Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pacific Palms Healthcare during CMS and state inspections, most recent first.
A resident readmitted with a UTI and an indwelling urinary catheter had no intake and output (I&O) monitoring or documentation, despite physician orders specifying catheter size and balloon volume and MDS findings of moderately impaired cognition and need for assistance with ADLs. During interviews, an RN stated I&O was not obtained because there was no physician order, and the DON reported that I&O is monitored only when a problem is identified. The facility was unable to provide an I&O policy, and this deficient practice resulted in an inability to determine whether the resident was appropriately hydrated and allowed the potential for fluid overload or infection to go unrecognized.
A resident with type 2 DM and moderately impaired cognition had a blood glucose level incorrectly documented by an RN as 551 g/dl instead of the actual 350 g/dl. The RN later acknowledged forgetting to record the correct value and did not correct the entry after the resident was transferred to a GACH. The DON confirmed awareness of the discrepancy and that the clinical record was not updated, contrary to facility policy requiring objective, complete, and accurate documentation to support interdisciplinary communication.
A resident did not receive physician-ordered Refresh Liquigel Ophthalmic Gel 1% for dry eyes at bedtime due to the medication not being available in the medication cart or house supply, and no documentation of pharmacy delivery or follow-up by nursing staff. The pharmacy had not processed the order, as over-the-counter medications require specific requests from the facility, and staff did not ensure the medication was obtained as per facility policy.
Call lights were not kept within reach for three residents. One resident with hemiplegia and a history of falling did not know where the call light was, another resident with Alzheimer’s Disease, epilepsy, and a history of falling had the call light placed between foam padding and siderails with the button dangling near the floor, and a third resident with Parkinson’s Disease, Alzheimer’s Disease, and severe cognitive impairment had the call light placed out of reach on the side of the bed. Staff and the DON stated call lights should be within reach so residents can request assistance.
Failure to Assess and Obtain Consent for Abdominal Binder Use: A resident with Parkinson's Disease, Alzheimer's Disease, dementia, severe cognitive impairment, and a G-tube was observed with an abdominal binder covering the tube site. An RNS stated the binder was used to prevent the resident from pulling out the G-tube and that the resident could not remove it easily. Record review showed no restraint assessment and no informed consent from the resident or responsible party, despite facility policy requiring a pre-restraint assessment and discussion of risks, benefits, and alternatives.
Failure to Develop Comprehensive Resident-Specific Care Plans: The facility did not develop and implement complete, resident-specific care plans for two residents. One resident with hemiplegia, severe cognitive impairment, and a left hand contracture had OT notes showing refusal to wear a left WHFO splint, but no care plan addressed the refusal. Another resident with anxiety disorder and seizure disorder had orders for Buspar and Depakote, but the anxiety and seizure care plans did not identify those meds as targeted interventions. The DON confirmed the missing care plan content.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents with DM and dialysis history. Records showed repeated insulin injections in the same arm for one resident and repeated injections in the same abdominal areas for another resident. LVNs stated injections should be rotated because repeated use of the same site can affect subcutaneous tissue and insulin absorption, and the DON stated failure to rotate sites can cause bruising.
A facility failed to properly manage ROM and mobility for three residents. One resident had knee splints increased from 30 minutes to 2-4 hours without a PT assessment, and the PT eval did not include objective knee ROM measurements. A second resident’s OT and PT evals identified impaired finger and ankle ROM but did not document measurements. A third resident had declining ambulation documented in RNA records, but the decline was not promptly escalated as staff described was expected.
Failure to Record Foley Output for Two Residents: The facility did not measure or document foley catheter urine output for two residents with indwelling catheters. One resident had moderate cognitive impairment and diagnoses including type 2 DM, while the other had severe cognitive impairment, CKD, BPH, and was dependent on staff for all ADLs. Staff stated output was not recorded unless ordered, although the DON acknowledged measuring output was important to prevent dehydration. The facility policy required an accurate record of daily output to help prevent CAUTIs.
GT feeding formula was not provided and documented as ordered for two residents with dysphagia and GTs. Observations showed feeding containers dated and started at times that did not match the ordered 2 p.m. start time, and the MARs had no documentation of the amount delivered per shift or per day. An LVN, the DON, and the MDSC all stated the formula should have been hung at the ordered time, tubing changed with new formula, and the amount delivered documented.
BIPAP care and maintenance were not completed for a resident with COPD and chronic respiratory failure. Staff observed water left in the humidifier canister, and record review showed no documentation that the BIPAP machine, mask, or tubing care was performed. The DON stated that if the care was not documented, it was not done. Facility policy and the BIPAP user guide required regular cleaning, emptying the humidifier, and filter replacement.
A CNA set up a meal tray for a resident ordered a fortified pureed diet, but the tray contained scrambled eggs that were not pureed. The resident had severe cognitive impairment, hemiplegia, and a left-hand contracture, and staff interviews confirmed the CNA knew the resident was on a puree diet but still passed the tray with the incorrect texture. The CK, RNS, and DON stated puree diets must be smooth and that CNAs are responsible for matching the meal ticket to the ordered diet.
A cook was not competent in preparing pureed scrambled eggs and oatmeal according to the facility’s recipes. He stated he mashed eggs by hand instead of using a blender or food processor and prepared oatmeal without modification, while the DS confirmed pureed foods were expected to be smooth and free of lumps. The deficiency placed 27 residents on a puree diet at risk for receiving food that did not meet ordered texture requirements.
Food was served below the required temperature for a resident with DM, hypoglycemia, GERD, and major depressive disorder. The resident said meals were not always delivered warm, and a pancake checked at the tray line measured 130.8 degrees Fahrenheit instead of the 140 degrees Fahrenheit required by the facility log and meal service policy. The DS and RD both confirmed the expected temperature for pancakes was 140 degrees Fahrenheit.
A resident with hemiplegia, severe cognitive impairment, and an upper-extremity impairment had a physician order for a fortified puree diet, but during observation her meal tray contained scrambled eggs that were not pureed. CNA staff confirmed the eggs were not pureed, and the CK stated a puree diet must be completely smooth. The RNS reviewed the record and noted the resident’s diet had been changed to puree due to dental status, while the DON stated the wrong diet consistency could lead to swallowing difficulty and aspiration.
Unsafe Food Storage and Preparation Practices: Staff personal items were found in the kitchen prep area, a sanitizer bucket was placed in a food prep sink, and breakfast items were not consistently temperature-checked before service; one pancake was 130.8 degrees F when checked. The ice machine was dirty, and two residents had refrigerated personal food items that were undated, including opened deli items and fried chicken. The RD stated resident food should be dated and food temperatures should be checked prior to serving.
The facility failed to keep accurate medical records when RNA documentation did not match actual care for three residents. One resident with hemiplegia and severe cognitive impairment was documented as receiving RNA feeding assistance at breakfast and lunch, but the RNA admitted he only set up the tray and left the room. Another resident with OA, polyneuropathy, and morbid obesity was documented as wearing both knee extension splints for 2 hours, but the RNA and resident stated the splints were worn for about 40 to 60 minutes. A third resident with DM and difficulty walking had weekly RNA ambulation documentation that did not match the daily records.
Staff failed to follow infection prevention and control practices involving hand hygiene, tube feeding equipment, water management documentation, and C-diff isolation. An LVN did not clean hands when entering and exiting a resident’s room, a feeding line was found on the floor without a cap and was not replaced, the facility lacked complete monitoring and documentation for its water management program, and contact isolation for a resident with active diarrhea and C-diff-related concerns was not consistently implemented or documented.
A resident with hemiplegia, hemiparesis, and severe cognitive impairment had RP consent for the COVID-19 vaccine, but the IPN found no documentation that the vaccine was actually given. The facility also lacked vaccine consent forms for three employees, and the IPN and DON stated the forms were needed to show staff were educated on the risks and benefits and offered the vaccine per policy.
Failure to inform a resident about insulin site rotation risks: A resident with DM and renal dialysis dependence received repeated insulin injections in the same site, preferred injections in the right arm, and stated she was not aware of the risks of using the same site repeatedly. The MAR, location of administration report, and progress notes showed multiple same-site injections with no documentation of education, while the DON stated residents must be educated that repeated injections in the same site can cause bruising or harm.
A resident with DM, difficulty walking, and a sacral pressure injury had a decline in ambulation while on an RNA walking program with a FWW. Documentation showed the resident’s walking distance dropped from 150 ft to 80 ft and then 40 ft, but staff did not notify the physician when the decline occurred. Interviews confirmed staff expected changes in ambulation to be reported to the LVN/DON and then to the provider, and the facility policy required physician notification for a significant change in condition.
A resident received mirtazapine for depression manifested by poor appetite, but the admission record, H&P, psychiatric notes, and MDS did not document depression or major depressive disorder as an active diagnosis during the period reviewed. The DON stated the first available documentation of depression was in a later psych note, while the medication had already been in continuous use.
