Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Haven Subacute And Healthcare Center during CMS and state inspections, most recent first.
IV access care was not properly documented for three residents receiving IV therapy. One resident with a midline catheter had no admission measurement of external catheter length and the care plan did not include arm circumference or catheter-length monitoring. Two residents with peripheral IVs had unlabeled insertion sites, and one of those lines was also missing RN documentation in the IV MAR/progress notes. Staff confirmed the missing labels and documentation.
Respiratory care was not provided as ordered for one resident, and oxygen equipment was not kept clean or properly dated for several others. A resident receiving continuous O2 was observed at the wrong flow rate, while other residents’ O2 concentrators had visible dust and debris. In addition, one resident’s nasal cannula tubing and humidifier were not dated, and another resident’s tubing was found with an outdated date instead of being changed weekly as required.
Kitchen Sanitation and Equipment Deficiencies: During a kitchen tour, the Cook and surveyor observed multiple dirty food-contact utensils with crusted residue, watermarks, and films; damaged utensils including melted, cracked, and chipped items; heavily marred cutting boards; a wet blender stored with visible water inside; a microwave with crusted food residue and splatters; and a stove hood with black, greasy residue. The Cook acknowledged the findings, and the Administrator and DON were later informed.
Incomplete POLSTs and inaccurate immunization documentation were found for several residents. Two residents had COVID-19 records that showed vaccination entries but the route was documented as if testing had been performed instead of the vaccine being given. Other residents had POLST Section D left blank or marked inconsistently with advance directive acknowledgements and H&P findings, including one resident with no capacity and another with capacity, while social services and nursing staff acknowledged the records were incomplete or inaccurate.
The facility failed to maintain an accurate infection surveillance program and failed to store linens and disposable washcloths in sanitary conditions. The IP relied on antimicrobial use to track infections, did not include residents with signs and symptoms of infection who were not on antibiotics, and the monthly and quarterly CAI/HAI totals were inconsistent. Several residents were misclassified in the surveillance log, including residents listed with bloodstream infections or cirrhosis as an infection, and clean and soiled linens plus disposable washcloths were observed stored improperly.
Incomplete Informed Consent for Psychotropic Medications: The facility failed to obtain or complete informed consent before giving psychotropic meds to two residents. One resident received valproate sodium without documented consent in the chart, and another resident’s consent forms for diazepam, trazodone, Rexulti, and mirtazapine were missing required details such as duration, signatures, and dates. Staff reviewed the records and confirmed the missing consent information.
Failure to maintain a clean and homelike environment in Room A was identified when surveyors observed brownish-gray particles along the base moldings, gray stains on the bathroom floor, and yellow-brown discoloration on the sink. RNA 3 and the Maintenance/Housekeeping Director both verified the findings, and the director stated the areas needed cleaning and that the sink discoloration was from chlorhexidine and a rusted drainer.
A resident with depression and epilepsy received valproate sodium via GT for mood stabilization, but the order did not identify a target behavior and the record did not show nonpharmacological interventions were tried before use. The MDS Coordinator later stated the medication was actually reordered for seizures and that the original mood-stabilizer indication was inaccurate; the resident’s care plan addressed mood disorder, aggressive verbal outbursts, suicidal behavior, and depression.
A resident with depression and epilepsy received valproate sodium via GT as a mood stabilizer, and the care plan included monitoring for psychotropic side effects and adverse reactions such as unsteady gait, dry mouth, and vomiting. However, the medical record lacked documented evidence that staff monitored for these effects, and the MDS Coordinator verified the finding while the Administrator and DON acknowledged it.
A resident with severely impaired cognition and no capacity to make decisions sustained a witnessed fall and was sent to the ED for a head CT after a body check showed no visible injury and the resident denied pain. Surveyors found the SBAR, neuro check, and fall risk documentation were inaccurate, including entries marked not clinically applicable and incorrect use of flowsheet codes, and the fall risk form also failed to reflect the resident’s recent fall.
A resident’s GT care was not provided as observed when the tube was disconnected from the resident, the tubing was hanging on the pump pole without a date, and the tubing tip was uncovered. RN 3 verified the findings and stated the tubing must be dated and capped to prevent infection. The resident had an order for Glucerna 1.5 via GT pump.
Pain Medication Given Outside Ordered Pain Range: A resident admitted to the facility had an order for hydrocodone-acetaminophen PRN only for pain rated 7 to 10, but the MAR showed the medication was administered for pain levels of 5 and 6. An RN confirmed the medication should not have been given for those pain scores, and the DON stated nurses were expected to document pain accurately and administer pain meds as ordered.
A resident with ESRD receiving hemodialysis had an incomplete bedside dialysis emergency kit that lacked a scissor clamp, and the dialysis access sites were not consistently or accurately assessed as ordered. The resident had a tunneled catheter in the left upper chest and an AV fistula in the left upper arm, but nursing documentation repeatedly showed inconsistent access locations and missing bruit/thrill and infection assessments. The DON verified the kit was incomplete, and an RN acknowledged the access should have been assessed and documented correctly.
Medication Storage and Labeling Deficiencies: A resident had a jar of Desitin paste with the resident’s name and room number left at bedside without a documented MD order, rather than secured in a locked med storage area. In addition, an RN and LVN found oral anti-diarrheal meds stored in the same bin as suppositories and enemas, and another medication bin contained bottles of magnesium, vitamins, acetaminophen, and stool softener in a dirty, stained container; staff acknowledged the storage errors and that oral and non-oral meds should not be mixed.
Food Preferences Not Followed for a Resident: A resident with intact cognition received a lunch tray that included tomato even though tomato was listed as a dislike on the meal ticket and was also excluded in the physician’s diet order and care plan. The tray contained buns, breaded chicken, fries, lettuce, and tomato, and the DSS verified that the resident’s diet order and dislikes should have been honored.
Incomplete Antibiotic Stewardship Review: A resident with no capacity to make decisions had a positive urine culture for ESBL and was ordered IV Zosyn. The infection screening form documented some signs and symptoms, but the analysis section was left incomplete and did not state whether McGeer’s criteria were met. There was no documentation that the physician was notified that the resident did not meet criteria, and the IP confirmed the form was incomplete.
COVID-19 vaccination education, offering, and documentation were incomplete for one resident and several staff members. A resident with no capacity to make decisions had a refusal documented, but the record did not identify the representative who refused the vaccine or the staff member who provided education. Staff records also lacked proof of education for an LPN who declined the vaccine, proof of vaccination for a CNA vaccinated outside the facility, and verification of vaccination status for two newly hired staff members.
The facility failed to follow its abuse policy requiring immediate suspension of staff under investigation after a resident with impaired decision-making capacity alleged that one CNA threw her call light and another unplugged it, and staff documented unexplained scratches on the resident’s arm. Both CNAs were scheduled and allowed to work later that day, including one assigned to the resident, and there was no documentation of suspension or complete investigative interviews, such as with the roommate. Leadership reported that the CNAs were cleared based on staff interviews and call light data review, but could not provide records showing suspension or detailed timing of the investigation, resulting in an incomplete abuse investigation before the CNAs returned to work.
The facility did not ensure RNs were properly trained or assessed for competency in reconstituting and administering IV medications, resulting in a medication error involving amphotericin B that contributed to the death of a resident with severe fungal infection and respiratory failure. The RN involved had not received training on the medication, did not verify the product or dosage, and was not signed off for competency in IV medication preparation.
A resident with a complex medical history received a fatal overdose of amphotericin B after the pharmacy dispensed the wrong formulation and a nurse failed to verify the medication against the physician's order. The nurse administered over three times the maximum recommended dose at an excessive rate and concentration, resulting in the resident's rapid decline and death. The pharmacy also failed to label the medication as high alert, and facility policies for medication verification were not followed.
A resident with mild oropharyngeal dysphagia and a physician-ordered mechanical soft, chopped diet was served long pieces of napa cabbage instead of chopped vegetables as required. Staff, including an LVN, the DSS, and the Speech Therapist, confirmed that the vegetables did not meet the prescribed size and texture, despite clear orders and facility policy.
