Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Pico Rivera Healthcare Center during CMS and state inspections, most recent first.
Unsafe Food Holding and Storage Practices: Kitchen staff failed to keep cold foods at safe temps when broccoli salad and yogurt were held above required limits during tray line service, with an ice bath not fully surrounding the yogurt containers. Surveyors also found improperly sealed dry goods, a can of diced red peppers without a received date, and resident refrigerator items lacking time labels needed to track the 72-hour storage limit.
Medication administration errors occurred during a med pass when an LVN gave aspirin from a bottle without a visible expiration date, gave gabapentin without checking the resident’s RR despite an order to hold if RR was below 12, and substituted fish oil for an ordered omega-3 product without clarifying the order. The DON stated nurses should verify ordered parameters and that the therapeutic interchange form did not list fish oil and [NAME] oil.
Failure to Ask Resident Preference Before Placing Bib During Meals: A resident with asthma, HTN, and moderately impaired cognition was observed wearing a bib at breakfast, and he stated staff placed it on him without asking if he wanted to wear it. His record showed he had the capacity to make decisions, and his care plan directed staff to involve him in decision-making and encourage his choices. A CNA and the DON both stated he should be asked for permission before a bib is placed on him because it is a dignity issue.
Improper Filing of Psychiatric Notes in Another Resident's Record: The facility failed to keep medical records private when a resident's psychiatric progress notes were filed in another resident's chart. One resident had dementia, major depressive disorder, and severely impaired cognition, while the other resident had intact cognition and could request access to her medical record. The MRS and ADM confirmed the notes were filed incorrectly and stated this was a HIPAA violation.
A resident with dementia, agitation, and depression received Depakote for bipolar disorder even though psychiatry notes and the PA did not diagnose bipolar disorder. The MAR showed repeated Depakote administration over multiple months, while staff acknowledged the diagnosis list and MDS included bipolar disorder based on a telephone order rather than the prescriber’s evaluation. The DON and MDS nurse stated the resident could have received unnecessary medication because the bipolar diagnosis was not supported by the psychiatric assessment.
Inaccurate MDS Coding of Bipolar Disorder: A resident with dementia, agitation, and depression was coded on the MDS as having bipolar disorder even though psychiatry notes and the PA did not diagnose bipolar disorder. The order summary included Depakote for bipolar disorder, which confused the MDSN, but the LVN and DON stated the resident’s psychiatric evaluations did not support that diagnosis and that the MDS should not have added it.
A resident with bipolar disorder, major depressive disorder, severe cognitive impairment, and psychotropic medication use had a significant change in mental condition with increased behavioral disturbances, confusion, and refusal of care. The MDSN and DON stated a new PASRR Level 1 should have been completed because the prior PASRR was negative and no longer matched the resident’s updated diagnoses and treatment needs, but it was not submitted.
A resident with dementia, legal blindness, and severely impaired cognition and vision had an unwitnessed fall after attempting to self-toilet. The RN said a post-fall evaluation was completed by nursing, while the DON stated the facility no longer held IDT meetings after falls and used the post-fall evaluation instead, even though it did not include input from other departments or reevaluate fall-prevention interventions.
Unlabeled G-Tube Feeding Bottle: A resident with a g-tube, severe cognitive impairment, and diagnoses including dementia and malnutrition had a tube feeding bottle observed hanging by the bed without the resident’s name or the date and time it was opened. The bottle was seen twice with only the rate written on it, while the LVN and DON stated nurses were responsible for labeling the formula bottle with the resident’s name, date, and time to identify the correct feeding and track how long it had been in use.
Respiratory Monitoring and Oxygen Documentation Deficiencies: An LVN observed a resident with new wheezing, gave a PRN breathing tx, and placed the resident on O2, but did not document the O2, complete a COC assessment, or document required VS and respiratory assessments. The resident was later transferred to the hospital and diagnosed with hypoxic respiratory failure and septic shock. In a separate finding, another resident on O2 had no No Smoking/Oxygen in Use sign posted outside the room, and staff confirmed the sign should have been displayed.
Fluid Restriction Not Followed for Resident Receiving Hemodialysis: A resident with ESRD, CHF, DM, and dialysis treatment had a physician order and care plan directing a fluid restriction with no water pitcher at bedside, yet surveyors observed a filled water pitcher on the bedside table. The LVN stated the pitcher should not have been given to the resident, and the DON confirmed fluid restriction orders for hemodialysis residents were important to prevent fluid retention or overload.
Inaccurate Controlled Medication Documentation for Tramadol: A resident with a right femur fracture and arthritis had tramadol orders for pain and before rehab. During review of the West Station med cart, the tramadol bubble pack count did not match the controlled drug record after an LPN stated he administered a dose but forgot to document it in the narcotic book. The DON stated controlled meds should be documented upon administration, and the facility policy required recording the resident name, quantity remaining, and nurse signature.