MDS Did Not Reflect Resident’s Anxiety Disorder: The facility failed to ensure a resident’s MDS accurately reflected the resident’s condition. Record review showed the resident had major depressive disorder, moderate cognitive impairment, and care needs including assistance with eating, oral hygiene, dressing, toileting hygiene, bathing, and lower body dressing. The record also included an Ativan order for anxiety manifested by physical restlessness, care plan notes of new anxiety episodes with physical restlessness and combativeness, and a psychiatry note indicating anxiety, but the MDS did not identify an anxiety disorder. The MDSC and DON stated the MDS should accurately reflect the resident and the resident’s condition.
Failure to update the care plan for a resident’s insulin injection site preference. A resident with type 2 DM, renal dialysis dependence, and intact cognition preferred insulin injections in the right arm and declined the abdomen and left arm near the dialysis access site. Staff documented repeated injections at the same site, but there was no revised care plan addressing the resident’s preference and associated risks, and the DON stated residents must be educated about harm from repeated use of the same site.
A resident with hemiplegia, a left-hand contracture, and severe cognitive impairment was on an RNA feeding program for breakfast and lunch, but staff only set up the meal tray and left her unattended during meals. Observations showed she ate independently without supervision, and one meal was removed before she finished eating. CNA and RNA staff stated they did not stay with her, while the QAN and DON said RNA staff were supposed to remain with the resident throughout the meal to supervise and encourage intake.
Failure to remove unneeded peripheral IV catheters for two residents. One resident with moderate cognitive impairment and a history of colon cancer and DM2 had an IV still in the wrist after IV hydration ended, and stated the site was painful and she did not know why it remained. Another resident with severe cognitive impairment and CKD had an IV line still in place despite no current MD order, IV fluids, or IV meds. Staff confirmed the lines should have been discontinued per policy when therapy ended.
A resident with DM, difficulty walking, and pressure-related skin injury was ordered to be seen by neurology and a wound doctor, but the record showed no documentation that either consult occurred. Staff, including an LVN, SSD, TN, and DON, confirmed there was no documentation of transportation being arranged or of the specialists seeing the resident, despite the physician orders.
Failure to obtain an ordered valproic acid level for a resident receiving Depakote for seizure disorder. The resident had anxiety disorder and seizure disorder, and the consultant pharmacist recommended monitoring the level with the next lab draw. The physician later ordered routine valproic acid monitoring, but the lab requisition was not made and the test was not drawn, while the DON confirmed the omission.
Incorrect Texture Toast Served to A Resident: A resident with DM, GERD, and depression was ordered a regular texture, consistent carbohydrate, no added salt diet, but she reported receiving toast chopped up and mushy instead of regular toast. The Diet Profile card incorrectly listed mechanical soft and toast not toasted, and the DS acknowledged the notes were wrong. The RD stated staff should follow the ordered diet texture so residents can eat it and prevent weight loss.
Arbitration Agreement Not Explained in Resident-Understood Language: The facility failed to ensure a binding arbitration agreement was explained in a language two residents could understand. One resident preferred Spanish and had impaired decision-making capacity, yet signed an English agreement and later stated he would have understood it if written in Spanish. Another resident had memory impairment and moderately impaired cognition, signed the agreement, but could not recall what she signed or its purpose. The AA and DON stated the agreement should be explained in simple terms, with an interpreter when needed, and RP involvement for confused or forgetful residents.
A resident on hospice care did not receive weekly hospice RN visits as agreed in the hospice plan. The resident had respiratory failure, dysphagia, a gastrostomy, and a cerebral infarction with right-sided impairment, lacked decision-making capacity, and required extensive assistance with ADLs. The hospice flow sheet showed gaps in RN visits, and the LVN and DON stated facility staff did not follow up when weekly visits were missed; the OSR ordered skilled nursing visits once weekly and CHHA visits twice weekly.
The facility did not follow physician orders for pain medication dosing for a resident, continued to administer a discontinued higher dose, and failed to document proper handling of unused medication. Additionally, a controlled substance for another resident was stored in an unlocked refrigerator and not removed or destroyed after discontinuation, contrary to facility policy. Staff interviews revealed confusion and lack of adherence to procedures for controlled substances.
A resident with an open thigh wound requiring daily dressing changes did not have Enhanced Barrier Precautions (EBP) implemented, as the Treatment Nurse did not wear a gown and there was no EBP signage outside the room. Staff interviews revealed a lack of understanding and oversight regarding EBP requirements for residents with wounds, despite facility policy mandating such precautions.
The facility failed to maintain accurate advance directives for two residents, leading to incomplete and invalid documentation. One resident's form was outdated and not discussed with the responsible party, while another's form lacked clear consent details. The facility's policy requires that advance directives be prominently displayed in medical records, but this was not adhered to.
The facility failed to accurately document the use of bedrails in the MDS assessments for two residents, leading to potential inaccuracies in care. Both residents had side rails in use, which were not reflected in their MDS documentation. The MDS Coordinator stated the rails were used for aiding and turning, not as restraints, and thus did not affect the MDS coding, contrary to facility policy and MDS guidance.
The nursing staff failed to update fall risk care plans for two residents, placing them at risk for recurrent falls. One resident, with an amputation and coordination issues, fell on a specific date, but their care plan was not revised. Another resident, with dementia and Alzheimer's, was identified as a high fall risk but had a fall without subsequent care plan updates. The DON confirmed the care plans were not updated, contrary to facility policy.
The facility failed to timely implement dietary recommendations and adequately monitor weight loss in two residents. One resident, with dementia and dysphagia, did not receive an appetite stimulant promptly, and their intake of nutritional supplements was not properly documented. Another resident, with muscle wasting and malnutrition, did not receive recommended nutritional supplements due to a lack of clear documentation and rationale for discontinuation. The facility's policies for weight assessment and intervention were not followed, placing residents at risk for further weight loss.
The facility failed to ensure kitchen staff were trained and competent, leading to two issues: improper knowledge of chlorine sanitizer concentration by DW and DA2, and Cook1 not following recipes, resulting in chunky pureed spaghetti and insufficient meat sauce. DW and DA2 were absent from training, causing confusion about sanitizer ranges, while Cook1 rushed food preparation and did not report shortages.
The facility failed to follow the standardized recipes and portion sizes for a pureed diet, affecting 16 residents. The pureed spaghetti served was lumpy and required chewing, contrary to dietary requirements. Additionally, residents received incorrect portion sizes of meat sauce and did not receive pureed garlic bread as per the menu. These deficiencies were confirmed by staff interviews and observations.
The facility failed to maintain safe food storage and preparation practices, including the absence of soap at a handwashing sink, improperly labeled and stored food items, and inadequate storage of resident-brought food. These deficiencies could lead to contamination and foodborne illnesses.
The facility failed to implement its antibiotic stewardship program, leading to the administration of antibiotics without meeting McGeer Criteria for four residents. Antibiotics were prescribed for conditions such as Bullous Pemphigoid, UTIs, and bronchitis without proper justification, as the necessary subcriteria were not documented.
A resident with glaucoma and diabetes did not receive timely follow-up with an optometrist or referral to an ophthalmologist, despite recommendations and worsening vision. The facility's staff acknowledged the oversight, and the resident's care plan lacked specific actions for ensuring necessary eye care consultations.
A facility failed to accurately account for a dose of morphine sulfate ER for a resident. An LVN administered the medication but did not sign the Narcotic and Hypnotic Record, leading to a discrepancy between the record and the medication card. The facility's policy requires reconciliation of controlled substances upon administration, including recording the time, quantity remaining, and nurse's signature.
A facility failed to ensure a physician responded to a consultant pharmacist's recommendation for a gradual dose reduction of Depakene for a resident with bipolar disorder. The resident's clinical record lacked documentation of the physician's response, and the resident remained on the same dose since August 2022. The Director of Nursing acknowledged the oversight, noting that the facility's policy for contacting prescribers and documenting responses was not followed, increasing the risk of adverse effects.
A resident with multiple sclerosis was prescribed hydroxyzine for itching but had not used it for months, as her symptoms were managed with Benadryl. Despite a physician's order to discontinue hydroxyzine due to non-use, the facility failed to do so, citing the resident's preference to keep it. The DON confirmed the oversight, noting the risk of side effects from concurrent use of both medications.
A facility failed to perform a gradual dose reduction (GDR) or document a clinical rationale for a resident on Depakene for bipolar disorder. Despite a consultant pharmacist's recommendation, the physician did not respond or adjust the medication dosage, leaving the resident on the same dose since August 2022. The Director of Nursing acknowledged the oversight, which was contrary to the facility's policy on medication tapering and GDR.
A facility failed to assess a resident's mental capacity before having them sign an arbitration agreement. The resident, with cognitive impairments and a history of cerebral infarction, did not recall signing the document, and their family confirmed the resident's inability to sign due to a stroke. The Admissions Assistant acknowledged that a staff member signed on behalf of the resident, contrary to the facility's policy requiring explanation to the resident or their legal representative.
