Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Ocean Park Healthcare during CMS and state inspections, most recent first.
A resident with impaired cognition and a history of falls sustained a fall with severe R shoulder pain and was sent to the hospital, where initial x-rays showed no fracture. Weeks later, ongoing pain led to an MRI that revealed nondisplaced fractures of the humerus and scapula, but the facility did not report the unusual occurrence to the SSA within 24 hours after the fracture was identified.
Delayed Notification of MRI Results: A resident with impaired cognition and a history of falls sustained a fall with severe right shoulder pain and was sent to a GACH, where x-ray findings were negative. The resident later had an MRI that showed nondisplaced humerus and scapular fractures, but the results were emailed to the ADON and not relayed to the ordering MD until the next day because the ADON had already left and no one else could access the email. Facility notes did not document follow-up on the imaging report, and staff confirmed the resident continued to have pain and limited RUE function.
A resident with severe cognitive impairment and multiple medical conditions was discharged without a care-planned discharge process or a complete discharge summary/post-discharge plan of care. The discharge documentation lacked key elements such as the discharge destination, dates, physician follow-up, post-discharge plans, equipment needs, medication reconciliation, and nursing details on functional status, vitals, activity, nutrition, and skin condition. The DON confirmed that the IDT meeting form before discharge was incomplete and that there was no discharge care plan, contrary to facility P&Ps requiring comprehensive discharge planning, documentation, and review with the resident/representative.
A resident with dysphagia, adult failure to thrive, and severe cognitive impairment had a care plan and physician orders requiring close monitoring of nutritional status, including regular weights and documentation of poor PO intake. Records showed inconsistent and often poor meal intake, missing weight documentation for two consecutive months, and no RD follow-up after an initial assessment despite ongoing low intake. CNAs and an LVN reported the resident frequently refused meals, ate as little as 0–25% of meals, and primarily consumed Ensure. The DON confirmed that the resident’s nutritional and hydration needs were not closely evaluated by the RD and that the resident was not consistently eating according to facility documentation, in contrast to facility policies requiring comprehensive, regularly updated nutrition care.
The facility did not ensure that nurses and nurse aides had documented annual competency assessments, as four out of five employee files reviewed lacked proof of required training. Both the DSD and DON confirmed that competency evaluations are necessary to assess staff skills in areas such as ADL, medication administration, and IV infusion, but missing documentation indicated that these assessments were not consistently performed.
The facility did not post actual hours worked by licensed and unlicensed nursing staff responsible for resident care, instead displaying only projected hours with incomplete information for each shift. The Director of Staff and Development confirmed that actual hours were not being posted, contrary to facility policy requiring this information to be updated and accessible within two hours of each shift's start.
Surveyors found expired IV medical supplies, including StatLock catheter stabilization devices and IV start kits, in a medication storage cart. A nurse supervisor confirmed the supplies were expired and acknowledged they should have been removed according to facility policy.
Surveyors identified improper sanitation and food handling practices, including grime buildup on juice/soda gun dispenser tubing, lack of labeling on bulk juice containers, and improper storage of a dry food scoop on top of a storage bin. These deficiencies were confirmed by dietary staff and were not in accordance with the facility's policies for maintaining clean and sanitary food service areas.
A resident with severe cognitive impairment and multiple diagnoses was placed in a geri-chair with a lap tray and had bed siderails raised without proper physician orders, care plan documentation, or informed consent. Staff confirmed that these devices, which restrict movement, require specific assessment and consent per facility policy, but these steps were not completed, resulting in a violation of the resident's rights.
A resident with cognitive impairment and total dependence on staff for ADLs was found in a room with a strong urine odor, with wet bedding and clothing, as observed by surveyors and confirmed by a CNA. The CNA stated the odor was due to the resident not being changed as required, and the DON acknowledged the need for a pleasant, odor-free environment per facility policy.
Two residents with cognitive and mobility impairments were subjected to physical restraints, including bed siderails and a geri-chair with a lap tray, without proper physician orders, informed consent, or care plan documentation. Staff acknowledged that these devices restricted movement and were used inappropriately, contrary to facility policy requiring assessment, documentation, and consent for restraint use.
A resident with cognitive impairment and multiple medical conditions was discharged to an ALF, but the facility failed to send the required advance transfer/discharge notice to the Ombudsman as outlined in policy. The DON sent the notification after the discharge, contrary to the requirement for a 30-day advance notice.
A resident was incorrectly documented as having schizophrenia on the MDS without supporting evidence, despite having other diagnoses such as chronic pulmonary edema, atrial fibrillation, and anxiety disorder. The MDS nurse acknowledged the error, and the DON confirmed that proper documentation was lacking, contrary to facility policy requiring accurate and substantiated assessments.
The facility did not obtain or document required PASARR Level II evaluations for two residents with mental health diagnoses and cognitive impairment, despite positive Level I screenings indicating the need for further assessment. Staff interviews and record reviews confirmed that no follow-up with the PASARR office was documented, and the facility's policy to coordinate PASARR recommendations with care planning was not followed.
A resident with severe cognitive impairment and multiple medical conditions was observed with bed siderails in use, but there was no physician order or care plan addressing this intervention. Both nursing staff and the DON confirmed that facility policy requires a care plan for devices that may restrict movement, but none was developed in this case.