Medication Labeling and Storage Deficiencies: An LVN administered aspirin from a manufacturer bottle that lacked an expiration date, an East Station med room refrigerator was found at 50 F with multiple refrigerated meds and vaccines stored inside, and an opened Lantus Solostar pen for a resident with DM was kept in a med cart beyond the manufacturer’s 28-day in-use limit and was administered multiple times. The DON stated the aspirin bottle should have been replaced, the refrigerator temperature was out of range, and the expired insulin should have been removed earlier.
Failure to Offer Meal Substitutions: A resident with asthma, HTN, and moderately impaired cognition was observed at lunch with several uneaten items remaining on the tray. CNA did not ask why the resident did not eat the food or offer substitute items, despite the care plan directing staff to offer substitutes for refused or poorly eaten meals. The RD stated CNAs were expected to gather more information and provide available substitutes when a meal was refused or partially eaten.
A CNA placed a breakfast tray on a bedside table taken from another resident’s room without sanitizing it first, an LVN administered eye drops without washing hands after oral meds and PPE changes, and EBP signage was not displayed above a resident’s bed as required. The affected residents had significant cognitive impairment and diagnoses including DM, CKD, dementia, and MDRO-related precautions.
A resident with moderate cognitive impairment missed several doses of prescribed antibiotics for a UTI and refused a scheduled suprapubic catheter change. Nursing staff did not notify the PCP about the missed doses or the refusal, and documentation was lacking, despite facility policy requiring such notifications and documentation.
Three residents with respiratory conditions did not receive oxygen therapy as ordered, and their oxygen saturations were not accurately monitored while on supplemental oxygen. Nursing staff assessed oxygen levels on room air instead of during oxygen administration, and oxygen flow rates were not set according to physician orders. The DON confirmed that these actions did not follow physician orders or facility policy.
A facility failed to maintain resident confidentiality by not removing identifiable information from a GT feeding bottle before disposal. A resident's name was found on the bottle in the trash, contrary to the facility's policy. Staff acknowledged the oversight, emphasizing the need to de-identify information to protect privacy.
A facility failed to develop a care plan for a resident exhibiting teeth grinding behavior, despite the resident's severe cognitive impairment and dependence on staff. Staff interviews confirmed awareness of the behavior, which should have been addressed per the facility's care plan policy.
A facility failed to display 'No Smoking/ Oxygen in Use' signs for a resident using an oxygen concentrator, as required by policy. The resident, with severe cognitive impairment and multiple health issues, was observed without the necessary warning signs on multiple occasions. Staff acknowledged the oversight and the associated safety risks.
A facility failed to maintain a medication error rate below five percent, resulting in a 21.43% error rate. An LVN administered six oral medications simultaneously to a resident with dysphagia, leading to the resident's inability to swallow the medications properly. The resident's care plan required specific interventions for safe swallowing, which were not followed, resulting in a significant medication error.
A resident with dysphagia was not assessed for swallowing ability before medication administration, leading to a significant medication error. The LVN attempted to give multiple oral medications at once, contrary to the resident's care plan, resulting in the resident's inability to swallow the pills. The facility's policies for safe medication administration were not followed, posing a risk of aspiration or choking.
A resident with specific dietary needs was not offered alternative meals despite expressing dissatisfaction with the food provided. The resident, who was on a controlled carbohydrates, no added salt diet with a dysphagia mechanical soft texture, consistently ate less than 25% of her meals. Facility staff failed to follow policy by not offering an alternative menu, potentially impacting the resident's nutritional status and quality of life.
The facility failed to implement proper infection control practices for two residents. A resident with respiratory symptoms was not placed on isolation precautions, contrary to facility policy, risking infection spread. Another resident's nasal cannula was observed touching the floor, posing a risk of bacterial contamination and respiratory infection. Staff acknowledged these lapses, highlighting deficiencies in maintaining a safe environment.
Unsafe Food Holding and Storage Practices
Penalty
Summary
Food safety practices were not maintained in the kitchen when cold food items were held at unsafe temperatures during meal service. During observation, one cup of pre-plated broccoli salad measured 68 F and another cup held in an ice bin measured 66 F, even though the recipe required the salad to be refrigerated at less than 41 F until service and the Dietary Supervisor identified it as a potentially hazardous food containing dairy. The Dietary Supervisor stated the salad had not been identified or corrected before the observation and acknowledged it may have been on the tray line for approximately 30 to 45 minutes. Cold holding was also not properly maintained for bowls of yogurt during tray line or pre-service handling. The yogurt was observed in an ice holding bin, but the ice did not fully surround the containers, and one bowl measured 42.1 F. A Dietary Aide stated she had set up the ice holding bin and acknowledged it was not set up correctly because the ice bath should have covered the containers to maintain appropriate temperatures. Facility policies reviewed during the investigation stated cold foods and cold desserts were to be held at 40 F or less. Additional food storage deficiencies were identified in dry storage and in a resident refrigerator. One box of beans and one box of lentils were observed not adequately sealed in the dry goods rack, and a small can of diced red peppers was stored without a received date or expiration date. In Resident Refrigerator A, food items for two residents and one resident were not labeled with the time they were placed in the refrigerator. Staff stated the facility’s policy limited storage to 72 hours from the time received and required food items to be labeled with both date and time to determine when that limit had been exceeded.