Failure to Monitor Intake and Output for Catheterized Resident
Penalty
Summary
The facility failed to monitor, document, and record intake and output (I&O) for a resident who was readmitted with an indwelling urinary catheter and a diagnosis of urinary tract infection. The resident’s admission face sheet showed an initial admission and subsequent readmission with a UTI diagnosis, and the MDS dated 6/27/2025 documented moderately impaired cognition and a need for partial/moderate assistance with toilet hygiene, bathing, and dressing. The physician’s orders specified a 16 French indwelling urinary catheter with a 10 cc balloon. Despite this, review of the clinical record revealed no I&O documentation for this resident. During an interview and concurrent record review, RN 1 confirmed that the resident was admitted with an indwelling catheter and acknowledged that I&O was not taken because there were no physician orders to do so. In a separate interview, the DON stated that residents’ I&Os are monitored only if a problem is identified. Additionally, when surveyors requested the facility’s policy and procedure on I&O, the facility was unable to provide one. This deficient practice resulted in the inability to determine if the resident was hydrated appropriately and had the potential for fluid overload and/or infection to go unrecognized.
Inaccurate Documentation of Blood Glucose Result
Penalty
Summary
The facility failed to ensure accurate documentation of a resident’s blood glucose result in the medical record. Resident 1, who had type 2 DM and moderately impaired cognition, required partial to moderate assistance with several ADLs. A progress note dated 3/17/2026 documented the resident’s blood glucose level as 551 g/dl, far above the stated normal range of 80–100 g/dl. During a subsequent interview, RN 1 acknowledged that this documented value was incorrect and that the resident’s actual blood glucose was 350 g/dl. RN 1 stated she forgot to document the correct blood glucose number and did not correct the entry after the resident was transferred to a GACH, despite recognizing that it was important to document the correct information for accuracy and safety. The DON confirmed being informed by RN 1 that the correct blood glucose level was 350 g/dl, not 551 g/dl, and that RN 1 should have corrected the clinical record. The facility’s charting and documentation policy required that all services and changes in a resident’s condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Provide Ordered Ophthalmic Medication
Penalty
Summary
The facility failed to provide a resident with Refresh Liquigel Ophthalmic Gel 1% as ordered by the physician for dry eyes at bedtime. The resident, who was admitted with diagnoses including paraplegia and required substantial to maximal assistance with activities of daily living, reported not receiving the prescribed eye drops at night. Upon review, it was found that the medication was not present in the medication cart or the facility's house supply closet. Nursing staff confirmed the absence of the medication and indicated there was no record of pharmacy delivery receipts for the eye drops. Further investigation revealed that the pharmacy had not processed the order for the Refresh eye drops until the day of the survey, as the pharmacy does not automatically provide over-the-counter medications unless specifically requested by the facility. There was no documentation that the facility had contacted the pharmacy regarding the missing medication. According to facility policy, nursing staff are responsible for ensuring residents have a sufficient supply of prescribed medications and for communicating with the pharmacy if medications are unavailable. This lapse resulted in the resident not receiving the prescribed treatment for dry eyes.
Call Lights Not Kept Within Reach for Three Residents
Penalty
Summary
The facility failed to ensure call light devices were within reach for three sampled residents. During observation and interview, Resident 7, who had diagnoses including hemiplegia, hemiparesis affecting the left dominant side, stiffness of the left shoulder, elbow, and hand, and a history of falling, stated he did not have a call light and did not know where it was. The call light was observed behind the bed, and an LVN later moved it to the resident’s right side. Resident 7’s MDS indicated he was cognitively intact, used a wheelchair, and required varying levels of assistance with transfers, toileting hygiene, bathing, dressing, and oral/personal hygiene. Resident 100 was observed with the call light placed between the left side foam padding and the left side siderails, with the button dangling near the floor. Resident 100 had diagnoses including a history of falling, epilepsy, and Alzheimer’s Disease, and her H&P indicated she did not have the capacity to understand and make decisions. Her MDS showed she required maximal assistance for bed mobility, bathing/showering, and toilet hygiene, moderate assistance for dressing, and setup assistance for eating. Her care plan identified her as at risk for falls related to balance problems during transition and assistance needed during walking and bed mobility, and included an intervention to educate her to use the call light to ask for assistance. Resident 121, who had diagnoses including Parkinson’s Disease, Alzheimer’s Disease, and dementia, was assessed as having severe cognitive impairment and being dependent on staff for all ADLs. During observation, the resident’s call light was not within reach and was on the left side of the bed. A CNA stated the call light was not in reach and needed to be in reach. The facility’s policies stated that residents’ rights include dignity and that when a resident is in bed or confined to a chair, the call light should be within easy reach, and residents who cannot use their call light should be checked frequently.
Failure to Assess and Obtain Consent for Abdominal Binder Use
Penalty
Summary
The facility failed to obtain informed consent, complete a restraint assessment, and monitor the use of an abdominal binder for Resident 121. Resident 121 was admitted and readmitted with diagnoses including Parkinson's Disease, Alzheimer's Disease, and dementia, and the MDS dated 11/17/2025 indicated severe cognitive impairment and total dependence on staff for all ADLs. The admit/re-admit nursing evaluation dated 11/12/2025 documented a G-tube. During a concurrent observation and interview on 11/19/2025, Resident 121 was observed with an abdominal binder in place covering the G-tube site. The RNS stated the binder was being used to prevent the resident from pulling out the G-tube and that the resident could not remove the binder easily. During record review, the RNS stated there was no assessment for abdominal binder use and no informed consent obtained from the resident or responsible party. The DON stated a restraint is a device that restricts a resident's movements, and the facility policy required a pre-restraint assessment and informing the resident and/or responsible party about the risks, benefits, and alternatives to restraint use.
Failure to Develop Comprehensive Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-specific care plan for Resident 13 related to refusal to wear a left WHFO splint. Resident 13 was admitted with hemiplegia and a left hand contracture, and the MDS dated 9/11/2025 indicated severe cognitive impairment and impairment of the left upper extremity. Occupational therapy documentation dated 11/16/2025 stated Resident 13 was non-compliant with wearing the left WHFO, and an observation on 11/19/2025 noted a left hand and wrist contracture. During interview, the OT stated Resident 13 was being seen twice weekly and was working on tolerance to the splint, but often refused to wear it. The DON stated there was no care plan created regarding refusal of the left WHFO splint. The facility also failed to develop and implement a comprehensive care plan for Resident 9 related to the use of Buspar and Depakote. Resident 9 was admitted and readmitted with diagnoses including anxiety disorder and seizure disorder, and a history and physical dated 6/9/25 indicated fluctuating capacity to understand and make decisions. The order summary dated 11/20/25 showed Buspar 10 mg twice daily for anxiety manifested by uncontrollable screaming/yelling and Depakote DR 500 mg twice daily for seizure disorder. However, the care plan for anxiety, initiated 11/12/23, did not identify Buspar as a targeted intervention, and the seizure disorder care plan, initiated 11/1/23, did not identify Depakote as a targeted intervention. During interview, the DON stated the facility failed to create a comprehensive care plan related to the use of Resident 9's Buspar and Depakote. The DON stated the seizure care plan did not list Depakote as a targeted intervention and the anxiety care plan did not list Buspar as a targeted intervention. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and the behavioral assessment policy stated the interdisciplinary team will evaluate behavioral symptoms and develop a plan of care accordingly.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two sampled residents, Resident 11 and Resident 125, both of whom had type 2 diabetes mellitus and a history of renal dialysis. The facility’s records showed that Resident 11 had orders for insulin lispro before meals and insulin glargine at bedtime, and the location administration reports documented repeated injections in the right arm over multiple dates. Resident 11 stated she preferred insulin injections in her right arm, did not like injections in her abdomen, and her left arm had a dialysis access site. For Resident 125, the physician order included insulin lispro by sliding scale before meals and at bedtime. The location administration report showed repeated insulin glargine injections in the abdomen, including multiple administrations in the left upper quadrant and right lower quadrant. During interviews, LVN 1 and LVN 3 stated that the residents received injections to the same site on multiple occasions and that insulin injections should be given to different sites because repeated use of the same site can affect subcutaneous tissue and insulin absorption. The DON stated insulin injections should follow professional standards of practice by rotating injection sites and that failure to rotate injection sites can cause bruising to the skin. The facility’s policy titled Insulin Administration stated insulin may be injected into the upper arm, thighs, or abdomen and that injection sites should be rotated, preferably within the same general area.
Failure to assess ROM, splint tolerance, and declining ambulation
Penalty
Summary
The facility failed to provide appropriate ROM and mobility services for three residents. Resident 101 was admitted with diagnoses including osteoarthritis, polyneuropathy, and morbid obesity, and the MDS showed functional limitations in both lower extremities. The care plan included knee extension splints and restorative ROM services. However, the order for both knee splints was changed from 30 minutes to two to four hours three times a week without a PT evaluation or assessment to establish safe wear time. During observation, the resident stated staff were putting the splints on for about 40 minutes at a time, and RNA 1 later stated the resident usually wore the knee braces for about an hour. OT 1 and PT 1 stated therapy staff were responsible for evaluating splints and determining tolerable wear time, and OT 1 stated there was no PT intervention or assessment around the time the wear time was increased. Resident 101’s PT evaluation dated 7/13/2025 documented impaired right and left knees, but it did not include objective ROM measurements for either knee. OT 1 stated the evaluation did not show how impaired the knees were, and PT 1 stated that when a joint has impaired ROM, the expectation is to document the measurements and degrees of ROM. Resident 55 was admitted with parkinsonism, anxiety disorder, and muscle wasting and atrophy, and the MDS showed functional ROM limitations in both lower extremities and one upper extremity. The OT evaluation dated 9/26/2025 identified impaired ROM in the left index, middle, ring, and little fingers, and the PT evaluation identified impaired ROM in the right ankle, but neither evaluation included objective measurements. OT 1 stated the evaluations did not indicate how impaired the joints were, and PT 1 stated ROM measurements and degrees should be documented during evaluation. Resident 113 was admitted with diabetes mellitus, difficulty walking, and pressure induced deep tissue damage of the sacral region. The resident stated they used to walk with staff using a walker but had become weaker and no longer walked with staff. The restorative order initially included ambulation with a front wheel walker three times weekly, and RNA documentation showed ambulation declined from 150 feet in July to 80 feet and then 40 feet in August. RNA 1 stated changes or decline should be reported to the LVN or DON, and the MDS coordinator stated the physician should be notified when ambulation declines from 150 feet to less than 100 feet. LVN 1 stated the physician should have been notified when the distance ambulated was trending down, and the DON and MD stated a decline in ambulation should be reported so the provider is aware and can evaluate the resident.