Surveyors found that expired and unlabeled medications, as well as unclean and unsanitary supplies, were not removed from multiple medication carts. Medications for internal and external use were stored together, and medication carts and treatment supplies were left unlocked and unattended. Expired medical and breathing supplies were found unsecured in a closet, and bedside medications were left on a resident's cabinet without proper documentation or secure storage. Staff interviews confirmed a lack of awareness and inconsistent adherence to facility policies regarding medication and supply storage.
Surveyors identified multiple failures in the infection prevention and control program, including inaccurate infection surveillance documentation, improper classification of infections, inconsistencies between surveillance logs and screening forms, and incomplete infection mapping. Environmental sanitation issues were observed, such as unsanitary storage of clean linens and resident personal items, and lapses in infection control practices for residents with indwelling medical devices, including catheter bags touching or dragging on the floor and missing evidence-based practice orders for a resident with a permacatheter.
A resident was found self-administering Alphagan eye drops without a physician's order, self-administration assessment, or care plan in place. Facility staff confirmed that these requirements were not met, despite facility policy mandating them for safe self-administration of medications.
A resident with no decision-making capacity received repeated PRN lorazepam orders for anxiety, but the facility did not document the physician's clinical rationale for extending these orders beyond 14 days, as required by policy. Medical records and staff interviews confirmed the absence of this documentation despite multiple renewals and administrations of the medication.
The facility did not develop care plans for two residents' use of medical devices, including padded side rails, an IV device, and a sequential compression device, as well as for a third resident's diabetes management and related medications. Staff confirmed these omissions during interviews, and medical record reviews showed the care plans lacked these essential interventions.
A resident with documented interests in watching TV and listening to music was frequently observed awake in bed without access to these activities, as the TV was either off, lacked sound, or the remote was out of reach. Staff did not consistently assist the resident in accessing preferred activities, despite care plan interventions specifying the need for individualized engagement, leading to unmet psychosocial needs.
A resident with multiple diagnoses and no decision-making capacity developed a hand wound that was observed by staff but not documented, reported to the physician, or communicated to the responsible party, despite care plan requirements. Staff acknowledged the wound and applied ointment but failed to follow reporting and documentation protocols.
Two residents with significant mobility impairments did not consistently receive restorative nursing care as ordered, including ROM exercises and application of splints. Documentation was incomplete or missing for several days, and staff could not confirm whether care was provided or simply not recorded. Observations found required splints not in use, and there was no evidence of resident refusal. Staff cited documentation issues and oversight during a system transition as contributing factors.
A resident experienced significant weight loss over a three-month period, and the facility failed to ensure the RD's nutritional recommendations were communicated to the physician or addressed by the IDT. The resident's weight status was not monitored as required, and interviews with the ADON and Food & Nutrition Services Director confirmed that proper tracking and intervention did not occur.
Surveyors found that two residents receiving enteral tube feedings did not have their head of bed (HOB) elevated to the required 30 degrees or above during feedings, as ordered by physicians and facility policy. Additionally, expired enteral feeding formula bottles were found stored in the subacute storage unit. Nursing staff and the DON confirmed these lapses in care and policy adherence.
Two residents did not receive proper respiratory care when staff failed to change and label nebulizer equipment and suction devices as ordered, and did not provide the correct type of emergency tracheostomy set for a resident on mechanical ventilation.
The facility failed to ensure proper documentation and administration of controlled medications, including hydrocodone-acetaminophen and tramadol, and did not adhere to physician orders for medication parameters and patch removal for several residents. Medications were administered without proper narcotic record documentation, a controlled medication was stored without a count sheet, a lidocaine patch was not removed as ordered, and medications were given outside of prescribed blood pressure and blood glucose parameters.
Surveyors observed multiple food safety and sanitation deficiencies, including improper storage of cleaning solutions near food, personal items in food storage areas, and unlabeled or expired food items in the kitchen and refrigerators. The Food & Nutrition Services Director was unable to provide required information on several food items, and these practices did not align with facility policies.
Surveyors identified failures in maintaining accurate quality control records for glucometers, improper use of whiteout to correct documentation, and medication refrigerator temperatures exceeding required limits. Additionally, ice buildup was observed in the kitchen walk-in freezer, with all findings verified by facility staff.
A resident with end stage renal disease and multiple catheters did not have complete documentation in the medical record for required catheter care and Quinton catheter monitoring on two PM shifts. Both an LVN and the ADON confirmed the missing entries, acknowledging that the care may have been provided but was not documented, resulting in an incomplete clinical record.
A resident with severe cognitive impairment did not have a copy of their advance healthcare directive obtained or filed in the medical record, despite facility policy and a POLST form indicating its existence. Staff interviews confirmed the document was not present, though a financial power of attorney was on file.
A staff member was observed adding low sodium broth instead of the required warm milk to pureed potatoes prepared for nine residents on pureed diets, including two on no added salt diets. This action did not follow the facility's established recipe, as confirmed by document review and staff verification.
Surveyors observed that pureed meals, served to nine residents, were prepared with lumps and excess water, failing to meet the required smooth consistency. The puree salad was also served at 60°F, which was not considered appetizing, and the temperature was not documented after cooling. The Food and Nutrition Services Director could not explain the issues with the salad's appearance or temperature.
The facility failed to ensure proper hand hygiene and glove use when handling ready-to-eat food, affecting 59 residents. An observation revealed a cook scratching his face with a gloved hand and then handling food without changing gloves or washing hands. Interviews confirmed staff were aware of proper procedures but did not consistently follow them.
The facility failed to ensure proper disinfection of glucometers according to the manufacturer's instructions, leading to potential spread of bloodborne pathogens. Observations and interviews revealed that staff were not following the correct disinfection procedures, and there was a general misunderstanding of the instructions for the disinfectant wipes used.
A resident with asthma and COPD self-administered three puffs of an inhaler instead of the prescribed one puff due to the failure of an LVN to follow physician's orders and facility policy. The resident was not assessed for self-administration, and no physician's order was obtained to allow it.
A facility failed to ensure that only licensed staff documented medications they administered. An LVN administered medication to a resident but did not document it, leading another LVN to sign the MAR incorrectly. This was confirmed by both LVNs and the DON, who stated that the practice was against facility policy.
IV access documentation and labeling failures
Penalty
Summary
The facility failed to provide the necessary care and services to maintain IV access for three residents reviewed for IV therapy. For Resident 100, who had no capacity to understand and make decisions, the medical record showed a physician order to measure arm circumference on admission and every seven days during dressing changes and to measure the external catheter length of the left upper arm midline catheter. However, the record did not show the midline external catheter measurement upon admission, and the care plan did not include interventions to measure the resident’s arm circumference or external catheter length. RN 1 confirmed the missing documentation and stated the external catheter length should have been measured to monitor catheter placement and dislodgement. For Resident 13, who had capacity to understand and make decisions, the record showed a physician order to start a peripheral IV and administer IV sodium chloride for hydration. RN 1 documented insertion of a peripheral IV on the back of the left hand with good blood return and that the resident tolerated the procedure well. When the resident was observed with the IV line in place, the site had no label showing the date, time, or staff initials. LVN 1 verified the missing label, and RN 1 stated the IV site must be labeled with the date, time, and initials when the catheter is inserted so it can be tracked for change timing. For Resident 34, who had no capacity to understand and make decisions and had severe cognitive impairment with a BIMS score of zero, the record showed orders for IV ceftriaxone and for a peripheral line. The resident was observed with a peripheral IV in the right hand that had no label with the date, time, or staff initials. RN 3 verified the unlabeled line and stated it should be labeled after insertion. The IV MAR also did not show documentation of the peripheral line insertion, and RN 5 stated that after insertion the documentation must be completed. The DON confirmed that the peripheral line had been started but was not documented in the progress notes and/or IV MAR.