Medication Administration Errors During Pass
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication pass, and the survey identified a 10.34% medication error rate involving two sampled residents. One error involved a resident with diagnoses including unspecified atrial fibrillation, hemiplegia, hemiparesis following cerebral infarction, and long-term anticoagulant use. During a medication pass, an LVN prepared aspirin 81 mg from a manufacturer bottle that did not have an expiration date visible. The LVN stated he could not find the expiration date on the bottle and planned to check the medication room after the pass, but he continued administering the aspirin along with the resident’s other medications. The resident’s order summary showed aspirin EC 81 mg daily for CVA prevention. The DON stated the aspirin bottle should have been replaced because it did not show an expiration date. A second resident with diagnoses including idiopathic peripheral autonomic neuropathy, ptosis, blepharochalasis, cataract, and varicose veins with pain was observed during medication administration by another LVN. The LVN entered the room with a blood pressure monitor and stated she did not need to check the resident’s BP because the resident was not on antihypertensive medications, and she planned to check vital signs later in the shift. The resident’s medication pass included gabapentin 100 mg with an order to hold for RR less than 12. The MAR documented gabapentin as administered even though the RR was recorded as 9 at the time of administration. During interview, the LVN stated she should have checked the RR before giving gabapentin and acknowledged that the medication should not have been administered if RR was less than 12. The same resident also had an order for omega-3 oral capsule 500 mg listed as [NAME] oil, but the medication pass included fish oil instead. The LVN stated she was not sure of the difference between fish oil and [NAME] oil and stated the facility would need to call the physician before changing medications. The DON stated nurses should check vital signs first when orders include parameters and stated that if RR was not checked as ordered, gabapentin could have caused respiratory depression and shortness of breath. The facility’s therapeutic interchange form listed omega-3 fatty acid interchanges such as Lovaza and Vascepa, but it did not list fish oil and [NAME] oil.
Failure to Ask Resident Preference Before Placing Bib During Meals
Penalty
Summary
The facility failed to ask one of two sampled residents, Resident 86, whether he preferred to wear a bib during meals. During a concurrent observation and interview on 4/7/2026 at 7:49 a.m., Resident 86 was observed wearing a bib while eating breakfast, and he stated that staff placed the bib on him without asking if he wanted to wear it. He said he could not remember the last time he wore a bib during meals and believed it was the facility's protocol, though he would have liked to have been given a choice. Resident 86's record showed he was initially admitted and later readmitted to the facility, with diagnoses including asthma and hypertension. His MDS dated 3/13/2026 indicated moderately impaired cognition and that he required set up and clean-up assistance with eating and oral hygiene, while his H&P dated 3/11/2026 stated he had the capacity to understand and make decisions. His care plans directed staff to allow him to be active in decision-making and to encourage his choices of care, clothes, and activity as capable. During interviews, a CNA stated Resident 86 should be asked whether he wanted to wear the bib before eating, and the DON stated wearing a bib could be a dignity issue and that Resident 86 should be given the opportunity to consent every time.
Improper Filing of Psychiatric Notes in Another Resident's Record
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when one resident's Psychiatric Progress Notes were filed in another resident's medical record. Resident 41 was admitted and readmitted to the facility, had diagnoses of dementia and major depressive disorder, and was documented in the MDS as having severely impaired cognition and requiring substantial assistance with multiple activities of daily living. Resident 41's H&P stated the resident did not have the capacity to understand and make decisions. Resident 52 was admitted and readmitted to the facility, had diagnoses of major depressive disorder and anxiety disorder, and was documented in the MDS as cognitively intact and dependent on staff for several activities of daily living. During a concurrent interview and record review, the Medical Record Supervisor found Resident 41's Psychiatric Progress Notes in Resident 52's medical record and stated they should not have been filed there. The MRS stated the incorrect filing was against facility protocol and a HIPAA violation, and that Resident 52 could request her medical records and receive Resident 41's notes. The Administrator also stated the notes should not have been filed in Resident 52's record and that they could expose Resident 41's information to someone who should not have access to it.