Failure to Record Foley Output for Two Residents
Penalty
Summary
The facility failed to monitor urine output for two sampled residents who had indwelling urinary catheters. Resident 15 was admitted with diagnoses including history of malignant neoplasm of the large intestine, type 2 diabetes, and presence of urogenital implants, and had a physician order for an indwelling catheter to gravity drainage. Resident 15’s MDS dated 9/25/2025 indicated moderate cognitive impairment, and during observation on 11/20/2025 at 8:16 a.m., the resident was noted to have an indwelling urinary catheter draining pale yellow liquid. Resident 121 was admitted and readmitted with diagnoses including chronic kidney disease, benign prostatic hyperplasia, and presence of urogenital implants. The resident’s MDS indicated severe cognitive impairment and dependence on staff for all ADLs, and the Admit/Re-Admit Nursing Evaluation dated 11/12/2025 at 10:30 p.m. documented a foley catheter in place. During a concurrent interview and record review on 11/20/2025 at 3:45 p.m., the records for Residents 15 and 121 showed no foley output recorded. The RNS stated the facility does not measure or record foley catheter urinary output unless there is a physician order, while the DON stated output was not measured unless ordered and that measuring output was important to prevent dehydration. The facility policy titled Catheter Care, Urinary stated the purpose was to prevent catheter-associated urinary tract infections and to maintain an accurate record of residents’ daily output.
GT Feeding Formula Not Provided and Documented as Ordered
Penalty
Summary
The facility failed to ensure gastrostomy tube feeding formula was provided and documented as ordered for two residents with GTs. Resident 28 was admitted with dysphagia, gastrostomy, and cerebral infarction affecting the left side of the body. The resident’s H&P described the resident as alert and cooperative, and the MDS showed the resident required extensive assistance with transfers, hygiene, showering, dressing, and bed mobility. During observation, Resident 28’s GT formula was seen dated with a start time that did not match the physician’s ordered 2 p.m. start time, and the feeding pump was observed off at one point and on at another. Resident 2 was admitted and readmitted with diagnoses including dysphagia, gastrostomy, and cerebral infarction, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed the resident required dependent assistance from two or more staff for transfers, hygiene, showering, dressing, and bed mobility. During observation, Resident 2’s GT formula was seen dated with start times that did not match the ordered 2 p.m. start time, including one container dated from the prior day and another started at 6 p.m., with the feeding pump turned on. During interview and record review, LVN 7 stated the GT feeding label should reflect the ordered 2 p.m. start time, the tubing should be changed when a new container was hung, and the amount of nutrition delivered should be documented. The DON and MDSC stated the nursing staff should have followed the physician’s order to start new formula at 2 p.m. daily and document the amount delivered. Review of the MARs for both residents showed no documentation of the amount of nutrition delivered per shift or per day. The facility policy for continuous pump enteral feeding required the formula label to be dated and timed when hung and required documentation of the date and time, amount and type of enteral feeding, and assessment data.
BIPAP Care and Maintenance Not Completed
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident 20 by not maintaining the resident’s BIPAP machine as indicated in facility policy and the BIPAP user guide. Resident 20 was readmitted with diagnoses including COPD and chronic respiratory failure, and the MDS indicated intact cognition. The resident’s orders directed BIPAP use from 8 p.m. to 7 a.m. every evening and night shift. During observation at the bedside, the resident’s BIPAP machine was found with water still in the humidifier canister, and an LVN stated the water used for the machine was purified water. Record review and staff interviews showed that BIPAP machine, mask, tubing care, and maintenance were not completed and were not documented in the resident’s records. The DON stated that if BIPAP machine, masks, tubing care, and maintenance were not documented, it was not done. The facility policy required distilled water in the humidifier, weekly cleaning of the humidifier and tubing, daily cleaning of masks and tubing, and regular replacement of filters. The BIPAP user guide also directed regular cleaning and checking of the tubing assembly, humidifier, and mask, weekly cleaning of the humidifier and tubing, daily emptying of the humidifier, and replacement of the air filter at least every 6 months or as needed.
CNA Passed Non-Pureed Food to Resident on Puree Diet
Penalty
Summary
The facility failed to ensure that one sampled CNA was competent and knowledgeable about serving a pureed diet when passing a meal tray to a resident. Resident 13 was admitted with hemiplegia and a contracture of the left hand, and the MDS dated 9/11/2025 indicated severe cognitive impairment, impairment of one upper extremity, and receipt of a mechanically altered and therapeutic diet. The facility's Diet Type Report dated 11/20/2025 showed a current physician's order for a fortified pureed diet. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was in bed with a meal tray set up and placed in front of her by CNA 3, and the tray contained scrambled eggs that were not pureed. In interview, CNA 3 stated she set up the tray and described the eggs as soft and like normal scrambled eggs, but not pureed, and acknowledged that Resident 13 was on a puree diet. A CK stated a puree diet had to be completely smooth with no chunks, and that the morning meal included scrambled eggs with cheese that would have looked different if it had been pureed. The RNS and DON both stated that serving the incorrect diet was risky and that CNAs were responsible for verifying the meal ticket matched the resident's ordered diet when passing trays.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that CK 1 was competent in preparing pureed scrambled eggs and oatmeal. The facility’s recipe for pureed eggs required the eggs to be pureed in a food processor or blender to a paste consistency before adding liquid, and the recipe for pureed hot cereal required the cereal to be pureed and then thinned until smooth and free of lumps. During interview, CK 1 stated that when he prepared scrambled eggs with cheese, he did not use a food processor or blender and instead mashed the eggs by hand, and for oatmeal he prepared it as usual without any modification. CK 1 also stated that they never puree the oatmeal and that it is very liquidy. The Dietary Supervisor stated she expected cooks to prepare the proper food texture according to the recipe and that pureed foods should be put in a blender or food processor to ensure the texture was smooth and free of lumps. She confirmed that CK 1 told her he had not pureed the oatmeal and had mashed the scrambled eggs by hand, and she stated that was incorrect. The job description for the cook indicated the cook was to prepare meals and cook food according to standardized recipes and special diet orders. The report states that 27 residents on a puree diet were placed at risk for receiving eggs and oatmeal that were not completely smooth and without lumps.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to serve food at the correct temperature for one sampled resident, Resident 131. Resident 131 was admitted with diagnoses including hypoglycemia, DM, GERD, and major depressive disorder, and the admission evaluation indicated the resident was alert and oriented and needed assistance with all ADLs. The order summary showed a diet order for consistent carbohydrate and no added salt regular texture diet starting on 11/10/2025. During interview, Resident 131 stated the food was not always delivered warm. At the kitchen tray line, the pancake temperature was checked and found to be 130.8 degrees Fahrenheit. The Dietary Supervisor reviewed the daily food temperature log and stated pancakes should have been 140 degrees Fahrenheit and that waffles or pancakes were not checked as indicated in the log, and the temperature that day was below the recommended temperature. The Registered Dietician also confirmed the pancake should have been 140 degrees Fahrenheit. The facility policy titled Meal Service, 2023, stated pancakes should be served at 140 F or higher and that the goal was to serve hot foods hot.