A resident was incorrectly documented as having schizophrenia in the MDS without sufficient supporting evidence or meeting DSM-V criteria. The MDS nurse and DON confirmed that the necessary documentation and symptoms were not present, resulting in an inaccurate assessment entry.
A resident with cognitive impairment and total dependence for ADLs was observed being transported in a geri chair with feet dragging on the floor and head partially unsupported. The CNA acknowledged the improper positioning and stated an intention to reposition the resident. The DON confirmed that proper positioning is required for safety, and facility policy emphasizes accident prevention. This incident reflects a failure to ensure safe positioning during mobility.
A resident with cognitive impairment and total dependence for ADLs was observed being transported in a geri chair with feet dragging on the floor and the head not fully supported. The CNA acknowledged the improper positioning, and the DON confirmed that residents should be fully supported and properly aligned in the chair to prevent injury, in accordance with facility policy.
Two residents' medical records were found to be incomplete or inaccurate: one had an Advance Directive Acknowledgement form with missing information, and another had a physician's progress note dated after discharge. These issues were confirmed by the MDSC and DON, with the physician attributing the error to high patient turnover and late entry practices.
A review of room sizes and a waiver request confirmed that 11 out of 12 rooms did not meet the required 80 square feet per resident in multiple occupancy rooms. Despite this, observations indicated that residents and staff had sufficient space to move and provide care, with necessary furniture and equipment accommodated.
A resident with a history of atrial fibrillation was admitted with a physician order for apixaban/Eliquis, but the medication was not transcribed into the MAR or administered. Nursing staff, pharmacy, and the attending physician all confirmed the omission, which was not detected during medication reconciliation or chart audits, resulting in missed doses of a high-risk medication.
A resident with a history of atrial fibrillation was admitted with physician orders for apixaban/Eliquis, but the medication was not transcribed into the facility's records or administered. Nursing staff did not complete medication reconciliation, and the pharmacy did not receive an order to dispense the drug. The DON confirmed the omission, and facility policy requiring accurate medication reconciliation was not followed, resulting in an incomplete and inaccurate medical record.
A resident with severe cognitive impairment and high fall risk was not provided with the required 1:1 supervision, as a CNA was assigned to supervise two residents at once. The CNA was not within arm's length when the resident attempted to get out of bed, resulting in a fall that caused a hip fracture. The incident was not immediately reported or documented, delaying assessment and intervention.
A resident with severe cognitive impairment was administered psychoactive medications without proper informed consent. The facility's records lacked necessary signatures from the resident or a legal representative, and the resident was without a surrogate decision-maker. The facility's policy required a bioethics committee for complex decisions, but none was in place, leading to uncoordinated care and delayed decision-making.
A facility failed to separate two residents after a reported physical altercation, contrary to its policy. One resident, with dementia and cognitive impairment, was hit by another resident. Despite being informed, the DON did not change their room arrangements, as both residents were cognitively impaired and did not recall the incident.
A resident with severe cognitive impairment and multiple diagnoses did not receive necessary ADL care, including toileting and bathing, from CNAs. Despite the care plan requiring maximal assistance, CNAs failed to perform duties such as repositioning and checking incontinent briefs. Interviews confirmed that CNAs did not adhere to facility policies requiring comprehensive resident care.
A resident with severe cognitive impairments did not receive necessary repositioning and incontinence care as per their care plan. CNAs failed to perform ADL care, including repositioning and checking incontinent briefs, during their shifts. Facility policies required such care to maintain residents' health and prevent complications.
A resident was not allowed to return to their original SNF after hospitalization, despite having the capacity to make medical decisions and expressing a preference to return. The facility failed to obtain a physician's order for a 7-day bed hold and did not document the resident's wishes, resulting in the resident being transferred to another SNF against their preference.
The facility failed to revise the care plan for a resident with impaired vision, resulting in a decline in daily activities and social interactions. The resident's missing eyeglasses were not addressed in the care plan, despite being essential for functioning and reducing fall risk.
The facility failed to ensure that training records for mandated reporter on abuse were completed for 2022. Interviews with staff confirmed they received annual training and knew the reporting procedure, but the administrator admitted that the 2022 training documents were missing. This indicates non-compliance with the facility's policy to maintain training records for four years.
A resident with a history of traumatic subarachnoid hemorrhage, muscle weakness, and other conditions was missing their corrective eyeglasses, leading to a decline in physical and psychosocial well-being. Despite informing the Social Services Director and being provided with unsuitable reading glasses, the resident could not engage in hobbies or socialize, increasing the risk of falls and isolation.
Failure to Timely Report Unusual Occurrence After Fall With Fractures
Penalty
Summary
The facility failed to report an unusual occurrence to the state survey agency within 24 hours for one resident who later was found to have a right humerus fracture and a right scapular fracture. The resident was admitted with diagnoses including abnormalities of gait and mobility, unspecified psychosis, and a history of falling, and the Minimum Data Set completed before the fall showed moderately impaired cognition and a need for partial/moderate assistance with toileting hygiene, bathing, dressing, and personal hygiene. After a fall on 4/12/2026, the resident was found on the floor and complained of 10/10 right shoulder pain, reporting that he had tripped while returning to his room. He was transferred to a general acute care hospital via 911, where an H&P on 4/13/2026 documented a ground level fall with resolving right shoulder and arm pain and no fracture seen on x-ray. The resident continued to have pain weeks later, therapy notes on 4/30/2026 indicated staff were awaiting MRI results of the right humerus, and an MRI completed on 5/5/2026 later showed a right nondisplaced humeral fracture and a right nondisplaced scapular fracture. The facility did not report the unusual occurrence to the SSA within 24 hours after the fracture was identified.