Unnecessary psychotropic medication use tied to unsupported bipolar diagnosis
Penalty
Summary
The facility failed to ensure that Depakote was prescribed and administered in accordance with the documented prescriber evaluation, diagnosis, and clinical indication for one resident. The resident’s record showed diagnoses including unspecified dementia, agitation, bipolar disorder, and major depressive disorder. The resident’s MDS indicated severely impaired cognition and need for assistance with multiple ADLs, and the order summary showed Depakote delayed release 250 mg twice daily ordered for bipolar disorder with uncontrollable extreme mood swings causing anger interfering with daily living activities. Record review showed the resident received Depakote repeatedly, including 15 administrations from 4/1/2026 to 4/8/2026, 62 administrations during March 2026, and 56 administrations during February 2026. During the concurrent interview and record review, the LVN stated the resident had dementia with behaviors and mood disorder symptoms, but the psychiatrist evaluation notes dated 3/13/2026, 3/7/2025, 12/5/2024, 4/4/2024, and 11/24/2023 did not indicate a diagnosis of bipolar disorder. The LVN stated the facility needed to remove bipolar disorder from the diagnosis list because the psychiatry provider did not diagnose it and there could be a risk the resident was on medication unnecessarily. The PA stated the resident had dementia with behavioral disturbances and depression, and stated the resident did not have bipolar disorder. The PA also stated it was not appropriate that MDS coded bipolar disorder as one of the diagnoses. The MDS nurse stated she became confused because a telephone order documented Depakote for bipolar disorder even though the PA did not diagnose bipolar disorder, and stated there was a risk the resident could have received unnecessary medications to treat bipolar disorder. The DON stated nursing staff were not qualified to diagnose and that if the psychiatry evaluation did not indicate bipolar disorder, the MDS should not have added bipolar disorder to the MDS.
Inaccurate MDS Coding of Bipolar Disorder
Penalty
Summary
The facility failed to accurately assess and code the MDS for one resident by documenting bipolar disorder without receiving that diagnosis from a physician. Resident 70’s record showed diagnoses including unspecified dementia, agitation, bipolar disorder unspecified, and major depressive disorder. The MDS dated [DATE] indicated the resident had severely impaired cognition, required supervision or touching assistance for some ADLs, and had an active diagnosis of bipolar disorder. The resident’s order summary report dated 4/8/2026 included physician orders for monitoring episodes of bipolar disorder and for Depakote 250 mg twice daily for bipolar disorder with uncontrollable extreme mood swings causing anger interfering with daily living activities. During interview and record review, the LVN stated the psychiatrist evaluation notes from 11/24/2023, 4/4/2024, 12/5/2024, 3/7/2025, and 3/13/2026 did not indicate bipolar disorder, even though the facility diagnosis list did. The LVN stated the diagnosis should be removed because the psychiatry provider did not diagnose bipolar disorder and there could be a risk the resident was on medication unnecessarily. The PA stated the resident had dementia with behavioral disturbances and depression, but did not have bipolar disorder, and that it was not appropriate for the MDS to code bipolar disorder as one of the diagnoses. The MDSN stated she became confused because a nurse documented a telephone order for Depakote for bipolar disorder, even though the PA did not diagnose the resident with bipolar disorder. The DON stated nursing staff were not qualified to diagnose and that if the psychiatry evaluation did not indicate bipolar disorder, the MDS should not have added it. The facility policy on certifying accuracy of the resident assessment stated that anyone completing a portion of the MDS must sign and certify the accuracy of that portion.
Failure to Update PASRR Screening After Mental Status Change
Penalty
Summary
The facility failed to submit a PASRR Level 1 Screening for one sampled resident after a significant change in mental condition. Resident 47 had diagnoses of bipolar disorder and major depressive disorder, severe cognitive impairment on the MDS dated 3/13/2026, and required substantial assistance with toileting, dressing, and footwear. The resident’s H&P dated 3/12/2026 stated the resident did not have the capacity to understand and make decisions, and physician orders dated 3/9/2026 included Depakote for mood disorder with angry outbursts and Mirtazapine for depression with poor oral intake. The record also showed a change in condition on 1/29/2025 with increased behavioral disturbances, leading the physician to transfer the resident to the GACH for evaluation. The GACH H&P dated 1/30/2026 documented major depressive disorder and bipolar disorder and admission for increased confusion and refusing care. A psychiatric progress note dated 3/7/2025 also documented diagnoses of major depressive disorder and bipolar disorder and use of psychotropic medication, including Depakote and Mirtazapine. During interviews, the MDS Nurse stated the facility was responsible for completing a new PASRR Level 1 when a resident experienced a significant change in mental condition, including a new mental illness diagnosis and/or psychotropic medication use. The MDS Nurse reviewed the resident’s prior PASRR Level 1 from 1/22/2021, which was negative for serious mental illness and psychotropic medication use, and stated a new Level 1 should have been completed and submitted to reflect the resident’s changed condition. The DON also stated that because of the resident’s diagnoses and psychotropic medication use, a new PASRR Level 1 should have been completed and submitted for a PASRR Level 2 assessment.
