Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Paradise Valley Health Care during CMS and state inspections, most recent first.
A resident with a periprosthetic right knee fracture was admitted with hospital orders for non-weightbearing (NWB) status on the right lower extremity and continuous use of a right knee immobilizer locked in extension, including during bed-to-chair transfers. The facility did not initiate or revise the care plan or admission orders to include NWB status or immobilizer use at the time of admission, and these orders were only entered later. Multiple CNAs and an RNA reported they were unaware of the resident’s immobilizer needs or weightbearing status, despite a sign in the room stating the immobilizer must be on at all times. A nurse acknowledged that NWB and immobilizer orders were not carried over on admission, and the DON stated that the plan of care should have included weightbearing status and immobilizer use and been communicated to all staff.
A resident with a periprosthetic right knee fracture was admitted with hospital orders for non‑weight bearing (NWB) on the right lower extremity and continuous use of a right knee immobilizer locked in extension, with PT to perform bed‑to‑chair transfers while maintaining NWB status. These orders were not entered into the physician order sheet or incorporated into the care plan at admission, and orders for the leg brace to be on at all times and to remain NWB were not started until weeks later. CNAs and an RNA reported they were unaware of the resident’s immobilizer requirements or weight‑bearing status, even though a sign at the bedside and the resident himself indicated the immobilizer was to remain on at all times. The DON acknowledged the importance of communicating weight‑bearing status and immobilizer use to staff, and the facility was unable to provide a policy for splint/immobilizer use, resulting in a failure to follow MD orders and to implement necessary safety measures.
A facility failed to ensure the PASARR was completed correctly for a resident with schizophrenia. The resident's diagnosis was not reflected in the PASARR, and the necessary Resident Review was not initiated within the required timeframe, potentially leaving the resident's mental health needs unmet.
A resident with severe cognitive deficits and a history of CHF was not weighed as ordered, leading to a five-pound weight gain within a week without notifying the MD. The facility lacked a formal system for communicating weight orders, relying on informal methods, which contributed to the oversight.
A resident with severe cognitive deficits and a history of congestive heart failure was at risk for pressure ulcers and had a deep tissue pressure injury upon admission. The facility failed to set the resident's low air loss (LAL) mattress according to the correct weight, as it was consistently set at 250 pounds instead of the resident's actual weight of 189 pounds. Staff acknowledged the incorrect setting but did not adjust it, and the Director of Nursing confirmed the importance of correct settings for pressure ulcer prevention.
The facility failed to provide timely care for the dialysis access sites of two residents, risking clotting. One resident's pressure dressing was not removed within the recommended 4-6 hours, contrary to physician orders. Another resident's post-dialysis care was not documented or performed timely. The facility's policy lacked specific guidance on dressing removal timing, contributing to the oversight.
Two residents were prescribed psychotropic medications without appropriate indications or monitoring of target behaviors. One resident was given quetiapine for dementia, which is not a psychotic diagnosis, and the other was prescribed lorazepam for anxiety without a proper diagnosis or target behavior, as the resident was non-verbal. The facility's policy on antipsychotic medication use was not followed, leading to potential unnecessary medication use.
A resident with immunodeficiency and an infection on her knee received wound care from an LN who failed to perform hand hygiene between glove changes, risking cross-contamination. The facility's policies require hand sanitization after glove removal, but this was not followed during the observed care.
A resident with multiple diagnoses, including diabetes and chronic kidney disease, repeatedly refused medications, but the facility failed to develop and implement a care plan to address these refusals. Interviews with staff and record reviews confirmed the lack of a care plan, highlighting poor documentation practices.
The facility failed to ensure staff were competent in managing a resident's diabetes by not notifying the medical doctor about multiple medication refusals, including insulin. Interviews with staff confirmed the importance of MD notification for adjusting medications and managing the resident's health condition.
Failure to Care Plan and Implement NWB and Immobilizer Orders for Orthopedic Resident
Penalty
Summary
The facility failed to develop and implement an appropriate care plan and admission orders to ensure safety interventions were in place for a resident with a periprosthetic fracture around an internal prosthetic right knee joint. The resident was admitted with hospital discharge instructions specifying non-weightbearing (NWB) status on the right lower extremity and continuous use of a right knee immobilizer locked in extension, including for bed-to-chair transfers. Despite these orders, the facility did not initiate or revise the resident’s care plan to include NWB status or immobilizer use upon admission, and these orders were not carried over to the physician’s order sheet at the time of admission. The leg brace order was not entered until later in the month, and the NWB and immobilizer orders were only documented several days after admission. During interviews, multiple staff members, including CNAs and a restorative nursing assistant, reported they were unaware of the resident’s need for a splint/immobilizer or his weightbearing status, even though a sign in the resident’s room indicated that the right knee immobilizer was to be on at all times. The resident himself stated that his immobilizer needed to be on at all times and that he participated in therapy exercises. A licensed nurse confirmed that the care plan had not been initiated or revised for NWB orders at admission and that immobilizer use was not in place at that time. The DON stated that the immobilizer and plan of care should have included the resident’s weightbearing status and that this information should have been communicated to all staff. The facility was unable to provide a policy and procedure for comprehensive care plans.