Respiratory Care and Oxygen Equipment Not Managed as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents receiving oxygen therapy. Surveyors identified that Resident 21, who had chronic encephalopathy, cerebellar stroke, was bed bound, and non-verbal, had a physician order for continuous oxygen at 3 liters per minute via nasal cannula every shift, but was observed receiving oxygen at 0.5 liters per minute instead of the ordered 3 liters per minute. The resident’s care plan also directed continuous oxygen via nasal cannula at 3 liters per minute. During the observation and concurrent record review, facility staff confirmed the physician’s order should have been followed. The facility also failed to maintain oxygen concentrators in a clean and sanitary condition for Resident 4, Resident 42, and Resident 68. Resident 4 was receiving humidified oxygen via T-bar to a tracheostomy, Resident 42 was receiving humidified oxygen via tracheostomy mask, and Resident 68 was receiving humidified oxygen via tracheostomy mask. In each case, the oxygen concentrator was observed with dust-like particles, including white and black particles around the flow meter area, dust on the top or back of the machine, and hairlike particles on the concentrator. Staff members acknowledged the equipment was dirty and stated it should be clean for infection control, while the infection preventionist stated the oxygen concentrators should be cleaned regularly. The facility further failed to follow its oxygen equipment dating and replacement process for Resident 45 and Resident 35. Resident 45, who had capacity to understand and make decisions and was receiving oxygen continuously via nasal cannula, had oxygen tubing and a humidifier that were not labeled with a date to show when they were last changed. Resident 35, who had no capacity to understand and make decisions and had severely impaired cognition, was observed with oxygen tubing dated 6/30/26 even though the tubing was 12 days past that date. Facility staff confirmed the tubing should be labeled and changed weekly, and the report states the tubing for ventilators and oxygen must be changed weekly and as needed.
Kitchen Sanitation and Equipment Deficiencies
Penalty
Summary
The kitchen was found to have multiple sanitation and equipment issues during an initial tour with the Cook. Several food portioning utensils were observed dirty, including stainless steel scoops, ladles, spatulas, knives, tongs, and a rubber spatula, with dry, crusted residue, fuzzy films, dry watermarks, and in one case discoloration and staining. The Cook verified the findings and stated the dirty utensils and kitchenware should have been rewashed and cleaned to prevent contamination. The kitchen also contained utensils and food-contact items that were not in good repair. Two stainless steel scoops with gray handles were partially melted, a stainless steel whisk with a gray-greenish handle was partially cracked, a stainless steel spatula with a black handle was partially melted, and a rubber spatula with a red handle had a chipped edge. The Cook verified these findings and stated the worn-out kitchen utensils and kitchenware should have been replaced. Additional observations showed a green, brown, and blue cutting board that were fuzzy, heavily marred, and had deep grooves and pits. A heavy-duty blender used for puree preparation was stored wet with visible water inside. The kitchen microwave used to warm residents’ food was dirty with dry, crusted food residue in the door and dry food splatters inside. The hood over the stove had black, greasy residue. The Cook acknowledged the findings and stated the microwave was cleaned once a day and the hood was cleaned weekly and by an outside company every three months. The Administrator and DON were later informed and acknowledged the findings.
Incomplete POLSTs and inaccurate immunization documentation
Penalty
Summary
The facility failed to maintain accurate medical records for five sampled residents by leaving POLST and advance directive information incomplete or documenting COVID-19 immunization status inaccurately. Review of facility documentation showed the clinical record was expected to be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition, and the immunization policy required COVID-19 vaccination details to be documented in the resident's medical record when administered. For Resident 3 and Resident 12, the immunization records showed they were administered the COVID-19 vaccination, but the route of administration was documented as "in both nostrils." The IP reviewed the records with surveyors and stated the licensed staff member who documented the entries had tested the residents for COVID-19 rather than administering the vaccination. The IP also stated COVID-19 testing was not the same as administering the vaccination and that accurate documentation was needed to correctly monitor immunization status. For Resident 54, the POLST dated 2/14/26 left Section D, Information and Signatures, blank even though the Advance Healthcare Directive Acknowledgment form stated the resident had no advance directive and was unable to complete one, and the H&P stated the resident had no capacity to understand and make decisions. For Resident 6, the POLST checked that an advance directive was not available and that VA had it, but the Advance Directive Acknowledgement form stated the resident did not have an advance directive and did not want to formulate one at that time; the H&P also stated the resident had no capacity to understand and make decisions. For Resident 45, the POLST Section D was left blank even though social services notes showed the resident did not have an advance directive and the H&P stated the resident had capacity to understand and make decisions.
Infection Surveillance and Linen Storage Failures
Penalty
Summary
The facility failed to maintain its infection prevention and control surveillance program from January through June 2026. The infection surveillance process was based on whether residents were prescribed antimicrobial medications, and the infection preventionist stated that residents who had signs and symptoms of infection but were not prescribed antimicrobials were not included in surveillance. The infection preventionist was unable to identify how many residents had infections during that period without antimicrobial prescriptions. The monthly surveillance logs also did not match the quarterly summaries for January through March 2026, with inconsistent totals for CAIs and HAIs across the South Unit and Subacute Unit records. The facility also inaccurately documented several residents’ infections in the surveillance log. Resident 34 was listed with a blood infection and sepsis, but the infection screening evaluation did not show that the bloodstream infection met McGeer’s criteria, and the resident was transferred to an acute care hospital the same day the evaluation was completed. Resident 12 was listed with a UTI with an indwelling urinary catheter and also a blood infection with sepsis, but the medical record did not show an infection screening evaluation. Resident 79 was also listed with a blood infection and sepsis, but the medical record did not show an infection screening evaluation, and the acute care hospital record showed sepsis related to acute hypoxic respiratory failure with concern for pneumonia. The infection preventionist later verified that Residents 12, 34, and 79 should not have been categorized as bloodstream infections due to sepsis, but instead should have been categorized by the source of infection that led to sepsis. Resident 91 was listed in the surveillance log with cirrhosis categorized as an infection, although the infection preventionist confirmed cirrhosis was not a CAI and that the resident had been included because of rifaximin use. The facility also failed to maintain linen and supply storage in sanitary conditions. A shelf containing clean curtains was observed not fully covered in the laundry area and central supply room. An uncovered hamper containing soiled linens was observed stored in the hallway in front of Nurses’ Station B. In a resident room, two packs of disposable washcloths were observed placed on top of a trash bin near the door, including one pack that was unwrapped. Staff who were interviewed verified that the clean washcloths and the soiled linen hamper were not stored appropriately and should not have been left in those locations.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained and completed with the required information before psychotropic medications were administered to two residents. The report states that the facility’s policy required consent prior to initiation of a new psychoactive medication and that the prescriber must share material information needed for a resident or representative to make a treatment decision, including nonpharmacologic approaches, boxed warnings, approved or unapproved use, drug interactions, and monitoring for adverse effects. For one resident, who had no capacity to understand and make medical decisions, the record showed an order for valproate sodium as a mood stabilizer with documentation that risk and benefits were explained and informed consent was obtained from a family member. However, the medical record did not contain documented evidence that informed consent for the valproate sodium was actually obtained before the medication was administered. The resident received the medication multiple times during the review period, and facility staff, including the MDS Coordinator, ADON, and DON, reviewed the record and could not find the consent. For another resident, the record showed orders for diazepam, trazodone, Rexulti, and mirtazapine for anxiety, depression, poor intake, and psychosis-related behaviors. The Psychotherapeutic Drug Informed Consent forms for these medications were incomplete: several did not include the duration of therapy, some did not have the consent section checked, and some were missing the resident or representative name, signature, and date. Staff reviewed the forms and verified that the required consent information was missing.