Failure to Conduct IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) meeting after a resident with dementia, legal blindness, and severely impaired cognition and vision had an unwitnessed fall. Resident 70 was assessed as a high fall risk and required partial assistance with several activities of daily living. On 3/31/2025 at about 3:15 a.m., the resident yelled for assistance, and an LVN found him sitting on the floor after he had attempted to get up and use the restroom. The post-fall evaluation documented that the resident attempted to self-toilet, which caused the fall. During interviews, the RN stated the post-fall evaluation was completed by a licensed nurse after a fall and included fall details, contributing factors, medication changes, vital signs, and physical findings. The DON stated the facility no longer conducted IDT meetings after falls and used the post-fall evaluation instead, but also stated the post-fall evaluation was not equivalent to an IDT meeting because it did not include input from other departments or reevaluate interventions to prevent further falls. The resident’s care plan included an IDT for falls, and the facility policy stated staff would identify interventions related to the resident’s specific risks and causes to prevent falls and minimize complications.
Unlabeled G-Tube Feeding Bottle
Penalty
Summary
The facility failed to ensure that one sampled resident with a gastrostomy tube had the tube feeding bottle labeled with the resident’s name and the date and time the bottle was opened. Resident 8 was admitted and readmitted to the facility with diagnoses including dementia, protein-calorie malnutrition, and adult failure to thrive. The resident’s MDS indicated severely impaired cognition, substantial assistance needs for personal care, and the presence of a g-tube. The H&P stated the resident did not have the capacity to understand and make decisions, and the physician ordered Nepro 1.8 Cal Formula at 55 mL/hr for 20 hours via pump. During observation, Resident 8 was seen in bed with the g-tube feeding hung on a pole next to the bed. The feeding bottle contained approximately 950 mL of the 1000 mL formula, had only “55” written next to the rate, and did not have the resident’s name or the start date and time on it. The same unlabeled bottle was observed again later while the resident was connected to the feeding at 55 mL/hr. An LVN stated the nurse was responsible for labeling a new g-tube feeding bottle with the resident’s name and the date and time it was opened, and the DON stated the licensed nurses were responsible for correctly labeling the feeding with the resident’s name, date, and time opened. The facility policy stated to document the initials, date, and time the formula was hung.
Respiratory Monitoring and Oxygen Documentation Deficiencies
Penalty
Summary
The facility failed to complete adequate respiratory monitoring, documentation, and assessments for one resident who developed new wheezing and required a PRN breathing treatment and oxygen. The resident had diagnoses including pneumonia, sepsis, myocardial infarction, dementia, and gastrostomy status, and the H&P noted fluctuating capacity to understand and make medical decisions. On 2/14/2026, an LVN observed wheezing near the end of the shift, administered a PRN breathing treatment, and placed the resident on 2 liters of oxygen, but did not document the oxygen administration. The LVN stated the resident was restless, removed clothing, and removed the nebulizer mask during treatment. The record review and staff interviews showed that a change of condition assessment was not completed after the resident developed wheezing and required oxygen. The LVN stated the new onset of wheezing, restlessness, and oxygen requirement should have been considered a change of condition and that she endorsed the change to the oncoming nurse but did not document it. The oncoming LVN stated a change of condition assessment was not completed and she did not realize it should have been done during her shift. The DON stated a change of condition assessment should have been completed when the resident was wheezing and required oxygen administration. The report also found missing vital signs documentation during the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift, and missing documentation of oxygen saturation and respiratory assessments after PRN breathing treatments. The resident was transferred to the hospital about eight hours after the change in condition and was diagnosed with hypoxic respiratory failure and septic shock, and was intubated and admitted to the ICU. In a separate finding, another resident who was ordered oxygen had no No Smoking/Oxygen in Use sign displayed outside the room entrance, and staff confirmed the sign should have been posted.
Fluid Restriction Not Followed for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure fluid restrictions were followed for a resident receiving hemodialysis. Resident 67 was admitted and later readmitted to the facility with diagnoses including ESRD, CHF, and DM. The resident’s H&P stated the resident had the capacity to understand and make own medical decisions, while the MDS indicated moderate cognitive impairment, moderate assistance needed for bathing, hygiene, and clean-up assistance for eating, and that the resident received dialysis treatments. The physician order dated 12/3/2025 directed a fluid restriction with no water pitcher at bedside, and the care plan titled "At risk for fluid volume deficit/excess" also directed staff to observe the fluid restriction and keep no water pitcher at bedside. During a concurrent observation and interview on 4/7/2026, a water pitcher filled with water was observed on the resident’s bedside table. The LVN stated the pitcher should not have been given to the resident. The DON stated that following fluid restriction orders for hemodialysis residents was important to ensure they do not retain fluid or develop fluid overload. The facility policy stated residents with fluid restricted diets were to receive no more than the prescribed amount and that the physician’s order for fluid restriction would be followed.