Delayed Notification of MRI Results
Penalty
Summary
Facility staff failed to promptly review MRI results and immediately notify the ordering practitioner for a resident who had fallen and continued to have right shoulder pain. The resident was admitted with diagnoses including abnormalities of gait and mobility, unspecified psychosis, and a history of falling. The resident’s MDS showed moderately impaired cognition and need for partial/moderate assistance with several ADLs. After an unwitnessed fall, the resident complained of 10/10 right shoulder pain and was sent to a GACH by 911. The hospital H&P noted a ground level fall with resolving right shoulder and arm pain and no fracture on x-ray. Because the resident continued to have pain and guarded the right arm, therapy staff awaited MRI results before changing the therapy plan. The resident went to the MRI appointment with a facility staff member, and the imaging center later told staff the full report would be available in three days. The MRI report, dated 5/7/2026, showed a nondisplaced proximal humerus fracture involving the surgical neck, greater tuberosity, and lesser tuberosity, as well as a nondisplaced scapular fracture extending through the glenoid, scapular neck, and scapular body. Facility progress notes from 5/7/2026 through 5/10/2026 did not document follow-up on the imaging report. The MRI results were emailed to the ADON’s work email at 1:34 PM on 5/11/2026, but the ordering physician was not notified until 10:26 AM on 5/12/2026. The ADON stated the results were not reported sooner because the email arrived after the ADON had left the facility, and no one else had access to that email. The ADON stated critical test results must be relayed to the physician immediately. Interviews with the DON and nursing staff confirmed the resident continued to have pain and reduced right upper extremity function after the fall, and the DON stated nursing should follow up on test results and that delays in care can occur.
Failure to Complete Required Discharge Planning and Documentation
Penalty
Summary
Surveyors found that the facility failed to provide an effective and safe discharge for one resident by not following its own transfer and discharge policies and procedures. The resident had diagnoses including UTI, dysphagia, and adult failure to thrive, and an MDS assessment showed severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. Despite these needs, there was no care plan initiated regarding the resident’s discharge, including goals and interventions. The resident’s admission record showed a discharge date, and progress notes documented that the resident was discharged to a board and care facility, but the required discharge planning elements were not completed. Review of the discharge summary/post-discharge plan of care revealed that it was undated and missing multiple required components, including the discharge plan, effective date, discharge date, discharge destination, physician follow-up appointments, post-discharge plans and community referrals, equipment needs, medication reconciliation, and nursing details such as functional status, vital signs, activity, nutrition status, and skin assessment. The DON confirmed that the IDT meeting form held prior to discharge lacked information on the discharge location, discharge date, post-discharge plans, equipment needs, physician follow-up visits, and functional status, and acknowledged that the discharge plan was incomplete with no information ensuring continuity of care. These omissions did not comply with the facility’s written policies on facility-initiated transfers/discharges and discharging the resident, which require comprehensive documentation, resident/representative notification and orientation, and a post-discharge plan reviewed at least 24 hours before discharge.
Failure to Monitor and Follow Up on Poor Nutritional Intake for a Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to provide nutritional and hydration care and services consistent with a resident’s comprehensive assessment and care plan. The resident had diagnoses including dysphagia, UTI, and adult failure to thrive, with severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. The care plan for nutritional problems and dehydration risk, initiated on 12/17/2025, included goals to prevent malnutrition and interventions such as RD evaluation with diet change recommendations as needed and weekly or monthly weights as ordered. A physician order dated 12/26/2025 directed staff to monitor episodes of poor oral intake every shift and document meal percentages. Record review showed that the RD documented in July 2025 that the resident weighed 97 lbs, had a usual body weight range of 120–130 lbs, was on a regular diet with mechanical soft, finely chopped texture, and that weights and PO intake would continue to be monitored. The weight record showed weights of 102 lbs on 7/29/2025, 105 lbs on 8/5/2025, 110 lbs on 9/3/2025, and 106 lbs on 12/4/2025, but there were no documented weights for October and November 2025. The January 2026 intake log indicated the resident typically consumed 0–25% of most meals, with 25–100% at other times, reflecting inconsistent and often poor intake. Staff interviews confirmed ongoing poor intake and lack of effective follow-up. CNAs reported the resident frequently refused to eat, would spit food out, throw food away, or eat only about 25% at dinner, sometimes refusing meals entirely even when offered alternate trays. An LVN stated the resident did not eat much, had little appetite, and mostly drank Ensure rather than eating food on the tray. The DON acknowledged that facility documentation showed the resident was not consistently eating, that the last RD progress note was from July 2025, and that there had been no RD follow-up regarding the resident’s nutritional needs and risk of nutritional problems and dehydration, despite the resident’s poor and inconsistent intake and lack of appetite. Facility policies required comprehensive, person-centered care planning, regular review and updating of care plans, and multidisciplinary assessment of nutritional needs, but the documented monitoring and RD follow-up did not occur as outlined.