Incorrect Diet Consistency Served to Resident with Puree Order
Penalty
Summary
The facility failed to ensure that Resident 13 received the puree diet ordered by the physician. Resident 13 was admitted with diagnoses including hemiplegia and a contracture of the left hand, and her MDS dated 9/11/2025 indicated severe cognitive impairment, impairment of one upper extremity, and that she was receiving a mechanically altered and therapeutic diet. The facility’s Diet Type Report dated 11/20/2025 showed a current physician order for a fortified puree diet. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was in bed with her meal tray set up by CNA 3, and the tray contained scrambled eggs that were not pureed. CNA 3 later stated the eggs looked like normal scrambled eggs and were not pureed. CK 1 stated a puree diet must be completely smooth with no chunks and that the morning meal included scrambled eggs with cheese that would not look like a puree plate. RNS 4 reviewed the record and stated the resident’s previous minced and moist diet had been changed to puree due to dental status, and the DON stated that receiving the incorrect diet consistency could lead to difficulty swallowing and aspiration. The facility policy stated diets must be prescribed by the attending physician and tray identification was used to ensure residents received the ordered diet.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
Food was not stored and prepared under safe and sanitary conditions in the kitchen. During observation, staff personal belongings were seen on a kitchen cart in the food preparation area, and the Dietary Supervisor stated those items did not belong in the kitchen. In a separate observation, the food preparation sink had a red bucket labeled sanitizer in it while the sink was designated for food preparation only, and the Registered Dietician stated the sanitizer should not be in that sink while food was being prepared. During breakfast service, the pancake temperature was checked and found to be 130.8 degrees Fahrenheit. The Dietary Supervisor reviewed the Daily Food Temperature Log and confirmed the pancake should have been 140 degrees Fahrenheit. The menus and food temperature logs from 11/2/2025 to 11/19/2025 showed there were days when breakfast meat, pancakes, or waffles were not checked before service. The Registered Dietician stated food temperatures for pancake, toast, and breakfast meat should be checked prior to serving to ensure the food was warm when residents received it and to prevent foodborne illness. The ice machine was observed with a black unidentified substance on the inside, and the Maintenance Supervisor stated the inside of the ice machine was dirty. In the residents' refrigerator, one resident had opened and undated sliced cheese and deli meat, and another resident had undated fried chicken. The first resident had intact cognition and needed set-up assistance when eating, and the second resident had moderate cognitive impairment and also needed set-up assistance when eating. The Registered Dietician stated residents' food should be dated so residents would not acquire food borne illnesses.
Inaccurate RNA Documentation in Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents when RNA documentation did not match what occurred during care. For one resident with hemiplegia, a left-hand contracture, and severe cognitive impairment, the record showed an RNA feeding program order for breakfast and lunch. During observation, the resident fed herself while staff did not remain with her throughout the meal, and the RNA later stated he only set up the tray and left the room. He confirmed he did not feed the resident at breakfast or lunch and did not spend the documented 20 minutes with her, yet the task record showed the feeding program was completed for both meals. For another resident with osteoarthritis, polyneuropathy, morbid obesity, and lower-extremity ROM limitations, the care plan and order required both knee extension splints for two to four hours three times a week or as tolerated. The RNA daily documentation on one treatment day stated both splints were applied and tolerated for two hours. However, the resident was observed without the splints, stated they were worn for about 40 minutes, and the RNA later stated he had applied them for only 45 minutes and removed them after about one hour because the resident could not tolerate them longer. He acknowledged he documented two hours because that was what the order indicated and that the entry was not accurate. For a third resident with diabetes, difficulty walking, and a sacral pressure-related deep tissue injury, the weekly RNA documentation did not match the daily RNA documentation regarding ambulation distance from 8/3/2025 through 10/4/2025. The resident stated she used to walk with a walker and staff but had become weaker and no longer walked with staff. The RNA stated the weekly documentation should accurately reflect the daily documentation and that the records did not match. The facility policy stated documentation in the medical record must be complete and accurate.
Infection prevention and control failures with hand hygiene, tube feeding line handling, water management documentation, and C-diff isolation
Penalty
Summary
Staff failed to perform hand hygiene when entering and exiting a resident’s room. Resident 5 had diagnoses including hemiplegia, hemiparesis affecting the right dominant side, a gastrostomy tube, and stiffness of the right shoulder, elbow, and hand. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills and dependence for multiple ADLs. During observation, an LVN was seen not performing hand hygiene before entering the room or after exiting, and the LVN stated hand hygiene should be done before and after exiting the room and before interacting with the resident, but acknowledged it was not done during the observation. Staff also failed to replace a tube feeding line when it was found on the floor without a cap. Resident 96 had diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, a gastrostomy tube, and Type 2 DM. The resident’s H&P indicated the resident could make needs known but could not make medical decisions, and the MDS showed moderately impaired cognitive skills and dependence for all ADLs. During observation, the feeding tube connected to the resident was on the floor with no cap covering the end connected to the resident. An LVN later confirmed the tubing observed was the same tubing and stated that if tubing was on the floor, it would need to be replaced because it was exposed to dirt and increased the risk of infection due to contamination. The facility also failed to implement and document control measures per its water management program and failed to monitor, document, and implement contact isolation precautions for Resident 131. The maintenance supervisor stated the facility was only monitoring resident room water temperatures and boiler/water heater maintenance logs, and there were no other monitoring logs for control measures and limits. The infection preventionist and DON stated the water management program should have included monitoring and documenting control measures and limits to reduce the risk of Legionella. For Resident 131, the record showed diagnoses including UTI, pseudomonas infection, and DM, and the resident had active diarrhea with loose stools documented on multiple days. Contact isolation for stool C-diff was ordered on 11/14/2025, but the infection preventionist stated the resident should have been placed on contact isolation while awaiting test results and that staff did not follow through with the NP note indicating continued vancomycin and contact isolation. The infection preventionist also stated there was no documentation explaining why contact isolation was discontinued, and staff were observed or reported using hand hygiene practices inconsistent with the facility’s C-diff and isolation policies.
Failure to Document COVID-19 Vaccination for a Resident and Staff
Penalty
Summary
The facility failed to administer the coronavirus vaccination for one sampled resident and failed to offer and educate coronavirus vaccinations for three sampled employees in accordance with facility policy. Resident 5 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction. The resident's H&P dated 3/18/2025 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 9/17/2025 indicated severe cognitive impairment and dependence for multiple activities of daily living, including oral hygiene, toileting hygiene, upper and lower body dressing, and bathing. During record review, the Infection Preventionist Nurse stated the resident's responsible party gave consent for the coronavirus vaccine on 9/17/2025, but there was no documentation that the vaccine was actually received. For staff, the Infection Preventionist Nurse reviewed the Employee Tracking Record for Vaccination for 2025 and stated that RNS 3, LVN 8, and CNA 4 did not have a vaccine consent form for the 2025 coronavirus vaccine. The IPN stated the consent form serves as proof that the employee was educated about the vaccination risks and benefits. The DON stated it was important to educate and document staff coronavirus vaccinations to protect residents and staff from a coronavirus outbreak, and stated that 100% of employees should have been educated and offered the vaccine before and during respiratory season. The facility policy required documentation that staff were offered the vaccine or information on obtaining it, were provided education on benefits and risks, and had informed consent or verification of vaccination or exemption/delay.
Failure to Inform Resident About Insulin Site Rotation Risks
Penalty
Summary
The facility failed to inform one of two sampled residents, a resident with type 2 DM, dependence on renal dialysis, and cataract, of the risks associated with repeated subcutaneous insulin injections in the same anatomical site. The resident was admitted to the facility on 12/6/2023 and later readmitted, and the H&P dated 9/15/2025 indicated the resident had the capacity to understand and make decisions. The MDS dated 9/18/2025 indicated intact cognition and that the resident required varying levels of assistance with eating, oral hygiene, toileting hygiene, and bathing. Physician orders dated 9/14/2025 and 9/15/2025 included insulin lispro 3 units subcutaneously three times daily and insulin glargine 10 units subcutaneously at bedtime for DM. During interview, the resident stated she preferred insulin injections in her right arm, did not like injections in her abdomen, and her left arm had a dialysis access site. She stated she was not aware of the risks associated with repeated use of the same site for insulin injections. The LVN reviewed the MAR, location of administration report, and progress notes and stated the resident received injections to the same site on multiple occasions and that there was no documentation showing education about insulin site rotation. The DON stated residents had the right to refuse care and treatment, but nursing staff must educate residents that repeated injections in the same site can cause bruising or harm. The facility policy on Resident Rights stated residents have the right to be informed of and participate in their care planning and treatment and to participate in decision making regarding their care.
Failure to Notify Physician of Declining Ambulation
Penalty
Summary
The facility failed to notify the physician when Resident 113’s ambulation distance declined. Resident 113 was admitted with diagnoses including DM, difficulty walking, and a pressure-induced deep tissue injury of the sacral region, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS showed intact cognition and varying levels of assistance needed for ADLs. The resident stated they previously walked with a walker and staff but had become weaker and no longer walked with staff. Physician orders included a restorative ambulation program with a front wheel walker three times per week or as tolerated, with documentation of walking distance. RNA documentation showed the resident ambulated 150 ft weekly in July 2025, then 80 ft during the week of 8/3/2025 to 8/9/2025, and 40 ft during the week of 8/10/2025 to 8/16/2025. RNA 1 stated changes such as decline should be reported to the LVN or DON, who would notify the physician. The MDSC stated the physician was notified later in October for lower back pain, right leg weakness, and refusal to ambulate, and that ambulation declines from 150 ft to less than 100 ft should be communicated to the physician. LVN 1 stated the physician should have been notified by 8/11/2025 when the distance was trending down, and the DON and MD both stated the physician should be notified when ambulation declines. The facility policy required the nurse to notify the attending physician or on-call physician when there is a significant change in the resident’s physical, emotional, or mental condition.