Failure to Maintain Clean and Sanitary Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in Room A. During an environmental round, surveyors observed accumulation of brownish, grayish particles along the base moldings, gray stains on the floor between the sink and the toilet in the bathroom, and yellow brown discoloration above the drain stopper of the bathroom sink. The report states this was found in one of 37 rooms and that the condition posed a serious risk to residents' health and safety. The facility's Housekeeping Services policy stated that non-carpeted floors and other horizontal surfaces are to be cleaned daily and more frequently if there is spillage or visible soiling. RNA 3 verified the floor particles and gray stains and stated he would call housekeeping to take care of it. The Maintenance/Housekeeping Director also verified the findings in Room A, acknowledged that the particles and stains needed to be cleaned, and stated the sink discoloration was from chlorhexidine and a rusted drainer; he further stated he would get a pumice to scrub it. The Administrator and DON were informed and acknowledged the findings.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one of five sampled residents reviewed for unnecessary medications was free from unnecessary psychotropic medication use. Resident 9 had diagnoses of depression and epilepsy and was documented as having no capacity to understand and make medical decisions. The physician order dated 3/27/26 directed valproate sodium 250 mg/5 ml, 2.5 ml via GT every six hours as a mood stabilizer, and informed consent was obtained from a family member after the risks and benefits were explained by the physician. However, the order did not identify a target behavior for the medication, and the record did not show documented evidence that nonpharmacological interventions were implemented before the medication was used. Resident 9’s care plan addressed mood disorder with aggressive verbal outbursts, history of suicidal behavior, and depression, and included interventions to administer valproate sodium as ordered and to monitor for anger, labile mood, agitation, feeling threatened, thoughts of harming someone, and possession of objects that could be used as weapons. During interview, the MDS Coordinator stated the medication was being used to stabilize the resident’s mood, then later stated the physician reordered it with an indication for seizures and that the original indication as a mood stabilizer was inaccurate. The MDS Coordinator also verified that nonpharmacological interventions were not implemented prior to the use of valproate sodium.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
Resident 9’s medical record did not show documented evidence that the facility monitored side effects and possible adverse reactions related to valproate sodium use. Resident 9 was admitted and later readmitted to the facility, had diagnoses of depression and epilepsy, and the H&P stated the resident had no capacity to understand and make medical decisions. A physician ordered valproate sodium 250 mg/5 ml, 2.5 ml via GT every six hours as a mood stabilizer, and the MAR showed the medication was administered from 7/1/26 through 7/15/26. The resident’s care plan, dated 3/29/26, identified a mood disorder with aggressive verbal outbursts, a history of suicidal behavior, and depression. The interventions included monitoring, recording, and reporting increased anger, labile mood or agitation, feeling threatened by others or thoughts of harming someone, possession of objects that could be used as weapons, and observing for side effects and adverse reactions of psychotropic medication such as unsteady gait, dry mouth, and vomiting. Despite this care plan direction, the record did not contain documented evidence that the facility monitored for side effects or possible adverse reactions related to the valproate sodium medication. During interview and record review, the MDS Coordinator stated that psychotropic medication care plans should include monitoring for side effects and verified the findings, and the Administrator and DON acknowledged the findings.
Inaccurate Post-Fall Assessment and Fall Risk Documentation
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent further falls and injuries for one resident reviewed for falls. The deficiency centered on an inaccurate post-fall assessment after the resident had a witnessed fall while getting up from a wheelchair and landing on the floor on the left side, face down. The change of condition report documented that a body check was completed with no bruise, swelling, or forehead abrasion noted, the resident denied pain, and the PCP was notified before the resident was transferred to the ED for a head CT scan. Review of the post-fall documentation showed the SBAR communication form and progress note marked the skin evaluation and neurological evaluation as not clinically applicable to the change in condition. The neurological assessment flowsheet also contained inaccurate entries, including check marks placed under pupil response where no such option existed and check marks entered for hand grasp documentation in a manner that did not match the codes provided on the form. The report stated the codes on the flowsheet were not used appropriately, making the assessment inaccurate. The resident had a fall risk score of 6 documented in a progress note, and the fall risk evaluation dated the same day indicated the resident had no falls in the past three months even though the resident had just sustained a fall. The resident’s H&P stated the resident had no capacity to understand and make decisions, and the MDS showed a BIMS score of 3, indicating severely impaired cognition. During interview, RN 1 reviewed the documentation and stated the assessments were inaccurate, and the DON and Administrator acknowledged that the neurological check, SBAR, and post-fall assessments must be completed and documented accurately.
GT Tubing Left Undated and Uncovered
Penalty
Summary
Facility failed to provide necessary GT care and services for Resident 34. During the initial tour, Resident 34 was observed lying in bed asleep with the GT disconnected from the resident, while the GT tubing was hanging on the pump pole without a date and the tubing tip was uncovered. Medical record review showed an order for Glucerna 1.5 calories via GT pump at 65 ml per hour for 20 hours to provide 1300 ml per 1950 calories. During a concurrent observation and interview, RN 3 verified that the GT tubing was undated and the tubing tip was uncovered, and stated the tubing must be dated and the tip must have a cap to cover it to prevent infection. The Administrator and DON were later informed and acknowledged these findings.
Pain Medication Given Outside Ordered Pain Range
Penalty
Summary
The facility failed to ensure that Resident 101’s pain medication was administered according to the physician’s order. The resident was admitted on 6/29/26, and the order audit report showed hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every six hours as needed for pain rated 7 to 10, with instructions to hold the medication if the respiratory rate was below 12 breaths per minute or if the resident was sedated. Review of the MAR for June and July 2026 showed the medication was given on 6/30/26 at 0941 for a pain level of 5 and on 7/1/26 at 2032 for a pain level of 6, even though the order specified use only for pain rated 7 to 10. During the 7/13/26 interview and concurrent record review, RN 1 confirmed the medication should not have been administered for pain levels of 5 to 6 and verified the findings. The DON stated she expected licensed nurses to accurately document the resident’s pain level and administer pain medication as ordered by the physician.
Incomplete Dialysis Kit and Inconsistent Access Assessments
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with ESRD who received hemodialysis outside the facility. The resident had a left upper chest tunneled hemodialysis catheter and a left upper arm AV fistula, and the care plan and physician orders required daily and every-shift assessment of the dialysis access sites, including checking the AV fistula for bruit and thrill and monitoring the catheter for signs of infection, bleeding, bruising, redness, swelling, warmth, or drainage. During observation, the dialysis emergency kit kept at the resident’s bedside was found in a clear labeled bag containing gauze dressing and paper tape, but it did not include a scissor clamp. The DON verified that the kit was incomplete and stated it did not include a clamp scissor. Facility policy required assistance in maintaining homeostasis pre- and post-dialysis, assessment and maintenance of dialysis access patency, and daily assessment of the renal dialysis access, with documentation of the condition of the access site. Review of the dialysis communication records showed multiple instances where the access site was documented inconsistently or not assessed as ordered. Entries alternated between the left upper chest catheter and the left upper arm AV fistula, and several records showed no documented bruit and thrill assessment, no documented signs of infection, or incomplete pre- and post-dialysis assessments. RN 1 acknowledged that the catheter was on the left upper chest and the AV fistula was on the left upper arm and stated the access should have been assessed and documented correctly. The Administrator and DON were informed of the findings.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. During an initial tour, Resident 85 was observed in bed, awake and non-verbal, receiving oxygen via tracheostomy mask from an oxygen concentrator, and a jar of Desitin maximum strength paste with the resident’s name and room number handwritten on it was found on top of the resident’s nightstand. The resident’s order summary did not show a physician’s order for the Desitin paste, and the medication was present at bedside rather than secured in a locked medication storage area. An LVN later confirmed the jar was at the bedside and stated there should be no medications at bedside. The medication storage room inspection also found oral medications stored together with non-oral medications. In Medication Storage Room B, a bin contained oral anti-diarrheal medication boxes mixed with acetaminophen suppositories and enemas, and staff confirmed these items should not be stored together. The same room inspection found bottles of magnesium, Renavite, acetaminophen, and stool softener stored in a blue bin with brown and white stains at the base, and staff acknowledged the bin was dirty. The facility’s policy stated oral medications are to be kept separate from externally used medications and storage areas are to be kept clean, well-lit, and free of clutter.