Failure to Document Annual Nursing Staff Competency Assessments
Penalty
Summary
The facility failed to ensure that nursing staff met the required skills and competency evaluation requirements. During a review of employee files, it was found that four out of five files lacked documented proof of annual competency training. The Director of Staff Development (DSD) confirmed that competency training is required upon hire and annually, but acknowledged that missing documentation meant staff were not properly assessed in their skills related to resident care, including activities of daily living (ADL), medication administration, and intravenous infusion. The DSD stated that the absence of competency training could result in a decline in the quality of care provided to residents. The Director of Nursing (DON) also confirmed that employee competencies are intended to ensure nursing staff are assessed in their skills and remain up to date in performing their job duties. The DON described the process for skill assessment, which involves using a form to check required skills and document whether staff meet the necessary standards. Review of the facility's policy indicated that all nursing staff must meet specific competency requirements and participate in a facility-specific, competency-based training program. However, the lack of documented annual competency assessments for most reviewed staff files demonstrated noncompliance with this policy.
Failure to Post Actual Nursing Staff Hours as Required
Penalty
Summary
The facility failed to post the actual nursing hours worked by licensed and unlicensed nursing staff directly responsible for resident care for three consecutive sampled days. Observations on multiple days revealed that only projected hours were posted at the nursing station, with incomplete information for each shift. There was no calculation or posting of actual hours worked by unlicensed nursing staff, and no staffing information was posted for the previous day on each occasion. These postings did not meet the requirements for displaying actual staffing data, as only projected hours were visible to residents and visitors. During an interview, the Director of Staff and Development confirmed responsibility for the staffing postings and acknowledged that only projected hours were being posted, not the actual hours worked by staff. A review of the facility's policy and procedures indicated that actual hours worked by both licensed and unlicensed staff must be calculated and posted within two hours of each shift's start. The policy also required that the staffing information be accessible in a prominent location and include the resident census and shift schedule, which was not being followed as observed during the survey.
Expired IV Medical Supplies Not Removed from Storage
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and procedures regarding the storage and disposal of medical supplies. During an inspection of the IV medication storage cart, a Registered Nurse Supervisor confirmed the presence of expired medical supplies, including one StatLock catheter stabilization device, nine StatLock PICC Plus catheter stabilization devices, and four IV start kits. These items were found to be past their use-by or expiration dates. The facility's policy, as reviewed by surveyors, requires that all drugs, biologicals, and medical supplies be stored in a safe, secure, and orderly manner, and that discontinued, outdated, or deteriorated items must not be used and should be removed or destroyed. The expired supplies were still present in the storage cart at the time of the survey, indicating a failure to adhere to these procedures.
Improper Sanitation and Food Handling in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple sanitation and food handling deficiencies in the facility's kitchen and food storage areas. The juice/soda gun dispenser tubing was found to have a brown grime buildup on two separate occasions, which was confirmed by both a Dietary Aide and the Dietary Supervisor. The responsible staff indicated that cleaning the tubing was typically assigned to the person who cleans the ice machine, while the Dietary Supervisor stated that the company maintaining the juice/soda gun dispenser should handle the cleaning. Additionally, two bulk juice containers connected to the juice gun system were not labeled with received or use by dates, a fact verified by the Dietary Aide, who noted that it usually takes about a week to use up a bag or box of juice. Further, a large dry food storage scoop was observed sitting on top of a dry food storage container in the dry food storage room, rather than being stored in a manner that prevents contact with the outside of the containers. The Dietary Supervisor confirmed this improper storage method. Review of the facility's policy and procedures indicated that all food service areas, utensils, and equipment are to be kept clean and maintained in good repair, which was not adhered to in these instances.
Failure to Obtain Informed Consent for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint by not completing informed consent for the use of bed siderails and a geri-chair with lap tray, as required by individualized assessment. The resident in question had diagnoses including encephalopathy, COPD, and unspecified dementia, with severely impaired cognitive skills and required moderate assistance for activities of daily living. Despite these conditions, there was no physician order for the use of bed siderails, and the care plan did not address their use. Additionally, the medical record lacked informed consent documentation for both the bed siderails and the geri-chair with lap tray. Observations over several days showed the resident sitting in a geri-chair with a lap tray in the hallway, sometimes unattended, and later lying in bed with bed siderails up. Staff interviews confirmed that there should have been orders and care plans for these devices, and that informed consent was necessary due to the potential for these devices to restrict movement. The physical restraint assessment recommended the use of a geri-chair with tray due to poor safety judgment, but documentation was incomplete and did not reflect proper assessment or consent procedures. Facility policy required that any device restricting a resident's movement, such as bedrails or a geri-chair with a tray, be considered a restraint if the resident could not remove it independently. The policy also mandated a physician's order and informed consent for such devices, specifying the reason, benefit, type, and duration of restraint. In this case, these requirements were not met, resulting in a violation of the resident's right to be treated with respect and dignity regarding the use of physical restraints.
Failure to Maintain Odor-Free, Clean Environment for Dependent Resident
Penalty
Summary
The facility failed to maintain a clean, odor-free, and well-kept environment for one of five sampled residents by not ensuring that the resident's room and adjacent hallway were free from foul odors. During an observation, two surveyors detected a strong urine odor in the resident's room and the nearby hallway. Further inspection with a CNA revealed that the resident's bedding, draw sheet, under pad, and pants were wet with urine, and the CNA acknowledged that the odor was due to the resident not being changed in a timely manner. The CNA also stated that residents should be changed every two hours to prevent such issues. The resident involved had cognitive impairment and was dependent on staff for activities of daily living, including toileting and personal hygiene. The facility's own policy required a clean, sanitary, and pleasant-smelling environment, including clean bed linens. The Director of Nursing confirmed the expectation for a home-like, odor-free environment. The failure to provide timely incontinence care resulted in a foul-smelling environment in the resident's room and adjacent hallway, directly contravening facility policy and resident rights.