Psychotropic Medication Used Without Clear Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that mirtazapine was used to treat a medical condition that was diagnosed and documented in the medical record for one resident. Resident 9 was admitted and later readmitted with diagnoses including anxiety disorder and seizure disorder, but the admission record did not list major depressive disorder. The resident’s history and physical from 6/9/25 also did not identify depression or major depressive disorder as a current diagnosis or part of past medical history. The resident’s order summary showed mirtazapine 7.5 mg by mouth at bedtime was prescribed on 7/7/25 for depression manifested by poor appetite. However, review of the clinical record and psychiatric progress notes dated 8/18/25 and 9/14/25 did not list depression or major depressive disorder as active diagnoses, and the MDS assessment dated 9/17/25 did not identify depression as an active diagnosis in Section I. During interview, the DON stated the facility failed to ensure the medication was used for a diagnosis clearly documented in the medical record between 7/7/25 and 11/9/25, and stated the 11/9/25 psychiatric note was the first available documentation of depression even though the medication had been continuously used since 7/7/25.
MDS Did Not Reflect Resident’s Anxiety Disorder
Penalty
Summary
The facility failed to ensure the MDS accurately reflected Resident 74’s condition. Resident 74 was admitted with diagnoses including major depressive disorder. A review of the resident’s MDS dated [DATE] showed moderate cognitive impairment, setup assistance with eating, moderate assistance with oral hygiene and upper body dressing, and dependence for toileting hygiene, bathing, and lower body dressing. During a concurrent review with the MDSC, the resident’s record also showed an order for Ativan 0.5 mg every 6 hours as needed for anxiety manifested by physical restlessness, and the care plan documented new episodes of anxiety manifested by physical restlessness and combativeness. The MDSC stated the psychiatry note dated 10/27/2025 indicated Resident 74 was diagnosed with anxiety, but the MDS dated [DATE] did not indicate an anxiety disorder. The MDSC stated the anxiety disorder should have been reflected in the MDS. During interview, the DON stated the MDS assessment should accurately reflect the resident to ensure the resident is receiving proper care and treatment. The facility policy on Charting and Documentation stated documentation in the medical record should be objective, complete, and accurate.
Failure to Update Care Plan for Insulin Injection Site Preference
Penalty
Summary
The facility failed to revise the comprehensive care plan for one sampled resident who preferred not to have subcutaneous insulin injection sites rotated. Resident 11 was admitted on 12/6/2023 and later readmitted, with diagnoses including type 2 DM, dependence on renal dialysis, and cataract. The H&P dated 9/15/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 9/18/2025 indicated intact cognition. Physician orders dated 9/14/2025 and 9/15/2025 included insulin lispro 3 units subcutaneously three times daily and insulin glargine 10 units subcutaneously at bedtime for DM. During interview, Resident 11 stated she preferred insulin injections in her right arm, did not like injections in her abdomen or left arm where she had a dialysis access site, and said she was not informed of the risks associated with repeated use of the same injection site. A concurrent interview and record review with an LVN showed Resident 11 received injections to the same site on multiple occasions, and there was no documentation of an updated care plan addressing the resident’s preference and associated risks. The DON stated residents have the right to refuse care and treatment, but nursing staff must educate residents that repeated injections in the same site can cause bruising or harm, and that the care plan must be updated by an RN or LVN for changes to resident care or condition.
RNA Feeding Program Not Supervised During Meals
Penalty
Summary
The facility failed to ensure that a resident on the restorative nursing assistant (RNA) feeding program was supervised during meals. Resident 13 was admitted with hemiplegia and a contracture of the left hand. Her MDS dated 9/11/2025 indicated severe cognitive impairment, impairment of one upper extremity, and a need for supervision or touching assistance. Her order summary showed an order for the RNA feeding program with breakfast and lunch. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was positioned in bed with her meal tray set up in front of her, but staff did not stay with her during the meal. Later that day at 12:22 p.m., she was observed feeding herself lunch, ate the vegetables, and did not consume the meat or potatoes before RNA 1 removed the tray. CNA 3 stated staff only set up the tray and did not stay in the room while she ate. The QAN and DON stated RNA staff were supposed to remain with the resident throughout the meal, assist with feeding, supervise safe eating, and encourage intake. RNA 1 stated he only set up the tray and left because he had other residents to attend to.
Failure to Remove Unneeded Peripheral IV Catheters
Penalty
Summary
The facility failed to discontinue peripheral IV catheters for two residents after IV therapy was no longer ordered. One resident was admitted with a history of malignant neoplasm of the large intestine and type 2 diabetes and had moderate cognitive impairment. On observation, the resident was found with an IV on the right wrist covered by a dry dressing and stated she had pain at the IV site and did not know why it was still present. The registered nurse supervisor confirmed the resident had received two days of IV hydration that ended, but the IV catheter remained in place with an insertion date 8 days earlier, despite the facility stating IV catheters should be removed after 3 to 4 days or when therapy is completed. A second resident, who had chronic kidney disease, benign prostatic hyperplasia, and urogenital implants, had severe cognitive impairment and was dependent on staff for all ADLs. The resident's nursing evaluation documented an IV on the right-hand side, and later observation showed an IV line on the right forearm. The registered nurse supervisor confirmed there was no physician order for an IV line and no IV hydration or medications ordered, and stated the IV line should be discontinued because there was no indication for it. The DON stated IVs can remain in place up to 4 days and should be discontinued as soon as possible once treatment is completed, and the facility policy stated peripheral IV catheters are to be removed when therapy is discontinued.
Failure to Complete Ordered Specialty Consults
Penalty
Summary
The facility failed to ensure that Resident 113 was assessed by a neurologist and a wound doctor as ordered by the physician. Resident 113 was admitted with diagnoses including DM, difficulty walking, and pressure-induced deep tissue damage of the sacral region. The H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed intact cognition with varying levels of assistance needed for activities of daily living. Record review and staff interviews showed a physician order dated 6/23/2025 for a neurology consult, and another order dated 6/30/2025 scheduled a neurologist appointment for 10/28/2025 at 9:00 a.m. LVN 1, the SSD, and the TN each stated there was no documentation that transportation was arranged or that the resident went to the neurologist appointment, and no documentation that the neurologist saw the resident. The TN also stated there was a physician order dated 10/6/2025 for a wound doctor consult for bilateral heel intact, blood filled blisters, but there was no documentation that the wound doctor saw the resident.
Failure to Obtain Ordered Valproic Acid Level
Penalty
Summary
The facility failed to monitor a resident’s valproic acid level related to the use of Depakote for seizure disorder as ordered by the physician. Resident 9 was admitted with diagnoses including anxiety disorder and seizure disorder, and her history and physical noted fluctuating capacity to understand and make decisions. She was prescribed Depakote DR 500 mg by mouth twice daily, and the consultant pharmacist recommended monitoring the valproic acid level with the next scheduled lab draw. The attending physician later ordered routine laboratory monitoring, including the valproic acid level, to be drawn every three months in November, February, May, and August on the second Tuesday of the month, with no other orders to hold, cancel, or delay the test. The final lab report showed that all other ordered labs were drawn and reported, but there was no requisition for the valproic acid level and no indication that it had been canceled by the physician. The DON stated the facility failed to monitor the valproic acid level as required by the physician’s order.
Incorrect Texture Toast Served to Resident
Penalty
Summary
The facility failed to serve regular texture toast to one of three sampled residents, Resident 98. Resident 98 was readmitted to the facility with diagnoses including DM, GERD, and major depressive disorder. The MDS dated 9/1/2025 indicated Resident 98 had intact cognition and needed set-up assistance when eating. The Order Summary Report showed that starting on 11/11/2025, Resident 98 was ordered a consistent carbohydrate diet, no added salt, with regular texture. During an interview on 11/19/2025, Resident 98 stated she wanted regular toast but was receiving it chopped up and mushy. In a concurrent interview and record review, the Dietary Supervisor reviewed the resident's Diet Profile card and found it listed mechanical soft and toast not toasted, which she stated was wrong because the resident's diet order was for regular texture. The Registered Dietician stated staff should follow the menu and the ordered diet texture so residents can eat it and prevent weight loss. The facility policy on Menu Planning stated the diet manual and physician-ordered diets should mirror the nutritional care provided by the facility.
Arbitration Agreement Not Explained in Resident-Understood Language
Penalty
Summary
The facility failed to ensure the binding arbitration agreement was explained in a language the resident could understand for two sampled residents. Resident 78 was admitted with diagnoses including type 2 DM, HTN, and hemiplegia. The H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS identified Spanish as the preferred language. The arbitration agreement dated 10/12/2023 showed the resident signed an English version. During interview, Resident 78 stated he could not recall signing the agreement and said he would have remembered and understood it if it had been written in Spanish. Resident 82 was admitted and later readmitted with diagnoses including type 2 DM, HTN, and muscle weakness. The H&P documented memory impairment and forgetfulness, and the MDS indicated moderately impaired cognition. The arbitration agreement dated 6/6/2023 showed the resident’s signature, but during interview Resident 82 could not recall what she had signed or the purpose of the agreement. The AA stated the agreement should have been explained in a manner residents could understand, including through an interpreter and simple terms, and that the RP should have been contacted if a resident was confused or forgetful. The DON stated that if a resident’s preferred language was not English, an interpreter had to be used to ensure understanding before signing, and that confused or forgetful residents needed RP involvement. The facility policy stated the agreement must be explained in a form and manner the resident understands, including in a language the resident understands.