Failure to Implement and Communicate NWB and Immobilizer Orders for Orthopedic Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for non‑weight bearing (NWB) status and continuous right knee immobilizer use for a resident admitted with a periprosthetic fracture around an internal prosthetic right knee joint. Hospital discharge summaries directed that the resident remain non‑weight bearing on the right lower extremity, with the knee immobilizer applied full‑time and locked in extension, and that PT perform bed‑to‑chair transfers with the resident remaining NWB. Despite these orders being in place at the time of admission, the resident’s NWB status and immobilizer use were not entered into the physician order sheet or incorporated into the care plan upon admission. Licensed nursing staff later acknowledged that NWB and immobilizer orders were not initiated at admission and that orders for the leg brace to be on at all times and to remain NWB on the right lower extremity with PT bed‑to‑chair transfers were not started until several weeks after admission. Surveyor interviews further showed that direct care staff were unaware of the resident’s immobilizer and weight‑bearing requirements. Two CNAs stated they did not know whether the resident used an immobilizer and were unaware of his weight‑bearing status, and an RNA reported the resident was not on the splint/immobilizer list and that he did not know the resident’s weight‑bearing status. During observation, the resident was noted to have a sign at the bedside stating the right knee immobilizer was to be on at all times, and the resident confirmed that the immobilizer needed to remain on continuously and that he participated in therapy exercises. The DON stated it was important that the immobilizer use and weight‑bearing status be communicated to all staff and that LNs were expected to follow up on orthopedic precautions, but the facility could not provide a policy and procedure for splint/immobilizer use. The surveyors concluded that the failure to carry out NWB and continuous immobilizer orders placed the resident at risk for worsening of the fracture, unsafe movement of the injured limb, potential falls, and additional injury.
Failure to Correct PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed correctly for a resident with a diagnosis of schizophrenia. Upon admission, the resident's diagnosis of schizophrenia was not reflected in the PASARR, dated March 21, 2024, nor in a subsequent PASARR dated June 10, 2024. This discrepancy was identified during a joint interview and record review with the Minimum Data Set (MDS) Nurse, who acknowledged that the PASARR should have been reviewed and corrected to reflect the resident's serious mental illness. The Director of Nursing (DON) also confirmed that the PASARR should have been revised to ensure the resident received appropriate mental health treatment. A directive from the California Department of Health Care Services indicated that the facility is required to initiate a Resident Review when there is a variance between the Minimum Data Set and the screening from the hospital. The facility did not initiate the necessary Resident Review within the required 72 hours of identifying the variance, leading to the potential for the resident's mental health needs to be unmet.
Failure to Monitor CHF Patient's Weight as Ordered
Penalty
Summary
The facility failed to provide resident-centered care in accordance with professional standards for a resident with congestive heart failure (CHF). The resident, who had severe cognitive deficits, was admitted with a history of CHF and was under orders for daily weights to be taken three times a week. However, the facility did not adhere to these orders, as the resident's weight was not consistently monitored as prescribed. This oversight was identified during interviews and record reviews, where it was revealed that the resident gained five pounds within a week, a significant indicator of worsening CHF symptoms, yet the medical doctor was not notified of this weight gain. The deficiency was further highlighted by the lack of a formal system for communicating weight orders to the Restorative Nurse Assistants (RNAs), who relied on informal methods such as a cheat sheet. The Director of Nursing acknowledged that the facility did not meet the professional standards of practice for the resident's CHF care plan, as the weight gain was not reported to the physician, potentially delaying necessary care. The facility's policy was supposed to align with the American Heart Association's guidelines, which emphasize the importance of monitoring weight changes in CHF patients.
Failure to Adjust LAL Mattress Settings for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were set according to the physician's order for a resident at risk for pressure ulcers. Resident 47, who was admitted with a history of congestive heart failure and severe cognitive deficits, was identified as being at risk for pressure ulcers and had a deep tissue pressure injury (DTPI) upon admission. Despite this, the LAL mattress for Resident 47 was consistently set at 250 pounds, which did not match the resident's recorded weight of 189 pounds. This discrepancy was observed during multiple visits, and the staff, including a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), acknowledged the incorrect setting but did not adjust it. The Director of Nursing (DON) confirmed that the LAL mattress was intended to manage the DTPI on Resident 47's heels and emphasized the importance of setting the mattress correctly to prevent further pressure ulcer injuries. However, the LN admitted to not knowing how to adjust the mattress settings and indicated that the maintenance director was responsible for such adjustments. The facility's policy on pressure ulcer prevention and the manufacturer's guidelines both highlighted the necessity of setting the mattress according to the patient's weight, which was not adhered to in this case.