Failure to Ensure Residents Are Free from Physical Restraints Without Proper Assessment and Documentation
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints unless required for medical treatment. For one resident with severe cognitive impairment and multiple diagnoses, including encephalopathy, COPD, and dementia, there was no physician's order for the use of bed siderails, and no informed consent was obtained for the use of bed siderails or a geri-chair with a lap tray. The care plan did not address the use of bed siderails, and the physical restraint assessment was not properly documented. Observations showed the resident was repeatedly placed in a geri-chair with a lap tray and left unsupervised, and was also found in bed with siderails up, without the necessary documentation or consent. Another resident with cognitive impairment, abnormal gait, Parkinson's disease, and psychosis was found with a geri-chair parked alongside the bed, restricting movement. Staff interviews confirmed that placing the geri-chair in this manner could restrict the resident's ability to get out of bed and potentially lead to entrapment or injury. Staff acknowledged that this practice constituted a restraint and was unsafe for the resident. Facility policy requires that restraints only be used for the safety and well-being of residents, with a physician's order and informed consent, and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraints as any device that restricts a resident's freedom of movement and cannot be easily removed by the resident. The observed practices did not comply with these requirements, as devices were used in ways that restricted residents' movement without proper assessment, documentation, or consent.
Failure to Provide Timely Discharge Notification to Ombudsman
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer/discharge to the Office of the State Long-Term Care Ombudsman for a resident who was discharged to an assisted living facility. According to the facility's policy, both the resident and the Ombudsman are to receive a 30-day written notice prior to an impending transfer or discharge. However, the record review showed that the discharge notification for the resident was sent to the Ombudsman via fax on the same day as the surveyor's interview, which was after the resident had already been discharged. The resident involved had a history of epilepsy, chronic pancreatitis, and muscle weakness, and required moderate assistance with activities of daily living due to moderately impaired cognitive skills. The DON confirmed during the interview that the notification was sent after the discharge and initially believed there was a 30-day window post-discharge to notify the Ombudsman, but upon reviewing the policy, acknowledged that advance notice was required. This failure to provide timely notification was contrary to the facility's own procedures and could have impacted the resident's rights regarding the discharge process.
Inaccurate MDS Assessment Entry for Resident Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of assessment entries for a resident by incorrectly documenting a diagnosis of schizophrenia on the Minimum Data Set (MDS) without sufficient supporting documentation. The resident, who had a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder, was assessed as having severely impaired cognitive skills for daily decisions. However, the MDS included an active diagnosis of schizophrenia, which was not substantiated by the resident's medical records or behavioral observations. Interviews with the MDS nurse revealed that the schizophrenia diagnosis was entered in error, as there was no documentation meeting DSM-V criteria to support it. The Director of Nursing confirmed that a proper diagnosis requires supporting documentation from a medical professional, which was not present in this case. Facility policy requires the interdisciplinary team to conduct accurate and timely assessments using the MDS and other relevant forms, but this process was not followed for the resident in question.
Failure to Obtain and Document PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASARR) Level II evaluation was obtained and maintained in the charts for two residents who screened positive for mental disorders or intellectual disabilities. For both residents, documentation showed that they had diagnoses such as anxiety, dementia, and depressive disorder, and were dependent on staff for activities of daily living. Their PASARR Level I screenings indicated the need for a Level II evaluation, but there was no evidence in the records that the required follow-up with the PASARR Level II office occurred, nor was there documentation of any contact or response from the PASARR office. Interviews with the MDS nurse and the Director of Nursing confirmed that the facility's process requires follow-up with the PASARR Level II office if no response is received within three days. However, in both cases, the facility did not document any follow-up actions or communications. The facility's policy states that staff should coordinate recommendations from the PASARR Level II determination with resident assessments and care planning, but this was not done for the two residents identified in the report.
Failure to Develop Care Plan for Bed Siderail Use
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing the use of bilateral bed siderails for a resident with multiple diagnoses, including encephalopathy, COPD, and unspecified dementia. The resident was assessed as having severely impaired cognitive skills and required moderate assistance to supervision for activities of daily living. Despite these needs, there was no physician order or care plan in place for the use of bed siderails, as confirmed by a review of the resident's records and care plan documentation. Observations on the specified date revealed the resident lying in bed with the bed siderails up. Both a registered nurse and the director of nursing acknowledged during interviews that a care plan and physician order should have been present for the use of bed siderails, especially since such devices may restrict movement and are considered restraints if the resident cannot remove them independently. Facility policies reviewed also indicated that care plans must be developed for any device that may restrict a resident's movement, but no such plan was found for this resident.