Missed Weekly Hospice Nurse Visits
Penalty
Summary
The facility failed to ensure that a resident under hospice care was visited by hospice licensed nurses weekly as required by the hospice care agreement. The resident was admitted and readmitted with diagnoses including respiratory failure, dysphagia, gastrostomy, and cerebral infarction affecting the right side of the body. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident required dependent assistance from two or more staff for transfers, hygiene, showering, dressing, and bed mobility. A review of the hospice staff visitation flow sheet showed hospice licensed nurse visits on several listed dates, but the LVN stated the nurses did not visit weekly during 9/2025 and early 10/2025, and facility staff did not follow up regarding the missed visits. The physician’s certification for hospice benefit indicated the family agreed to skilled nursing visits once weekly and CHHA visits twice weekly. The DON stated staff should have followed up to ensure the weekly hospice licensed nurse visits occurred as agreed. The resident’s OSR ordered hospice care under routine level of care, with skilled nursing visits once a week and CHHA visits twice a week, and the care plan stated hospice staff would render care during their visits.
Failure to Follow Physician Orders and Secure Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not following physician orders and facility policies regarding controlled substances. For one resident with low back pain and difficulty walking, the physician had discontinued Hydrocodone-Acetaminophen 10-325mg and ordered a lower dose of 5-325mg. However, staff continued to dispense and administer the 10-325mg tablets, with no documentation of tablet splitting or proper disposal of unused portions. The resident confirmed receiving the full 10-325mg tablet, and staff interviews revealed uncertainty about the administration process and a lack of adherence to the new order. In another instance, a bottle of Lorazepam Intensol, a controlled substance prescribed for anxiety, was found stored in an unlocked refrigerator in the medication room, contrary to facility policy requiring controlled substances to be kept in a locked container separate from non-controlled medications. Staff interviews indicated a misunderstanding of the storage requirements, with some believing the locked refrigerator was sufficient, while others acknowledged the need for an additional lock on the narcotic container. Additionally, the same bottle of Lorazepam Intensol for the second resident remained in the refrigerator six months after the medication had been discontinued by the physician. Staff failed to remove and properly dispose of the discontinued narcotic, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that discontinued controlled substances should be promptly removed and destroyed to prevent accidental administration.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open left thigh wound requiring daily dressing changes. The Treatment Nurse (TN) did not wear a gown while preparing to perform the dressing change and was unaware that EBP was required for the resident, believing that the absence of an indwelling device meant EBP was unnecessary. There was also no EBP signage posted outside the resident's room to alert staff of the need for these precautions. The resident had a history of a left femur fracture, multiple pelvic fractures, and muscle weakness, and was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care for a ruptured blood blister on the left medial thigh extending to the knee, including cleansing, application of Santyl ointment, and covering with gauze. Observations confirmed that the TN did not don a gown before starting the dressing change, and the lack of signage meant other staff were not alerted to the need for EBP. Interviews with the TN, Infection Preventionist (IP) Nurse, and Director of Nursing (DON) revealed a lack of understanding and oversight regarding the implementation of EBP for residents with open wounds. The facility's policy required EBP for residents with wounds, but both the IP and DON were unaware that the resident's wound was still open and being treated, resulting in the failure to implement appropriate precautions and signage.
Failure to Maintain Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that the medical records of two residents, Resident 18 and Resident 83, were up to date concerning advance directives, as per the facility's policy and procedure. Resident 18, who was moderately impaired in cognitive skills and required maximal assistance with self-care, had an advance directive acknowledgment form filled out in 2022. However, the Social Service Director (SSD) was unaware of who completed the form and acknowledged that it was not valid. The SSD stated that the form should have been discussed with Resident 18's responsible party (RP), who would need to fill out the form. Resident 83, who was severely impaired in cognitive skills and dependent on staff for self-care, had an advance directive acknowledgment form dated 9/11/2024. The form indicated that neither the resident nor the RP had executed an advance directive and did not wish to do so at the time. However, the SSD could not confirm which family member provided verbal consent, nor whether the consent was given over the phone or in person, rendering the form incomplete and invalid. The facility's policy, revised in December 2016, requires that residents be provided with information about their right to formulate an advance directive. If a resident is incapacitated, this information should be given to their legal representative. The policy also mandates that the existence of an advance directive be prominently displayed in the medical record. The Director of Nursing (DON) emphasized the importance of having an advance directive to ensure the facility is aware of the resident's or family's wishes regarding end-of-life care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to provide accurate information in the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in care and services. Resident 81 was admitted with multiple diagnoses, including atrial fibrillation, congestive heart failure, and dementia. The MDS for Resident 81 indicated moderate cognitive impairment and maximal assistance needed for self-care and functional abilities, with no use of bedrails. However, an observation revealed that the upper side rails were in use, contrary to the MDS documentation. The MDS Coordinator confirmed the use of side rails for aiding and turning in bed, stating it did not meet the criteria of a restraint, and thus did not affect the MDS coding. Similarly, Resident 83's MDS indicated severe cognitive impairment and dependency on self-care and functional abilities, with no use of bedrails. An observation showed the upper side rails were up, contradicting the MDS. The MDS Coordinator again confirmed the use of side rails for aiding and turning, stating it did not meet the criteria of a restraint. The facility's policy required a change in status assessment when a restraint is used, which was not reflected in the MDS. The MDS 3.0 Section P guidance specifies that if bedrails meet the definition of a physical restraint, their use must be coded as such, which was not done in these cases.
Failure to Update Fall Risk Care Plans
Penalty
Summary
The nursing staff failed to update and revise the fall risk care plans for two residents, which had the potential to place them at risk for recurrent falls. Resident 106 was admitted with an amputation above the knee, lack of coordination, and difficulty walking. Despite a fall on 9/21/2024, the care plan was not updated to reflect this incident. The resident's initial fall risk assessment indicated they were not at risk, but the care plan was not revised after the fall, as confirmed by the Director of Staff Development. Resident 170, diagnosed with dementia, Alzheimer's disease, and hypertension, was identified as a high fall risk with a score of 13 on the fall risk assessment. After a fall on 1/8/2024, the care plan was not updated to reflect this incident. The Director of Nursing verified that the care plans for both residents were not updated following their falls, which is crucial for monitoring the effectiveness of interventions. The facility's policy requires care plans to be updated with any significant changes, but this was not adhered to in these cases.
Failure to Implement Dietary Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to implement the recommendations of the Registered Dietitian (RD) in a timely manner and did not adequately assess, monitor, and evaluate interventions to prevent further weight loss in two residents. Resident 42, who had a history of dementia, dysphagia, and pressure-induced deep tissue damage, experienced significant weight loss. The RD recommended an appetite stimulant, Megestrol Acetate, on August 6, 2024, but the order was not placed until August 29, 2024. Additionally, the facility did not consistently monitor Resident 42's weekly weights or document the intake of nutritional supplements, such as Boost Plus, which were often not consumed in full due to the resident feeling too full during meals. Resident 79, diagnosed with muscle wasting, congestive heart failure, and malnutrition, also experienced significant weight loss. The RD recommended Boost Glucose Control to be administered twice daily on August 13, 2024, but the order was not effectively implemented. The supplement was initially ordered on August 15, 2024, but was discontinued the same day without clear documentation or rationale. The resident continued to lose weight, and the facility did not conduct weekly weight assessments to monitor the effectiveness of interventions, as recommended by the RD. The facility's policies and procedures for weight assessment and intervention, as well as nutritional assessment, were not adequately followed. The multidisciplinary team failed to prevent, monitor, and intervene for undesirable weight loss, as evidenced by the lack of timely implementation of dietary recommendations and insufficient documentation of residents' nutritional intake and weight changes. This oversight placed both residents at risk for continued weight loss and associated health complications.
Deficiencies in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in their duties, leading to two significant issues. Firstly, during an observation in the dishwashing area, it was found that the Dishwasher (DW) and Dietary Aide (DA2) were not knowledgeable about the correct concentration strength of the chlorine sanitizer used in the dish machine. DW incorrectly tested the sanitizer concentration with dirty gloves and misread the acceptable range, while DA2 was also unsure of the correct range. The Dietary Supervisor (DS) confirmed that both DW and DA2 were absent during the in-service training on sanitizers, leading to their confusion between chlorine and quaternary sanitizers. The facility's policy indicated that the acceptable range for chlorine sanitizer should be 50-100 PPM, but DW and DA2 were not aware of this due to their absence from training. Secondly, Cook1 did not follow standardized recipes when preparing a pureed diet, resulting in a chunky texture that was not smooth, and failed to prepare enough zesty meat sauce to meet the residents' needs. Cook1 admitted to rushing and not adding enough liquid to the spaghetti mixture, and also miscalculated the amount of meat needed, leading to a shortage. Cook1 did not notify the Dietary Supervisor when the meat sauce ran out, which could have allowed for alternative arrangements. The facility's recipe for spaghetti with zesty meat sauce required the use of milk for liquid, which was not followed. The cook's job description emphasized the importance of planning food quantities and reporting any issues, which was not adhered to in this instance.