Inaccurate Controlled Medication Documentation for Tramadol
Penalty
Summary
The facility failed to ensure accurate documentation for one resident’s tramadol on the controlled medication count sheet/controlled drug record after the medication was administered. Resident 109 was admitted with diagnoses including aftercare for a right femur fracture and arthritis, and the history and physical indicated the resident had the capacity to understand and make decisions. The physician orders included tramadol HCl 25 mg by mouth every 8 hours as needed for moderate pain and tramadol HCl 25 mg prior to rehab for moderate to severe pain. During inspection of the West Station medication cart, the resident’s tramadol bubble pack contained 13 tablets while the controlled drug record showed 14 tablets remaining. The eMAR showed the last dose was documented as given at 9:59 a.m., and LVN 7 stated he administered tramadol around 10 a.m. but forgot to document it in the controlled medication book. LVN 7 stated the medication should have been documented right after administration, and the DON stated nurses should assess pain, remove the medication, document on the narcotic sheet, administer it, and then document on the eMAR. The facility’s Controlled Substances policy stated the administering nurse is responsible for recording the resident name, quantity remaining, and nurse signature upon administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
A deficiency was cited for failure to ensure drugs and biologicals were labeled and stored according to accepted professional principles and facility policy. During medication administration to a resident with a history of atrial fibrillation, hemiplegia, hemiparesis following cerebral infarction, and long-term anticoagulant use, an LVN prepared aspirin 81 mg from a manufacturer bottle that did not display an expiration date. The LVN stated the expiration date could not be found and that the bottle would be checked later, but the aspirin was still administered during the medication pass. The DON stated the bottle should have been replaced because it did not show an expiration date and that it was not safe and effective to administer aspirin without one. A second deficiency involved the East Station Medication Room refrigerator, which was observed at 50 F while containing multiple refrigerated medications and vaccines. Items stored there included an unopened emergency kit with lorazepam, Humalog and Novolin R insulin pens, Afluria flu vaccine syringes, Humulin R insulin vials, Epogen, Ozempic pens, Prolia, Novolog Flexpens, insulin glargine pens, insulin lispro pens, a glucagon pen, and an opened tuberculin vial. The manufacturer labeling required refrigerated medications to be stored between 36 F and 46 F, while glucagon was required to be stored at room temperature. Staff stated the refrigerator temperature was out of range and that pharmacy would need to be contacted to reorder medications. The DON stated medications stored outside the recommended temperature range would not be safe and effective for residents. A third deficiency involved an opened Lantus Solostar pen for a resident with type 2 diabetes mellitus and diabetic neuropathy. The pen was found in a medication cart with an open date that placed it beyond the 28-day in-use limit required by the manufacturer. The LVN stated the insulin should have been removed from the cart because it had expired and would not be effective if administered. The resident’s MAR showed the Lantus Solostar had been administered seven times after the expiration period. The DON stated the insulin should have been removed from the cart earlier and that use of expired insulin increased the risk for hypo- or hyperglycemia.
Failure to Offer Meal Substitutions
Penalty
Summary
The facility failed to offer meal substitutions to Resident 86 when portions of the lunch tray were not eaten. Resident 86 was initially admitted and later readmitted to the facility, with diagnoses including asthma and hypertension. The MDS dated 3/13/2026 indicated moderately impaired cognition and that the resident required set up and clean-up assistance with eating and oral hygiene. The H&P dated 3/11/2026 indicated the resident had the capacity to understand and make decisions, and a physician order dated 3/9/2026 specified a no added salt diet. The care plan for alteration in nutritional status directed staff to offer a substitute for any meals refused or with poor intake. During observation on 4/6/2026, Resident 86 received lunch and pointed to the potatoes, green beans, and bean salad, stating he would try them but probably would not eat them. Later that meal, the tray still contained the potatoes, green beans, and bean salad, and CNA 2 removed the tray without asking whether the resident wanted substitutions for the uneaten items. In interview, CNA 2 stated he should have asked why the resident did not eat those items and offered substitute foods. The RD stated CNAs were expected to gather more information when a meal was refused or partially eaten and to offer available substitutes, and the facility policy stated that if a resident refuses or is unhappy with the diet, staff will create a care plan that the resident is satisfied with.