Inaccurate MDS Diagnosis Entry Due to Lack of Supporting Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by inaccurately documenting a resident's diagnosis in the Minimum Data Set (MDS). Specifically, a resident with a history of chronic pulmonary edema, atrial fibrillation, and anxiety disorder was incorrectly assessed as having an active diagnosis of schizophrenia on the MDS. This entry was made without sufficient supporting documentation or evidence that the resident met the diagnostic criteria for schizophrenia as outlined in the DSM-V. The MDS nurse acknowledged that the documentation did not support the diagnosis and that the resident did not exhibit symptoms such as hallucinations or delusions. Interviews with facility staff, including the MDS nurse and the Director of Nursing (DON), confirmed that the required criteria and supporting documentation for a schizophrenia diagnosis were not present. The DON stated that a medical professional's documentation is necessary before such a diagnosis can be recorded in the MDS. The facility's policy requires the interdisciplinary team to conduct accurate and appropriate resident assessments using the MDS, but this process was not followed in this instance, resulting in an inaccurate assessment entry for the resident.
Failure to Ensure Safe Positioning During Geri Chair Mobility
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment and dependence on staff for activities of daily living was observed being transported in a geri chair with their feet dragging on the floor and their head partially unsupported. The certified nursing assistant (CNA) acknowledged during the observation that the resident's position was not good, noting that the feet were dragging and the head was not fully resting on the chair, which could potentially cause harm. The CNA stated she intended to reposition the resident to correct these issues. Further interview with the Director of Nursing (DON) confirmed that residents should be properly positioned in a geri chair, with feet off the ground, body in straight alignment, and head resting on the back of the chair for comfort and safety. Review of facility policy indicated a commitment to maintaining a safe environment and providing supervision and assistance to prevent accidents. The observed failure to ensure proper positioning during mobility represented a lapse in following these standards for resident safety.
Failure to Ensure Proper Positioning in Geri Chair During Resident Transport
Penalty
Summary
Facility staff failed to ensure that a resident was safely positioned while being transported in a geri chair. During an observation, a certified nursing assistant (CNA) was seen pushing a resident in a geri chair with the resident's feet dragging on the floor and the resident's head only partially supported by the headrest, leaving it partially in midair. The CNA acknowledged that the resident's position was not good, noting that the feet were dragging and the head was not fully resting on the chair, and stated an intention to reposition the resident to prevent potential harm. The resident involved had cognitive impairment and was dependent on staff for activities of daily living, as documented in the Minimum Data Set. The Director of Nursing confirmed that residents should be properly positioned in the geri chair, with feet off the ground and the head fully supported, to ensure comfort and prevent injury. The facility's policy emphasized the importance of maintaining an environment free from accident hazards and providing adequate supervision and assistance to prevent accidents.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for two residents. For one resident with severe cognitive impairment and multiple diagnoses including diabetes, dementia, and schizophrenia, the Advance Directive Acknowledgement form was found incomplete, as neither option indicating whether an advance healthcare directive had been executed was checked. This omission was confirmed during a review with the Minimum Data Set Coordinator, who acknowledged the missing information on the form. For another resident, also with severe cognitive impairment and several medical conditions such as diabetes, schizophrenia, bipolar disorder, and Parkinson's disease, a physician's progress note was dated after the resident's discharge. The Director of Nursing verified the discrepancy, noting that the physician often enters notes in batches, which may have led to the error. The physician later confirmed that the incorrect dating was likely a mistake due to high patient turnover. Facility policy requires that all entries, including late entries, be accurately dated in the medical record.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 11 out of 12 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined through observation, interview, and record review. The Client Accommodation Analysis and a room waiver request provided by the Maintenance Director and DON confirmed that the majority of rooms were below the required square footage per resident, with calculations showing most rooms ranged from approximately 71.66 to 78.44 square feet per resident. During general observations, it was noted that both residents and staff had enough space to move about freely, and nursing staff were able to provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Transcribe and Administer Prescribed Anticoagulant Medication
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and administer a prescribed anticoagulant medication, apixaban/Eliquis, for a resident who was admitted from a general acute care hospital. The resident had a documented history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily as part of the hospital physician's transfer orders. Upon review, it was found that the medication was not entered into the facility's Medication Administration Record (MAR) and was not administered during the resident's stay. Interviews with nursing staff revealed that the admitting nurse was responsible for reviewing and reconciling the medication list from the transferring hospital, but the apixaban/Eliquis order was omitted during transcription. The pharmacy did not receive an order for the medication and therefore did not dispense it. The attending physician confirmed that the resident was supposed to be on an anticoagulant and had approved the existing transfer medications, but the omission was not identified until after the resident's transfer to another facility. Facility policy required that all new admission charts be audited within 72 hours and that medication reconciliation be performed to ensure all prescribed medications are accurately transcribed and administered. Despite these policies, the omission of apixaban/Eliquis was not detected during the admission process or subsequent chart audits, resulting in the resident missing prescribed doses of a high-risk medication.