Food Preferences Not Followed for a Resident
Penalty
Summary
The facility failed to ensure that Resident 5’s food preferences were followed when her lunch tray included tomato, even though tomato was listed as one of her dislikes on her meal ticket. During a dining room observation on 7/12/26 at 1218 hours, Resident 5 was sitting on her bed with a lunch tray on the overbed table that contained buns, breaded chicken, fries, lettuce, and tomato. Review of the meal ticket showed dislikes of orange juice, oranges, tomatoes, banana, honeydew, cantaloupe, milk or milk products, and fried foods. Resident 5 was admitted and later readmitted to the facility, and her annual MDS showed a BIMS of 15, indicating intact cognition. Her order summary for 7/2026 included physician orders dated 11/1/25 for a CCHO, NAS, regular, renal-restricted diet with no milk or dairy products, oranges, tomatoes, banana, cantaloupe, honeydew, and no fried foods. Her nutritional care plan dated 7/1/25 also directed staff to provide that diet and honor resident rights to make personal dietary choices. The DSS was informed of the observation and verified that although the resident was non-compliant with her diet, the diet order should have been followed and the resident’s dislikes should have been honored.
Incomplete Antibiotic Stewardship Review
Penalty
Summary
The facility failed to accurately determine whether Resident 2’s prescribed Zosyn met McGeer’s criteria. Resident 2 was admitted and later readmitted to the facility, had no capacity to understand and make decisions, and had a urine culture that was positive for ESBL. Based on the SBAR Communication Form, the physician was informed of the positive urine culture and ordered Zosyn intravenously for seven days. Review of Resident 2’s Infection Screening Evaluation showed that several items were checked as present, including age over the listed threshold, current active diagnosis of infection, myalgia, and urinary incontinence, while the resident was afebrile, had no indwelling catheter, no new onset of hypotension, and no elevated pulse or respiratory rate. However, the analysis section of the form was incomplete and did not state whether McGeer’s criteria were met. There was also no documentation that the physician was notified that Resident 2 did not meet McGeer’s criteria. The IP confirmed the form was incomplete and stated she was responsible for monitoring antibiotics and determining whether residents met McGeer’s criteria.
COVID-19 Vaccination Education and Documentation Not Completed
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination education, offering of the vaccine, and documentation were completed for one sampled resident and four of eight sampled staff members. Facility policy stated that residents and staff were to be educated on the risks and benefits of the COVID-19 vaccine, offered the vaccine, and have vaccination status documented in the medical record or employee record. The report also noted that the facility was to document refusals, medical contraindications, and education provided. For the resident reviewed, the medical record showed the resident had no capacity to understand and make decisions. The resident’s COVID-19 immunization record showed that the representative refused the vaccine, but the record did not identify which staff member provided the education or identify the representative who refused the vaccine. A separate consent form showed the resident did not wish to receive the COVID-19 vaccine, but it did not include the representative’s name, signature, or date for the refusal. The IP confirmed that the documentation was missing the representative’s name and the staff member who provided education. For staff, the facility used a worksheet to track vaccination status, but the record reviewed did not include documentation that one LPN who declined the vaccine was educated on the benefits and risks, and it did not include proof of vaccination for one CNA who reportedly received the vaccine outside the facility. Two newly hired staff members were listed as vaccinated based on what they stated at hire, but the IP stated their vaccination status was not verified. HR Payroll stated the facility stopped verifying COVID-19 vaccination status for newly hired staff in 2025 because they were told the information was not needed.
Failure to Suspend and Thoroughly Investigate Staff After Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and investigation policy after a resident alleged abuse by two CNAs. The facility’s policy, revised in 12/2023, required that when an allegation of abuse involving an employee is received, the employee must be immediately removed from the care of any resident and suspended during the pendency of the investigation, while the Administrator ensures residents are protected from physical and psychosocial harm. On 4/9/26 at 1050 hours, a SOC 341 documented that Resident 6 alleged that one CNA threw her call light at her and another CNA unplugged her call light. The facility’s records showed both CNAs were scheduled to work at 1500 hours that day, with one of them assigned to Resident 6, yet there was no documentation that either CNA was suspended as required by policy. Resident 6’s medical record showed she was admitted and later readmitted to the facility, with a history and physical dated 9/25/25 indicating she was alert, but a physician’s progress note dated 4/9/26 documented that she had no capacity to understand and make decisions. On 4/9/26, CNA skin observations and an IDT progress note documented two horizontal scratch marks on the inner right forearm, with the resident stating she did not know how the scratches occurred. Despite these findings and the abuse allegations, interviews and document reviews confirmed that both CNAs worked their scheduled shifts on 4/9/26, including the CNA assigned to Resident 6, and there were no Counseling/Disciplinary Notice forms or other documentation in their employee files indicating suspension. During interviews, the DSD confirmed that the facility used Counseling/Disciplinary Notice forms for suspended staff but none existed for the two CNAs, and acknowledged that both CNAs worked on 4/9/26 at 1500 hours. The Administrator stated that both CNAs were “cleared” to work before their shifts based on interviews with other staff and review of call light data, but also verified that the facility’s Summary of Investigations did not show the times of interviews and investigations. The Administrator further acknowledged that he did not interview Resident 6’s roommate at the time of the initial investigation and stated he should have followed up. The DON reported that the call light investigation was done before the police arrived and that the CNAs were suspended and cleared before that time, but was unable to provide documentation to show that suspensions occurred, and the Administrator and DON ultimately acknowledged the findings that the abuse allegations were not thoroughly investigated before allowing the CNAs to return to work.
Failure to Ensure RN Competency in IV Medication Preparation and Administration
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) were properly trained and competent in the preparation and administration of intravenous (IV) medications, specifically regarding the reconstitution of IV medications and the administration of amphotericin B. The Nursing Skills Competency Checklist for RNs did not include reconstitution of IV medications as a required competency, and RN 3 had not received training or been signed off as competent in this area. Additionally, RN 3 administered amphotericin B for the first time without researching the medication or recognizing the difference between amphotericin B and amphotericin B liposomal (AmBisome), as ordered by the physician. A resident with a history of mucormycosis, respiratory failure, tracheostomy, and ventilator dependence was ordered to receive amphotericin B liposomal (AmBisome) 350 mg in dextrose 5% 250 ml IV. The pharmacy delivered amphotericin B 50 mg vials and dextrose 5% solution to RN 3, who then administered the medication without verifying the specific product or dosage warnings. The packaging of the amphotericin B delivered did not match the physician's order, and RN 3 did not double-check the medication or consult additional resources prior to administration. This resulted in a medication error that contributed to the resident's death. Interviews with facility staff revealed that RNs had not been observed or signed off for competency in reconstituting IV medications, and the Director of Nursing (DON) expected nurses to look up unfamiliar medications but did not ensure this was done. The Clinical Consultant confirmed that RNs should have been trained and signed off for competency before reconstituting IV medications, but this had not occurred. The lack of proper training and competency assessment for IV medication preparation and administration led directly to the medication error and adverse outcome.
Medication Dispensing and Administration Error Leads to Resident Death
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, resulting in a significant medication error. The pharmacy dispensed conventional amphotericin B instead of the prescribed amphotericin B liposomal (AmBisome), which are different formulations with distinct dosing requirements. The physician's order specified amphotericin B liposomal 350 mg in 250 ml D5W to be administered over two hours, but the pharmacy delivered seven vials of amphotericin B 50 mg each, along with a 250 ml bag of D5W. The medication delivered did not match the physician's order, and the packaging included a warning that the maximum daily dose should not exceed 1.5 mg/kg, which was not observed. The nurse (RN) who administered the medication did not recognize the difference between the two formulations and prepared the entire 350 mg dose of amphotericin B in 250 ml D5W, administering it at a rate of 125 ml/hr. This resulted in the resident receiving over three times the maximum recommended dose of amphotericin B, at a concentration and rate higher than recommended by the manufacturer. The nurse did not double-check the medication label against the physician's order, nor did he research the medication prior to administration, despite the packaging containing a clear warning about dosing limits. The nurse also stated this was the first time he had administered amphotericin B and did not notice the discrepancy in medication names. The resident, who had a history of mucormycosis, respiratory failure, a tracheostomy, and was ventilator dependent, experienced a rapid deterioration in condition shortly after the infusion began and was found without a pulse a few hours later. The pharmacy's Chief Compliance Officer confirmed the error in dispensing and noted that the medication was not labeled with a high alert warning as required for high-risk medications. The Director of Nursing acknowledged that the nurse did not follow the facility's policy for verifying the right medication and dose prior to administration.