Infection Control Measures Not Followed for Three Residents
Penalty
Summary
Infection control measures were not followed for three residents during observation, interview, and record review. Resident 74 had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and dementia, and was documented as severely cognitively impaired and unable to understand or make decisions. The resident also had an order for enhanced barrier precautions due to colonized ESBL in the urine and a care plan directing cleaning and disinfection of high-touch surfaces. During breakfast setup, a CNA removed a bedside table from another resident’s room, placed Resident 74’s breakfast tray on it, and brought it to Resident 74’s bedside without sanitizing the table first. The CNA stated the table had been taken from another resident’s room and had not been sanitized before use. Resident 49 had diagnoses including peripheral autonomic neuropathy, ptosis, blepharochalasis, cataract, and varicose veins with pain, and was documented as moderately cognitively impaired with dependence on staff for multiple ADLs. During medication administration, an LVN prepared multiple oral medications and artificial tears eye drops for the resident while wearing PPE for enhanced barrier precautions. After administering the oral medications and changing PPE, the LVN did not wash hands before administering the artificial tears eye drops. The LVN stated she should have administered the eye drops first and washed her hands before giving them to prevent infection and spread of infection. The DON also stated handwashing should have occurred before administering the eye drops to prevent contamination and spread of infection. Resident 75 had diagnoses including DM, chronic kidney disease, and dementia, and was documented as having severe cognitive impairment and requiring maximal assistance with bathing, toileting, and personal hygiene. The physician order indicated enhanced barrier precautions for colonized MDRO and IV site/tubing, and the care plan directed posting signage for enhanced barrier precautions. During observation in the resident’s room, an EBP sign was seen outside the door, but no sign was observed above the head of the bed. The CNA stated residents should have an EBP sign above the head of the bed to alert staff to use PPE, and the IPN stated there should be an EBP sign to let staff know PPE was required when providing care.
Failure to Notify PCP of Missed Antibiotic Doses and Catheter Change Refusal
Penalty
Summary
The facility failed to ensure that the primary care provider (PCP) was notified regarding missed doses of an antibiotic and a refusal of a suprapubic catheter change for one resident. The resident, who had moderate cognitive impairment and was dependent for activities of daily living, missed several doses of Macrobid prescribed for a urinary tract infection (UTI) on three separate occasions. Nursing staff did not inform the PCP about these missed doses, with one nurse stating the resident was at dialysis during medication times and another nurse indicating they did not think notification was necessary. Documentation in the resident's clinical record did not reflect PCP notification for the missed doses, and facility policy required that missed medications be documented and the PCP notified. Additionally, the same resident refused a scheduled suprapubic catheter change as ordered by the PCP. Nursing and wound care progress notes confirmed the refusal, but there was no documentation that the PCP was notified of this refusal. Interviews with nursing staff and review of facility policy revealed that the PCP should have been informed of the refusal to obtain further orders for monitoring and care. The facility's policies required notification of the PCP for refusals of treatment or medication, but this was not followed in the resident's case.
Failure to Administer and Monitor Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not administering oxygen as per physician's orders and not accurately checking oxygen saturations. For one resident with a history of pneumonitis and acute pulmonary edema, the physician's order required oxygen at 3 liters per minute via nasal cannula, with titration up to 5 liters if oxygen saturation dropped below 89%. However, documentation showed that oxygen saturations were assessed while the resident was on room air, not while receiving supplemental oxygen as ordered. Another resident with chronic respiratory failure and hypercapnia had orders for continuous oxygen at 2 liters per minute via nasal cannula, with titration up to 5 liters for oxygen saturation below 92%. The resident's oxygen saturations were also assessed on room air, and observation revealed the oxygen tank was set at 1 liter instead of the ordered 2 liters. The nurse confirmed that oxygen should have been set at the correct rate and that oxygen saturations should be checked while the resident was receiving oxygen. A third resident, also with chronic respiratory failure and hypercapnia, had orders for oxygen at 2 liters per minute via nasal cannula, with titration up to 5 liters for oxygen saturation below 92%. This resident's oxygen saturations were similarly assessed on room air, and the oxygen tank was set at 2.5 liters. The nurse admitted to not having checked the resident's oxygen saturation that morning. The Director of Nursing confirmed that staff did not follow physician orders or facility policy, as oxygen was not administered or monitored as required.
Failure to De-identify Resident Information on Disposed GT Feeding Bottles
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from a gastrostomy tube (GT) feeding bottle before disposal. During observations on two separate occasions, the GT feeding bottle with the resident's name was found in the trash can in the resident's room. This practice was contrary to the facility's policy, which required the removal or obscuring of personal information from such items before disposal to protect resident privacy. The resident involved had a history of severe cognitive impairment and was dependent on staff for daily activities. The facility's staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), acknowledged the oversight and confirmed that the resident's information should have been de-identified before disposal. The facility's policy on enteral feeding disposal, revised in March 2023, clearly stated the requirement for de-identifying resident information to maintain privacy and confidentiality.
Failure to Care Plan for Teeth Grinding Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who exhibited teeth grinding behavior. This deficiency was identified during a review of the resident's records, which showed no care plans addressing this behavior despite the resident's severe cognitive impairment and complete dependence on staff for activities of daily living. The resident, who had been admitted and readmitted to the facility, had diagnoses including gastrostomy, cognitive communication deficit, dementia, and adult failure to thrive. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the resident's teeth grinding behavior was known and should have been care planned. The facility's policy on comprehensive person-centered care plans indicated that assessments and revisions should occur as residents' conditions change. However, the lack of a care plan for the teeth grinding behavior demonstrated a failure to adhere to this policy, potentially delaying appropriate care or treatment for the resident.