Failure to Transcribe and Administer Prescribed Anticoagulant Following Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete and accurate by not transcribing a prescribed medication, apixaban/Eliquis, from the hospital transfer orders into the facility's records. The resident, who had a history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily, was admitted from a general acute care hospital with clear physician orders for this anticoagulant. However, upon review, there was no entry for apixaban/Eliquis in the resident's order summary report or medication administration record (MAR), and no documentation that the medication was administered during the resident's stay. Interviews with nursing staff revealed that the admitting nurse was responsible for reviewing and reconciling the medication list from the transferring facility, but the medication was not transcribed or administered. The LVN assigned to the resident did not recall seeing an order for a blood thinner and did not administer one. The pharmacy supervisor confirmed that the pharmacy did not receive an order for apixaban/Eliquis and therefore did not dispense it. The RN supervisor acknowledged that the medication reconciliation was not completed due to a shift change, and the resident was transferred to another facility within two days, further complicating the process. The attending physician stated that he had approved the existing medications from the hospital transfer orders, including the anticoagulant, but the omission occurred during the transcription and reconciliation process. The DON confirmed that the medication should have been included in the MAR and administered as ordered. Facility policy required accurate medication reconciliation upon admission, but this process was not followed, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Provide Adequate 1:1 Supervision and Timely Reporting Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls due to severe cognitive impairment, generalized muscle weakness, impaired mobility, and dementia, was not adequately supervised as required by their care plan. The resident had a documented need for 1:1 sitter supervision to prevent falls, as recommended by the interdisciplinary team. However, the assigned CNA was responsible for supervising two residents simultaneously during the overnight shift, contrary to the facility's policy and the care plan's requirements for dedicated, focused supervision. On the night in question, the CNA was not within arm's length of the resident at all times and was unable to immediately assist when the resident attempted to get out of bed. The CNA reported being seated by the door or at the foot of the bed, and when the resident began to get up, the CNA rushed to assist but was not close enough to prevent the resident from lowering himself to the floor. The incident was not immediately reported to a licensed nurse, and there was no documentation of the fall in the sitter log. The CNA also admitted to assisting the resident back to bed with the help of another CNA, without notifying nursing staff as required by facility policy. As a result of the lack of close supervision and failure to follow reporting protocols, the resident sustained a comminuted, mildly displaced intertrochanteric fracture of the left hip. The injury was only discovered later when the resident complained of pain during care, prompting assessment and subsequent transfer to an acute care hospital. The facility's policies on fall prevention, sitter responsibilities, and incident reporting were not followed, contributing to the delay in assessment and intervention for the resident's injury.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, received care and support through informed decision-making, which respects the resident's values, needs, and interests. The deficiency involved the administration of psychoactive medications without obtaining proper informed consent. Resident 2 was admitted with diagnoses including psychosis, depression, anxiety, and Parkinson's disease. Despite being able to communicate needs, Resident 2 was assessed as unable to make medical decisions, with severely impaired cognition noted in the Minimum Data Set. The facility's records indicated that informed consent for several psychoactive medications was obtained, but the documentation lacked the necessary signatures from the resident, a responsible party, or the physician. The facility had applied for probate conservatorship for Resident 2, but the application was denied, leaving the resident without a legal representative or surrogate decision-maker. Interviews with facility staff revealed that the Interdisciplinary Team was making medical decisions for Resident 2, but there was no bioethics committee in place to assist with complex decision-making. The facility's policy for unrepresented residents required referral to a bioethics committee for interdisciplinary case review in situations where non-routine medical decisions were needed. However, this procedure was not followed for Resident 2, as the Director of Nursing confirmed the absence of a bioethics committee. This oversight resulted in a lack of coordinated care planning and delayed complex decision-making for Resident 2, violating the resident's right to informed consent and ethical decision-making in their care.
Failure to Separate Residents After Altercation
Penalty
Summary
The facility failed to immediately separate two residents following a reported allegation of physical abuse, which involved a resident-to-resident altercation. The incident occurred when one resident hit another on the hand. Despite the facility's policy and procedures requiring immediate separation of residents involved in altercations to prevent further aggression, the residents remained in the same room. The Director of Nursing (DON) was informed of the incident shortly after it occurred but decided not to conduct a room change because both residents were cognitively impaired and did not recall the incident. Resident 1, who was involved in the altercation, had been admitted to the facility with diagnoses including dementia, generalized muscle weakness, and metabolic encephalopathy. The resident's Minimum Data Set (MDS) indicated cognitive impairment and a need for partial/moderate staff assistance with activities of daily living. The facility's policy on abuse prevention emphasizes protecting residents from further harm during investigations, which was not adhered to in this case, potentially placing Resident 1 at risk for further abuse.
Failure to Provide Necessary ADL Care by CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) provided necessary activities of daily living (ADL) care for a resident, resulting in unmet toileting and bathing needs. The resident, who was admitted with diagnoses including encephalopathy, urinary tract infection, unspecified dementia, and Alzheimer's Disease, required maximal assistance for ADLs due to severely impaired cognitive skills. Despite the resident's care plan indicating the need for assistance with turning and repositioning every two hours, the CNAs did not perform these duties as required. Interviews revealed that CNA 6, who worked as a sitter, did not perform any ADL care, and CNA 5, who was assigned to the resident, only checked on the resident at the end of the shift. The Director of Staff and Development and the Director of Nursing confirmed that CNAs assigned as sitters are expected to perform ADL care, including checking incontinent briefs and repositioning. The facility's policy and procedure documents also outlined the expectation for CNAs to provide comprehensive resident care, including bathing, repositioning, and maintaining personal hygiene, which was not adhered to in this case.
