, was discharged to a board and care facility. The Nurse Practitioner (NP) had documented a discharge plan that included pain management with Gabapentin and acetaminophen, but not opioids. However, LN 1's discharge summary notes indicated that Resident 1 was discharged with 12 tablets of hydrocodone/acetaminophen, which was not part of the NP's plan. Interviews with LN 2 and LN 3 revealed that the Case Manager was responsible for initiating the discharge process, and LN 1 was responsible for Resident 1's discharge, including medication instructions. LN 2 stated that LNs should verify with the attending physician whether opioid medication should continue upon discharge. The Director of Nursing (DON) confirmed that LNs are expected to verify the discharge plan and reconcile medications, especially opioids, for safety. The facility's policy on discharge did not include verification of opioid medications with the provider, contributing to the oversight.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility staff failed to safely transfer a resident, who was reviewed for pain, from the bed to a wheelchair using a gait belt, resulting in a fracture to the resident's left humerus. The resident, who was admitted with diagnoses including End Stage Renal Disease and dependence on renal dialysis, required total assistance for transfers as per their care plan. On the day of the incident, two CNAs assisted in transferring the resident without using a gait belt, contrary to the facility's policy and the resident's care plan. During the transfer, the resident began to slip, and one of the CNAs grabbed the resident's hand, resulting in a popping sound and subsequent injury. The incident led to the resident experiencing severe pain and the cancellation of their dialysis session, necessitating hospitalization for the placement of a new dialysis access site. Interviews with the CNAs involved revealed a lack of adherence to the proper transfer protocol, as they did not use a gait belt and instead lifted the resident by her arms. The facility's policies clearly stated the requirement for using a gait belt for residents needing assistance with transfers, which was not followed in this case. The Director of Nursing acknowledged the failure to use a gait belt, which compromised the safety of the transfer.
Failure to Implement Covid-19 Isolation Precautions
Penalty
Summary
The facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19, which was identified during an annual recertification survey. Upon returning from the hospital, the resident was placed in a room with two other roommates without wearing a face mask, and the room was not set up for contact droplet isolation as required for Covid-19 cases. Instead, one of the roommates was on Enhanced Barrier Precautions (EBP), which did not provide adequate protection against Covid-19, as it did not require a specialized face mask or eye protection. The Manager of Staff Development and the Director of Infection Prevention both acknowledged that the resident should have been placed on contact droplet isolation immediately upon return from the hospital. The facility's policy on Covid-19 management and isolation precautions clearly indicated the need for N95 respirators, gloves, gowns, and eye protection, along with appropriate signage to notify personnel and visitors of the necessary precautions. The delay in implementing these measures placed other residents, staff, and visitors at risk of exposure to Covid-19.
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What surveyors actually found near you
We read the 493 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
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Nursing homes near National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Manor Sanitarium | 0.3 mi | ★★★★★ | 20 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Friendship Manor Nursing & Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
| South Bay Post Acute Care | 1.8 mi | ★★★★★ | 1 | 0 |
| Paradise Valley Health Care | 1.8 mi | ★★★★★ | 2 | 0 |
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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.