Failure to Provide Chopped Vegetables as Ordered for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual dietary needs of a resident with a physician-ordered mechanical soft, chopped diet. The resident, who had mild oropharyngeal dysphagia and reduced dentition, was observed during lunch receiving long pieces of napa cabbage, exceeding one inch in size, instead of the required chopped vegetables of approximately half an inch. The meal ticket and physician orders specified chopped meats and vegetables, and the facility's policy for dysphagia mechanical diets also required cooked vegetables to be chopped to about half an inch and soft to a mashable texture. Multiple staff, including an LVN, the Dietary Services Supervisor (DSS), and the Speech Therapist, confirmed that the vegetables served did not meet the prescribed dietary modification. The DSS and Speech Therapist both verified that the vegetables should have been chopped to thumbnail size, and the LVN acknowledged the discrepancy between the meal ticket and the food served. The resident's medical record and therapy notes supported the need for a mechanical soft, chopped diet to facilitate ease of swallowing.
Medication and Supply Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and medical supplies throughout the facility. Observations revealed that expired medications and supplies were not removed from several medication carts, including Medication Carts A, B, D, and E. In some instances, supplies were found to be unclean, with dust and residue present in trays and on equipment. Additionally, medications were found without proper labeling, and internal and external medications were stored together in the same compartments, contrary to facility policy and accepted professional standards. Further inspection showed that medication carts and treatment supplies were left unlocked and unattended, allowing potential unauthorized access. In one case, a medication cart was observed parked in a hallway, unlocked and unattended. Treatment supplies were also left unsupervised at a resident's bedside during care, and staff interviews confirmed that this was a common practice. In another instance, a can of orange juice without an expiration date was found in a medication room snack drawer, and bedside medications were observed on a resident's cabinet without proper documentation or secure storage. The facility also failed to ensure that medical, breathing, and treatment supplies were properly secured and stored. Large quantities of expired supplies, including skin protectant ointments, normal saline, and tracheostomy supplies, were found in an unlocked closet adjacent to a resident's room, exposed to dust and debris. Staff interviews indicated a lack of awareness regarding the proper storage and monitoring of these items, and some staff cited past supply shortages as a reason for improper storage. The facility's policies required that all medications and supplies be stored securely, labeled appropriately, and kept clean and sanitary, but these standards were not consistently met.
Infection Control Program Deficiencies and Environmental Sanitation Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, documentation, and environmental sanitation. The Infection Preventionist (IP) did not accurately document the onset of infection symptoms, instead recording the antibiotic start date as the onset date for all residents on the surveillance logs. Additionally, infections were not properly classified as healthcare-associated (HAI) or community-acquired (CAI), with some being marked as recurrent, maintenance, or prophylactic without supporting documentation. The surveillance logs and infection screening evaluation forms contained inconsistent information, and the monthly mapping of infections did not include all cases or specify the microorganisms involved. Environmental observations revealed unsanitary storage of clean linens and resident personal items. In the laundry area, clean linens were stored near non-linen items such as keys, water bottles, and cleaning supplies, and clean curtains were not fully covered. Resident closets in multiple rooms contained exposed and disorganized diapers, gowns, and linens, some of which were stored on the floor or in contact with potentially contaminated surfaces. These conditions were verified by staff during interviews and acknowledged as having the potential for contamination. Direct care observations identified lapses in infection control practices related to indwelling medical devices. For example, one resident's indwelling urinary catheter bag and tubing were observed touching the floor, and another resident's urinary catheter privacy bag was seen dragging across the floor while the resident was in a wheelchair. Additionally, a resident with a permacatheter for hemodialysis did not have an order for evidence-based practices (EBP) for infection prevention, despite facility policy requiring such measures for residents with indwelling medical devices. These failures were confirmed by staff and through medical record review.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering Alphagan eye drops without the necessary clinical safeguards in place. The resident had two bottles of the medication in the bedside drawer and reported self-administering the drops since admission. Review of the resident's medical record revealed there was no physician's order for the medication, no assessment to determine the resident's ability to self-administer, and no care plan addressing self-administration. The facility's policy requires that residents be informed of their right to self-administer medications and that appropriate assessments and care plans be completed. Interviews with facility staff, including an LVN, the ADON, and the DON, confirmed that medications must have a physician's order, a self-administration assessment, and a care plan before a resident can self-administer. Staff verified that none of these requirements were met for the resident in question. The absence of these safeguards meant the resident was self-administering medication without documented clinical oversight or planning.
Lack of Physician Rationale for Extended PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not documenting the physician's clinical rationale when extending PRN lorazepam orders beyond 14 days. According to the facility's policy, PRN orders for psychotropic drugs should be limited to 14 days unless the prescribing practitioner documents the rationale and indicates the duration for the extended order. Medical record review showed that the resident had multiple PRN lorazepam orders renewed and administered over several periods, but there was no documentation of the clinical rationale for these extensions in the medical record. The resident in question was noted to lack capacity to understand and make decisions, and had a history of anxiety manifested by hyperventilation, for which lorazepam was prescribed and administered via gastrostomy tube. Despite repeated renewals of the PRN lorazepam orders, the required physician documentation justifying the continued use was not present in the medical record, as confirmed by a registered nurse during interview and record review.
Failure to Develop Comprehensive Care Plans for Resident-Specific Needs
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of three residents. For one resident, there was no care plan created to address the use of bilateral padded side rails and an intravenous (IV) device, despite physician orders for both interventions and repeated observations of their use. Staff interviews confirmed the absence of care plans for these devices, and there was no documentation of the resident or representative's request for the padded side rails in the medical record. Another resident had a physician's order for the application of a sequential compression device to both lower extremities for deep vein thrombosis (DVT) prophylaxis. However, the care plan did not include this intervention. Staff interviews verified that the care plan was missing this essential component, and it was acknowledged that the resident required assessment and a care plan for the device. A review of a closed medical record for a third resident revealed diagnoses of Type 2 diabetes mellitus (DM), diabetic chronic kidney disease, and diabetic ophthalmic complications. The resident had active orders and administration of insulin and oral antidiabetic medications, but there was no care plan developed to address the management of DM or the use of these medications. Staff confirmed the absence of a comprehensive care plan for the resident's diabetes management.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident who was identified as enjoying activities such as watching TV, keeping up with the news, and listening to music. Multiple observations revealed that the resident was often awake in bed without the TV on or with the TV on but without sound, and the remote control was frequently out of the resident's reach. The resident was unable to operate the TV independently and required assistance to turn it on or adjust the sound, which was not consistently provided by staff. The resident's care plan included interventions to provide independent activities of choice and daily one-on-one visits, especially in the context of isolation due to a respiratory infection. Despite this, staff did not ensure that the resident had access to preferred activities, such as watching TV with sound or listening to music, as documented in the activity assessment. Interviews with staff confirmed that while activities staff visited the resident several times a week, there were lapses in ensuring the resident could engage in their chosen activities, resulting in unmet psychosocial needs.
Failure to Report and Document Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses including sepsis, Parkinson's Disease, schizophrenia, and dementia, who lacked capacity to make decisions, developed a red circular wound between the first and second fingers of the left hand. During observation and interview, a CNA reported the wound was likely due to the resident banging his hands and stated she had reported the wound to an LVN, who advised leaving it open to air. The resident's care plan required that skin conditions be reported to the physician and responsible party. Despite this, there was no documentation in the medical record regarding the wound, no physician's orders for treatment, and no evidence that the resident's responsible party or physician had been notified. The wound was observed on two consecutive days, and staff confirmed that no formal reporting or documentation had occurred, constituting a failure to provide appropriate treatment and care according to orders and the resident's care plan.
Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide necessary restorative nursing care and services to maintain or improve range of motion (ROM) for two residents with significant mobility impairments. For one resident with functional quadriplegia, physician orders and care plans required active and passive ROM exercises to the upper and lower extremities five times per week. However, documentation revealed multiple days where these exercises were not recorded as completed, and both restorative nursing assistants (RNAs) could not confirm whether the care was provided or simply not documented. The transition from electronic to paper records contributed to missed or incomplete documentation, and weekly summaries were also missing for certain periods. The resident reported receiving exercises less frequently than ordered and was not informed when sessions were missed. Another resident with severe cognitive impairment and contractures was ordered to receive passive ROM exercises and have splints applied to the left hand, elbow, and knee for specified durations. Observations on several occasions found the resident in bed without the required splints, and staff confirmed the splints were not in use at those times. Documentation for the application of splints and provision of ROM exercises was incomplete, with missing staff initials on several days and no record of the actual hours the splints were worn, as required to assess tolerance. Staff acknowledged that only the minutes spent applying splints were documented, not the duration of wear. Interviews with staff and review of records confirmed that restorative nursing interventions were not consistently provided or documented as ordered for both residents. There was no evidence of resident refusal for the missed interventions, and staff attributed the lapses to documentation issues and oversight during a system transition. The lack of consistent care and documentation posed a risk for further decline in ROM and functional mobility for the affected residents.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss in one resident, as evidenced by a lack of timely follow-up on the recommendations made by the Registered Dietitian (RD). The resident experienced a weight loss of 11 lbs, or 11.1%, over three months, which met the facility's criteria for significant weight change. Despite the RD recommending nutritional interventions, including the provision of a high-calorie nutritional formula and additional supplements, there was no documentation that these recommendations were communicated to the physician or addressed by the Interdisciplinary Team (IDT) Nutrition. The resident's weight status was not monitored as required, and the facility's policy for early identification and assessment of weight changes was not followed. Interviews with the Assistant Director of Nursing (ADON) and the Food & Nutrition Services Director confirmed that the resident's weight loss was not properly tracked or managed. The ADON was unable to provide evidence that the RD's recommendations were implemented or that the resident's ongoing weight loss was monitored. The Food & Nutrition Services Director also stated that the resident's weight should have been monitored weekly, indicating a lapse in adherence to facility protocols for nutritional monitoring and intervention.
Failure to Ensure Proper Enteral Feeding Administration and Storage
Penalty
Summary
The facility failed to ensure proper management and administration of enteral feeding services for two residents. Surveyors observed expired enteral feeding formula bottles stored in the subacute storage unit, which was confirmed by Central Supply staff. Additionally, the facility's policy required the head of the bed (HOB) to be elevated at least 30 degrees during enteral feeding to prevent complications, but this was not consistently followed. For both residents reviewed, medical records indicated they lacked capacity to make medical decisions and had physician orders specifying HOB elevation between 30 to 45 degrees during feedings. Direct observations showed that both residents were receiving enteral tube feedings with the HOB elevated less than 30 degrees. Nursing staff and the DON acknowledged that the HOB was not properly elevated during feedings, and the facility did not have a device to measure the exact angle of elevation. These failures were confirmed through interviews and concurrent observations with nursing staff, who verified that the required procedures were not followed during the administration of enteral feedings.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring respiratory support. For one resident, the nebulizer mask, tubing, and bag were not changed weekly as ordered by the physician, with equipment at the bedside dated beyond the required change interval. Both a registered nurse and a respiratory care practitioner confirmed that the equipment should have been changed and properly labeled, but it was not, as evidenced by the dates observed on the items. For another resident with a tracheostomy and on mechanical ventilation, the facility did not ensure the correct emergency tracheostomy set was available at the bedside. Instead of a cuffed tracheostomy set as ordered, an uncuffed set was provided. Additionally, the suction device (Yankauer catheter) was not changed weekly as per physician's orders, with an outdated device found at the bedside. Staff interviews confirmed these lapses in following physician orders and facility policy.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for several residents, resulting in multiple deficiencies related to the administration and documentation of controlled medications and adherence to physician orders. For one resident, a controlled medication (hydrocodone-acetaminophen) was administered without immediate documentation in the narcotic record, and the delivery receipt was not signed or dated when received. The nurse confirmed the medication was given before it was properly logged, and the ADON acknowledged that the delivery receipt should have been completed at the time of receipt. Another resident's controlled medication (tramadol) brought from home was found in a medication room without an accompanying narcotic count sheet. The ADON stated that the medication was received by staff during admission, but a new narcotic sheet was not started as required by facility policy. The existing count sheet was from a previous admission and did not reflect the current receipt and handling of the medication. Additionally, a resident with a physician's order for a lidocaine patch to be removed at a specific time was found to have the patch still in place past the ordered removal time. The nurse verified the patch was not removed as scheduled, despite documentation indicating otherwise. Another resident with orders for midodrine and insulin had medications administered outside of prescribed parameters: midodrine was given when blood pressure was above the ordered threshold, and insulin was not administered when blood glucose levels indicated it was needed. These failures were confirmed by staff review of the medical records and interviews.
Food Safety and Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to meet food safety and sanitation requirements as evidenced by multiple observations during a kitchen tour and review of facility policies. A red bucket containing sanitizing solution was stored next to food items such as sugar and food thickener, and a staff portable radio was found on the beverage preparation area. Inside the refrigerator, two bell peppers were noted to be soft, wrinkled, and blackened, and a bag of croissants was stored with an open date but without clear indication of when it should be discarded. Additionally, an unlabeled package of mushrooms was present, with no purchase date available, and the Food & Nutrition Services Director was unable to confirm when it was bought. Further, a staff's personal water bottle was found stored on the floor beneath ready-to-eat fruit in the walk-in refrigerator. In the walk-in freezer, a frozen pizza and a bag of tamales were both stored in plastic bags without labels or expiration dates, and the Food & Nutrition Services Director could not provide information on their purchase or expiration. These findings were verified with the Food & Nutrition Services Director and were not in accordance with the facility's policies, which require food storage areas to be used only for food and mandate weekly checks for expiration and use-by dates.
Deficiencies in Equipment Maintenance, Documentation, and Temperature Control
Penalty
Summary
The facility failed to ensure that essential resident care equipment and medication storage areas were maintained in safe operating condition. During an inspection of Medication Cart C, a glucometer was found with quality control records that did not accurately reflect the reference ranges listed on the test strip bottle. The quality control log documented incorrect reference ranges for both normal and high controls, which did not match those on the bottle. The LVN interviewed confirmed that the night shift nurse was responsible for quality control, and acknowledged the discrepancy in documentation. Further review of quality control records for two other glucometers revealed improper correction of documentation errors. Whiteout was used to alter entries on the Quality Control Records for Glucometers A and B, which completely erased the original information and made it impossible to refer back to previous entries. Both the ADON and DON confirmed that the facility's process should involve crossing out errors and initialing corrections, not using whiteout, and acknowledged that the observed practice was incorrect. Additionally, the medication refrigerator in Medication Room A was not maintained within the required temperature range. Multiple temperature checks showed readings above the acceptable limit, with the refrigerator containing various medications including insulin and Epogen. The presence of condensation and wet medication trays was also noted. In the kitchen, the walk-in freezer was observed with ice buildup along the door frame and on storage bins, which was verified by the Food and Nutrition Services Director.