Failure to Provide Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and services to a resident who required maximal assistance with repositioning and was incontinent of bladder. The resident, who had severe cognitive impairments and was unable to make medical decisions, was not repositioned every two hours as per their care plan. Interviews revealed that a Certified Nursing Assistant (CNA) assigned as a sitter did not perform any activities of daily living (ADL) care, including repositioning, during their shift. Another CNA, who was also assigned to the resident, only checked on the resident at the end of the shift, contrary to the facility's policy that sitters should assist with ADL care. Additionally, the resident was not kept clean to prevent urinary tract infections and skin injury, as required by the facility's policy on urinary incontinence. The Director of Staff Development and the Director of Nursing confirmed that CNAs working as sitters are expected to assist with ADL care, including checking incontinent briefs and repositioning. The facility's policies emphasized the importance of providing care to maintain or improve residents' ability to carry out ADLs and to manage urinary incontinence effectively.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return to their original skilled nursing facility (SNF 1) after being transferred to a general acute care hospital (GACH). The resident, who had a history of anxiety disorder and asthma, was initially admitted to SNF 1 and had the capacity to make medical decisions. Despite this, the resident was transferred to another skilled nursing facility (SNF 2) against their preference. The Admissions Director (AD) claimed not to have received any communication from the GACH regarding the resident's desire to return to SNF 1, and the Administrator admitted there was no documentation indicating the resident did not want to return. The facility's policy required a 7-day bed hold for residents transferred to a hospital, but there was no physician's order for such a hold for this resident. The Director of Nursing (DON) acknowledged that the nurse should have obtained this order and that there was no follow-up with the GACH's Case Manager before the resident was transferred to SNF 2. The facility's policy stated that residents should be allowed to return to an available bed in their previous location, but this was not adhered to in this case, leading to the resident being placed in a different facility without their consent.
Failure to Revise Care Plan for Vision
Penalty
Summary
The facility failed to revise the care plan for vision for Resident 32, who was readmitted with diagnoses including a history of falling, major depressive disorder, and generalized anxiety disorder. The Minimum Data Set (MDS) indicated that Resident 32 wore corrective lenses and had moderately impaired cognition. Despite this, the care plan was not updated to address the resident's missing eyeglasses, which were essential for daily functioning and social activities. The Social Services Director (SSD) confirmed that no care plan was made regarding the missing eyeglasses, and the Director of Nursing (DON) acknowledged the oversight, stating that Resident 32 had difficulty functioning without the eyeglasses and did not socialize or enjoy activities like watching TV and reading due to the lack of corrective lenses. The facility's policy and procedure for comprehensive, person-centered care plans require that measurable objectives and timetables be included to meet the resident's needs. However, this was not followed in the case of Resident 32. The DON admitted that the care plan was not followed up on and should have been revised by the SSD. The failure to update the care plan resulted in a decline in Resident 32's activities of daily living and social interactions, as well as an increased fall risk due to impaired vision.
Failure to Maintain Training Records on Mandated Reporter on Abuse
Penalty
Summary
The facility failed to ensure that training records for mandated reporter on abuse were completed for the year 2022. This deficiency was identified during interviews and record reviews. Licensed Vocational Nurse 3 (LVN 3) and Certified Nursing Assistant 3 (CNA 3) both stated they received annual training on mandated reporter on abuse and knew the procedure to report abuse within two hours to the facility's abuse coordinator, who is the administrator (Adm). However, during an interview, the Adm admitted that the facility could not find the training documents for 2022. The Social Services Director (SSD) also confirmed receiving annual training on mandated reporter on abuse and stated that any abuse allegations should be reported within two hours to the Adm, DON, or any supervisors. A review of the facility's policy and procedures, dated 02/2021, indicated that in-service and training records should be maintained for four years. The absence of the 2022 training documentation indicates a failure to comply with this policy, potentially leaving staff members uninformed about resident rights and facility responsibilities regarding mandated reporting of abuse.
Failure to Provide Corrective Eyeglasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. Resident 32, who has a history of traumatic subarachnoid hemorrhage, abnormalities of gait and mobility, muscle weakness, history of falling, major depressive disorder, and generalized anxiety disorder, was missing their corrective eyeglasses since 03/18/2024. The resident's Minimum Data Set indicated that they wore corrective lenses and had moderately impaired cognition. Despite the resident informing the Social Services Director about the missing eyeglasses and being provided with a pair of reading glasses, these were not suitable as the resident required tri-focal eyeglasses. This led to the resident giving up hobbies such as watching TV and reading newspapers and feeling unsafe due to impaired vision, which increased the risk of falls and social isolation. Interviews with various staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, confirmed that Resident 32 was known to wear eyeglasses all the time and enjoyed activities like watching TV and reading newspapers. However, since the eyeglasses went missing, the resident was no longer engaging in these activities and was observed to be staying in their room more often instead of socializing with other residents. The Director of Nursing also acknowledged the difficulty Resident 32 faced without their eyeglasses, noting that the resident did not go to the dining room to socialize and was at an increased risk of falls. The facility's policy on investigating incidents of theft and misappropriation of resident property indicated that residents have the right to be free from theft and that the facility provides measures to safeguard resident valuables. Despite this policy, the facility did not take timely and effective action to replace Resident 32's missing eyeglasses, leading to a decline in the resident's physical and psychosocial well-being. The Social Services progress notes indicated that the resident's medical power of attorney was involved in the process of obtaining a replacement prescription, but the insurance did not cover the cost, delaying the replacement of the eyeglasses.
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What surveyors actually found near you
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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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Nursing homes near Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Park Healthcare | 0 mi | ★★★★★ | 3 | 0 |
| Westwood Post Acute Care | 1.1 mi | ★★★★★ | 5 | 0 |
| Brentwood Health Care Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Ocean Pointe Healthcare Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Berkley West Healthcare Center | 1.2 mi | ★★★★★ | 13 | 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.