Failure to Follow Pureed Diet Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on a specific date, affecting 16 residents on a pureed diet. The pureed spaghetti served was observed to be dry, lumpy, and contained large pieces of pasta that required chewing, contrary to the requirements of a pureed diet which should be smooth and not require chewing. During an interview and taste test, both the Dietary Supervisor (DS) and the Registered Dietitian (RD) confirmed the inappropriate texture of the pureed spaghetti. Cook1 admitted to not blending the spaghetti long enough and not adding sufficient broth, attributing the error to rushing, which resulted in a texture that could pose a choking risk to residents. Additionally, the facility did not follow the lunch menu and portion sizes as prescribed for residents on a pureed diet. The residents received 1/2 cup of pureed meat sauce instead of the required 2/3 cup, and they did not receive the pureed garlic bread as listed on the menu. Cook1 acknowledged using the wrong scoop size and forgetting to prepare the pureed garlic bread, which could lead to inadequate nutritional intake for the residents. The facility's policy and menu planning guidelines were not followed, as confirmed by a review of the facility's menu and portion guide.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Firstly, there was no soap available at the handwashing sink in the kitchen, which was noted when a cook attempted to wash their hands. The cook and the dietary supervisor acknowledged the absence of soap, which is crucial for infection control and preventing foodborne illnesses. The facility's policy emphasizes the importance of having soap readily available for handwashing. Additionally, the facility did not properly label and store food items. Observations revealed a plastic bag of thawed raw sliced beef and logs of ground beef without thaw dates, as well as an open container of cottage cheese and a container of juice without open dates. A house shake was stored in a milk gallon, which posed a risk of contamination. The dietary supervisor admitted to not knowing when the beef was thawed and acknowledged the importance of labeling food with thaw and use-by dates to ensure safety. Furthermore, food brought in by residents from outside the facility was improperly stored. In the resident refrigerator, leftover food and TV dinners were found without use-by dates, and the TV dinners were not stored frozen as per manufacturer instructions. The dietary supervisor confirmed that the food was not labeled according to policy and should be discarded. The facility's policy requires perishable foods to be labeled with the resident's name, item, and use-by date, and stored in a refrigerator with tightly fitting lids.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for four out of five sampled residents, leading to the administration of antibiotics without meeting the McGeer Criteria. Resident 39 was admitted with conditions including Parkinsonism, Bullous Pemphigoid, and Type II Diabetes Mellitus. Despite being prescribed Doxycycline for Bullous Pemphigoid, the McGeer's Criteria documentation did not meet the necessary subcriteria for antibiotic use. Additionally, Resident 39 was given Amikacin Sulfate for a urinary tract infection without meeting the required subcriteria. Resident 96, who was readmitted with a urinary tract infection and ESBL resistance, was prescribed Cephalexin. However, the McGeer's Criteria form lacked the necessary subcriteria to justify the antibiotic's use. Similarly, Resident 37, admitted with hemiplegia and other conditions, was prescribed Bactrim for folliculitis, but the McGeer's Criteria documentation only met two of the required four subcriteria. Resident 42, readmitted with pneumonia and a urinary tract infection, was given Ceftriaxone for bronchitis. The McGeer's Criteria form did not indicate any subcriteria to justify the antibiotic's administration. The Infection Preventionist Nurse acknowledged the lack of documentation and follow-up to determine the effectiveness of the antibiotics, which is crucial to ensure residents are not on unnecessary antibiotics.
Failure to Ensure Timely Eye Care Follow-Up
Penalty
Summary
The facility failed to ensure timely follow-up with an optometrist and referral to an ophthalmologist for a resident diagnosed with glaucoma and other eye conditions. The resident, who was admitted with a history of end-stage renal disease, diabetes, left eye blindness, and glaucoma, was seen by an optometrist in March, who recommended a follow-up visit in six months. However, the facility did not arrange this follow-up appointment, nor did they refer the resident to an ophthalmologist, despite the resident's concerns about worsening vision in the right eye. The resident's medical records indicated a need for regular eye care due to his conditions, including glaucoma and diabetes, which can lead to complications such as diabetic retinopathy. Despite this, the facility's interdisciplinary team meetings and care plan did not address the necessary follow-up with eye care specialists. The resident's care plan included interventions for medication administration and monitoring for eye problems, but it lacked specific actions for ensuring timely optometry and ophthalmology consultations. Interviews with facility staff, including the Social Service Director, Registered Nurse Supervisor, and Director of Nursing, revealed an acknowledgment of the oversight in arranging the necessary follow-up care. The facility's policies and procedures required the coordination of ancillary services, including eye care, but these were not effectively implemented for the resident, leading to a deficiency in maintaining the resident's vision care needs.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of a controlled medication, specifically morphine sulfate ER, for Resident 10. During an observation and interview with a Licensed Vocational Nurse (LVN 1) at the West Station Cart 1, a discrepancy was noted between the Narcotic and Hypnotic Record and the medication card. The record indicated two doses were left, but the medication card contained only one dose. LVN 1 admitted to administering the missing dose earlier in the morning but failed to sign the Narcotic and Hypnotic Record at that time. The facility's policy on controlled substances, revised in April 2019, requires that controlled substances be reconciled upon administration. The nurse administering the medication is responsible for recording the time of administration, the quantity of medication remaining, and their signature. LVN 1 acknowledged that failing to sign the log could result in the resident receiving a controlled substance more often than prescribed, potentially leading to medical complications.
Failure to Address Pharmacist's Recommendation for Medication Review
Penalty
Summary
The facility failed to ensure that a physician responded to a consultant pharmacist's recommendation for a gradual dose reduction (GDR) of Depakene solution for a resident diagnosed with bipolar disorder. The consultant pharmacist had recommended on 8/3/24 that the physician consider reducing the dose or provide a clinical rationale for not doing so. However, there was no documentation in the resident's clinical record indicating that the physician responded to this recommendation. The resident had been on the same dose of Depakene since August 2022, and the facility did not document any contraindications for a dosage reduction. During an interview, the Director of Nursing (DON) acknowledged that the facility failed to ensure the physician responded to the pharmacist's request. The DON stated that the GDR request involved two medications, but only one was addressed, and there was no specific response regarding Depakene. The facility's policy required a licensed nurse to contact prescribers and document their responses, with follow-up if no response was received within 10 business days. However, this procedure was not followed, increasing the risk of adverse effects for the resident.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to discontinue the medication hydroxyzine for a resident, despite a physician's order to do so due to non-use. The resident, who was admitted with multiple sclerosis and had the capacity to make decisions, was prescribed hydroxyzine for itching but had not used it between August and October 2024. Instead, the resident's itching was effectively managed with Benadryl, another medication for itching and allergies. A consultant pharmacist recommended discontinuing hydroxyzine, and the physician agreed, provided it was not being used. However, the facility documented that the resident declined to have it discontinued, stating she still used it. The Director of Nursing acknowledged that the facility failed to follow the physician's order to discontinue hydroxyzine, as the Medication Administration Report showed no doses had been administered since August 2024. The facility's policy requires that medication regimens include only necessary medications, and the physician should identify when medications should be tapered or discontinued. The failure to discontinue hydroxyzine, despite its non-use and the effective management of symptoms with Benadryl, was a deficiency in adhering to the facility's medication therapy policy.
Failure to Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) or document a clinical rationale for not doing so for a resident prescribed Depakene solution for bipolar disorder. The resident, who was admitted with a diagnosis of bipolar disorder, had been on the same dose of Depakene since August 2022. A consultant pharmacist recommended a dose reduction or a documented rationale for not reducing the dose, but there was no response from the physician to this request, nor was there any documentation indicating a change in the medication dosage. During an interview, the Director of Nursing (DON) acknowledged the facility's failure to ensure the physician responded to the pharmacist's request for a GDR. The DON confirmed that the GDR request involved two medications, but only one was addressed, leaving the Depakene dose unchanged. The facility's policy on tapering medication and GDR, which requires periodic review of medication necessity and appropriate tapering, was not followed in this case, increasing the risk of adverse effects for the resident.
Failure to Assess Resident's Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to assess the mental capacity of a resident before having them sign a legally binding arbitration agreement. The resident, who was admitted with diagnoses including cerebral infarction, bipolar disorder, anxiety disorder, and dementia, was found to have moderately impaired cognitive skills according to their Minimum Data Set (MDS). Despite this, the resident's admission record showed that they had signed the arbitration agreement, which was meant to resolve disputes within the facility rather than in court. Interviews and record reviews revealed that the resident did not recall being informed about the arbitration agreement and did not recognize their signature on the document. The resident's family also confirmed that the resident was unable to sign for themselves due to a stroke. The Admissions Assistant admitted uncertainty about the resident's capacity to sign and stated that a facility staff member had signed the document, indicating it was the resident's signature. The facility's arbitration agreement required that it be explained to the resident or their legal representative in a manner they could understand, which was not adhered to in this case.
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What surveyors actually found near you
We read the 5,571 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marlora Post Acute Rehab Hosp | 0.1 mi | ★★★★★ | 31 | 1 |
| Coral Cove Post Acute | 0.5 mi | ★★★★★ | 45 | 0 |
| Ocean Ridge Post Acute | 0.5 mi | ★★★★★ | 23 | 0 |
| Shoreline Healthcare Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Bel Vista Healthcare Center | 0.6 mi | ★★★★★ | 3 | 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.