Incomplete Documentation of Catheter Care and Monitoring
Penalty
Summary
The facility failed to maintain a complete medical record for one resident reviewed for closed records. Specifically, there was inconsistent documentation regarding the monitoring and care of an indwelling urinary catheter and the checking of a Quinton catheter, which is used for hemodialysis access. The resident in question had diagnoses including end stage renal disease, dependence on renal dialysis, obstructive and reflux uropathy, and required both a Foley catheter and a Quinton catheter. Facility documentation required catheter care and monitoring every shift, with specific instructions to check for signs of infection, bleeding, and other complications, and to document these checks. Upon review of the resident's Treatment Administration Record (TAR) for April, it was found that there was no nursing documentation for the required catheter care and Quinton catheter checks on two PM shifts. Interviews with an LVN and the ADON confirmed the missing documentation, with both acknowledging that the care may have been provided but was not recorded. This lack of documentation resulted in the medical record being incomplete, as required by federal regulations and facility policy.
Failure to Obtain and File Advance Healthcare Directive
Penalty
Summary
The facility failed to obtain and include a copy of an advance healthcare directive in the medical record for one resident who was reviewed for advance directives. According to the facility's policy, staff are required to obtain a copy of the advance directive and ensure it is placed in the resident's health record. During the review, it was found that although the resident's POLST form indicated that an advance directive was available and had been reviewed, there was no documented evidence in the medical record that the actual advance healthcare directive had been obtained or filed. The resident in question had a severe cognitive impairment and had a California General Durable Power of Attorney for financial matters documented in the record, but not the advance healthcare directive. Interviews with the RN, Social Services Director, and Social Services Resource staff confirmed that the social services department was responsible for following up on advance directives. They verified that while the POLST referenced the existence of an advance directive, the document itself was not present in the resident's medical record.
Failure to Follow Pureed Diet Recipe During Food Preparation
Penalty
Summary
The facility failed to follow the prescribed menu and recipe for pureed potatoes during food preparation for nine residents on pureed diets, including two residents on no added salt pureed diets. During an observation, a staff member was seen adding low sodium broth to the pureed potatoes instead of the warm milk specified in the facility's recipe. This deviation from the established recipe was confirmed by the staff member involved. The review of facility documents and direct observation confirmed that the menu and recipe were not followed as required for residents receiving pureed meals.
Pureed Food Served with Poor Consistency and Inadequate Temperature Control
Penalty
Summary
The facility failed to ensure that food prepared in the kitchen, specifically pureed meals, was attractive in appearance and served at an appetizing temperature. During an observation of puree salad preparation, the salad was found to have lumps and water surrounding it, which did not meet the expected smooth, applesauce-like consistency as described by the staff. The staff member preparing the salad stated that the consistency would improve as it cooled, but the salad remained lumpy and watery at the time of observation. Further observation during trayline service revealed that the puree salad was served at 60 degrees Fahrenheit, which was not considered an appetizing temperature. The Food and Nutrition Services Director was unable to explain the presence of lumps and water in the salad and confirmed that the temperature of the salad after cooling was not documented on the food temperature log. Nine residents on puree diets were affected by the pureed meals prepared in the facility's kitchen.
Improper Hand Hygiene and Glove Use in Food Handling
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene and glove use when handling ready-to-eat food, affecting 59 residents who received meals from the kitchen. During an observation, Cook #1 was noted to scratch the side of his face with a gloved hand and then continued to pick up meat and cilantro without changing his gloves or washing his hands. Interviews with Cook #1, Cook #2, the Dietary Manager (DM), the Registered Dietitian (RD), the Administrator, and the Director of Nursing revealed that staff were aware of the proper procedures for glove use and hand hygiene but did not consistently follow them. The facility's policy on glove use, dated 2020, emphasized the importance of changing gloves when switching tasks to prevent foodborne illness. Despite this, Cook #1 did not adhere to the policy, and the DM confirmed that staff had been in-serviced on the correct procedures. The RD and the Administrator both stated that staff should not touch anything other than the food they are handling while wearing gloves. The Director of Nursing reiterated that staff were taught to wash their hands before putting on gloves and to change gloves if they touched anything else. This lapse in protocol was observed and confirmed through multiple interviews, highlighting a significant deficiency in the facility's food handling practices.
Improper Disinfection of Glucometers
Penalty
Summary
The facility failed to ensure staff properly cleaned glucometers according to the manufacturer's labeled specifications for use as a disinfectant to help prevent the spread of bloodborne pathogens. Observations revealed that two out of thirteen glucometers were not disinfected correctly during medication pass. Licensed Vocational Nurse (LVN) #4 was observed using Sani-Cloth AF3 wipes and bleach wipes interchangeably without following the correct disinfection procedure. LVN #5 was seen placing a used glucometer back into the cart without disinfecting it and later using Sani-Cloth AF3 wipes incorrectly, not adhering to the required wet-dwell time specified by the manufacturer. Interviews with other nursing staff, including LVNs #6, #7, and #8, revealed a general misunderstanding of the disinfection process and the meaning of the red 3 on the disinfectant wipe containers. The staff believed that the red 3 indicated a three-minute air-dry time, whereas the manufacturer's instructions required a three-minute wet-dwell time. The Infection Preventionist (IP) and the Director of Nursing (DON) also demonstrated a lack of awareness regarding the specific disinfection instructions for the Sani-Cloth AF3 wipes and bleach wipes. The DON acknowledged the confusion among the staff and admitted to being unaware of the specific directions on the disinfectant wipes. The Administrator also recognized the error and emphasized the need for staff to clean the glucometers before use, between residents, and before storing them in the cart, following the manufacturer's instructions. The facility's infection control policy required the disinfection of shared blood glucose meters after every use per the manufacturer's instructions, which was not being followed correctly by the staff.
Failure to Follow Medication Administration Policies
Penalty
Summary
The facility failed to ensure a resident who had not been assessed as safe to self-administer medications did not self-administer an inhaler, failed to follow physician's orders for administration of an inhaler, and failed to follow facility policy for medication administration. Resident #299, who was admitted with diagnoses including asthma, COPD, and chronic bronchitis, was observed self-administering three puffs of an inhaler instead of the prescribed one puff. The resident was not assessed for the ability to self-administer medications, and no physician's order was obtained to allow self-administration, nor was the order clarified to include 'May Keep at Bedside' as per facility policy. During an observation, LVN #5 handed the inhaler to Resident #299, who then self-administered three puffs consecutively. LVN #5 did not intervene or provide instructions to the resident to swish and spit out water after using the inhaler, as required by the physician's order. Instead, the resident swished water in their mouth and swallowed it. LVN #5 admitted to assuming the resident could self-administer the inhaler due to their cognitive status and did not consider it self-administration. The Director of Nursing (DON) confirmed that Resident #299 had taken three puffs of the inhaler and had a habit of swishing and swallowing water after using the inhaler at home. The DON also stated that the resident did not wish to self-administer medications and preferred nursing staff to administer them. The facility's policy and the physician's orders were not followed, leading to the resident receiving an incorrect dosage of medication.
Improper Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure that only licensed staff documented medications they administered during medication administration. During an observation, it was noted that a Licensed Vocational Nurse (LVN) administered medication to a resident but did not document the administration on the Medication Administration Record (MAR). Instead, another LVN signed the MAR, indicating that she had administered the medication, which was not the case. This discrepancy was confirmed during interviews with both LVNs and the Director of Nursing (DON), who stated that the expectation was for nurses to sign out medications at the time they were administered and only for medications they personally administered. The incident involved Resident #299, who was administered cholecalciferol 125 micrograms by LVN #5. However, the MAR showed LVN #9's initials, indicating she had administered the medication. LVN #5 admitted to forgetting to document the administration, and LVN #9 acknowledged signing the MAR despite not administering the medication. The DON and the Administrator both confirmed that this practice was against facility policy and expectations, emphasizing that each nurse should document only the medications they personally administered at the time of administration.
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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 Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove Post Acute | 0.5 mi | ★★★★★ | 4 | 0 |
| Alta Gardens Care Center | 0.7 mi | ★★★★★ | 43 | 0 |
| Garden Park Care Center | 1 mi | ★★★★★ | 6 | 0 |
| Citrus Post-acute | 1.2 mi | ★★★★★ | 6 | 0 |
| Chapman Care Center | 1.5 mi | ★★★★★ | 23 | 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 October 2026) and official state health department websites.