Failure to Provide Timely Dialysis Access Care
Penalty
Summary
The facility failed to provide proper care for the dialysis access sites of two residents, leading to a potential risk of clotting. Resident 2, who was readmitted with end-stage renal disease, had a pressure dressing on his left upper arm dialysis access that was not removed in a timely manner. Observations and interviews revealed that the pressure dressing was left on for longer than the recommended 4-6 hours, contrary to the physician's order and care plan. The Licensed Nurses (LNs) were expected to check and remove the pressure dressing to prevent clotting, but this was not done, as confirmed by both the outpatient dialysis nurse and the Director of Nursing (DON). Similarly, Resident 78, who also had end-stage kidney disease, experienced a lapse in post-dialysis care. After returning from dialysis, the pressure dressing on Resident 78's dialysis site was not changed within the recommended 4-6 hours. Interviews with the LNs and a review of the resident's medical records showed a lack of documentation regarding post-dialysis care and dressing changes. The DON confirmed that the expectation was for the LNs to provide timely post-dialysis care to prevent complications such as infection and clotting. The facility's policy on hemodialysis access care did not provide specific instructions on the timing for removing access dressings, contributing to the oversight. Both residents had clear physician orders for the removal of pressure dressings, which were not followed, leading to the potential risk of clotting at the dialysis access sites. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure in adhering to established care protocols for residents requiring dialysis.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to provide appropriate indications and monitor target behaviors for the use of psychotropic medications for two residents, leading to potential unnecessary medication use. Resident 16 was prescribed quetiapine, an antipsychotic medication, for dementia, which is not a psychotic diagnosis. The medication was not listed in the hospital discharge paperwork, and there was no clear indication for its use, as the resident did not exhibit sudden mood changes with agitation. The responsible party was unaware of the medication, and the Director of Nursing acknowledged that the indication for quetiapine should have been questioned and clarified. Resident 134, who was non-verbal and had no capacity to understand or make decisions, was prescribed lorazepam for anxiety without a proper diagnosis or target behavior. The resident's clinical record did not indicate a diagnosis of anxiety, and the target behavior for lorazepam was verbalizing anxiety, which was not possible due to the resident's non-verbal status. The staff, including the MDS nurse and the Director of Nursing, recognized that the indication for lorazepam should have been clarified to prevent unnecessary medication use and confusion among staff members. The facility's policy on antipsychotic medication use requires re-evaluation of such medications upon admission and within two weeks, and states that diagnoses alone do not warrant their use. However, this policy was not followed for Residents 16 and 134, resulting in the inappropriate use of psychotropic medications without proper indications or monitoring of target behaviors.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during wound care for a resident with immunodeficiency and an infection on her right knee. The resident, who was readmitted with an unstageable pressure sore on her right heel, was observed receiving wound care from a Licensed Nurse (LN) who did not perform hand hygiene consistently after removing gloves. The LN prepared supplies, removed old dressings, and applied new ones without sanitizing her hands between glove changes, which is a critical step in preventing cross-contamination and infection. During an interview, the LN admitted to not performing hand hygiene after glove removal, citing that she usually brings a spray for this purpose but forgot it on the day of observation. The Director of Nursing confirmed that the facility's expectation is for staff to sanitize their hands every time gloves are removed to prevent cross-contamination. The facility's policies on wound care and infection prevention emphasize the importance of hand hygiene, yet these procedures were not adhered to during the observed wound care session.
Failure to Develop and Implement Care Plan for Medication Refusals
Penalty
Summary
The facility failed to ensure a care plan for a resident's refusal of medications was developed and implemented. The resident, who was admitted with diagnoses including orthopedic aftercare following surgical amputation, diabetes with chronic kidney disease, had multiple instances of refusing medications such as Gabapentin, insulin glargine, and a tuberculin test. Despite these refusals being documented in the resident's medical records and medication administration records, no care plan was created to address these refusals. Interviews with various staff members, including CNAs, LNs, the PT, the ADON, and the DON, confirmed the lack of a care plan and highlighted the importance of having one to ensure all healthcare providers are aware of the resident's care needs. The ADON and DON acknowledged the deficiency, noting that the absence of a care plan for the resident's medication refusals was due to poor documentation by the nursing staff. The facility's policy and procedure on requesting, refusing, or discontinuing care or treatment indicated that a reassessment and appropriate changes to the care plan should occur if a resident's refusal of treatment results in a significant change of condition. However, this policy was not followed, leading to the deficiency in the resident's care plan documentation.
Failure to Notify MD of Medication Refusals
Penalty
Summary
The facility failed to ensure staff were competent in managing a resident's diabetes when they did not notify the resident's medical doctor about his medication refusals. The resident, who was admitted with diagnoses including orthopedic aftercare following surgical amputation, diabetes with chronic kidney disease, had multiple episodes of refusing medications such as Gabapentin, tuberculin test, and insulin glargine. Despite these refusals, the medical doctor was not notified, which was against the facility's policy that requires MD notification after two or more consecutive refusals of treatment or medications. Interviews with the licensed nurse, assistant director of nursing, and director of nursing confirmed the importance of notifying the medical doctor to adjust the resident's medications and manage his overall health condition. The failure to notify the MD was documented in the resident's medication administration record and nursing progress notes, highlighting a significant lapse in following the facility's policy and ensuring proper medical oversight for the resident's care.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Manor Nursing & Rehab Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Reo Vista Healthcare Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Hillcrest Manor Sanitarium | 1.6 mi | ★★★★★ | 20 | 0 |
| National City Post Acute | 1.8 mi | ★★★★★ | 25 | 0 |
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