Failure to Display Oxygen Warning Signs
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its policy for a resident using an oxygen concentrator. Observations on multiple occasions revealed that there were no 'No Smoking/ Oxygen in Use' signs displayed on the entrance door or inside the room of the resident who was using an oxygen concentrator. This oversight was noted during observations on January 6th and 7th, 2025, where the resident was seen lying on the bed with the oxygen concentrator at the bedside, yet no warning signs were present. The resident in question was admitted to the facility on December 18th, 2024, with diagnoses including cirrhosis of the liver, generalized muscle weakness, dysphagia, and depression. The resident's cognitive skills were severely impaired, requiring various levels of assistance for daily activities. The facility's policy, revised in October 2010, mandates the placement of 'No Smoking/ Oxygen in Use' signs for rooms where oxygen is administered. Interviews with staff, including an LVN and the Director of Staff Development, confirmed the absence of these signs and acknowledged the potential safety risks involved, emphasizing the importance of these signs in preventing fire hazards and ensuring safety during emergencies.
Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 21.43% error rate identified during a survey. This was due to six medication errors out of 28 opportunities for error, specifically involving Resident 43. The Licensed Vocational Nurse (LVN) 1 administered six oral medications simultaneously to Resident 43, who had a diagnosis of dysphagia, leading to the resident's inability to swallow the medications properly. Resident 43 had a medical history that included dysphagia, dementia, and encephalopathy, which impaired her cognitive abilities and required supervision for eating and maximal assistance for personal care. Her care plan indicated the need for a puree diet and thin liquids, with specific interventions to aid safe swallowing, such as giving smaller bites and sips, double swallows, and chin tucks. Despite these precautions, LVN 1 attempted to administer multiple medications at once, contrary to the care plan and physician orders that allowed for medications to be crushed and mixed with food if necessary. During the medication pass, LVN 1 observed that Resident 43 was unable to swallow the pills, which remained on her tongue despite multiple attempts to encourage swallowing with water. The Speech Language Pathologist and Director of Nursing later confirmed that administering several medications at once was inappropriate for Resident 43, given her condition. The facility's policy and job description for LVNs emphasized safe medication administration, which was not adhered to in this instance, resulting in a significant medication error rate.
Failure to Assess Swallowing Ability Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 43, was assessed for swallowing ability prior to administering oral medications. Resident 43, who had a history of dysphagia, dementia, and encephalopathy, was observed during a medication pass where the Licensed Vocational Nurse (LVN 1) attempted to administer multiple oral medications at once. Despite Resident 43's inability to swallow the medications, LVN 1 continued to encourage the resident to swallow, resulting in the medications remaining on the resident's tongue. Resident 43's medical records indicated a diagnosis of dysphagia and a care plan that required specific interventions for safe swallowing, including the use of speech therapy and the administration of medications in a crushed form mixed with food. However, during the medication pass, LVN 1 did not adhere to these interventions and attempted to administer whole pills, which Resident 43 was unable to swallow. The Speech Language Pathologist (ST) confirmed that Resident 43 was at risk of choking and recommended administering one pill at a time or crushing the medications. The Director of Nursing (DON) acknowledged that the best practice would have been to assess Resident 43's ability to swallow before administering medications and to give one medication at a time. The facility's policy and procedure for administering medications emphasized the importance of safe and timely administration, which was not followed in this instance. The failure to adhere to the care plan and facility policies resulted in a significant medication error, posing a risk of aspiration or choking for Resident 43.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences and offer an alternative menu for a resident, identified as Resident 75, which had the potential to impact the resident's nutritional status and quality of life. Resident 75, who was cognitively intact and had the capacity to understand and make decisions, was on a controlled carbohydrates, no added salt diet with a dysphagia mechanical soft texture. Despite these dietary requirements, the resident expressed dissatisfaction with the meals provided, stating that she only ate the fruit and drank the milk, and felt she was not eating enough. Observations and interviews revealed that Resident 75 consistently ate less than 25% of her meals and was not offered alternatives when she expressed dislike for the food. A Certified Nursing Assistant (CNA) confirmed that the resident had not been offered an alternative menu, despite the facility's policy requiring CNAs to inform the charge nurse if a resident ate less than 50% of their meal. The Licensed Vocational Nurse (LVN) and the Registered Dietician (RD) were not informed of the resident's dissatisfaction, and the Dietary Supervisor (DSS) stated that a diet communication slip should have been sent to the kitchen to request a substitute. The facility's policy and procedure indicated that residents who do not like the menu item should be given an alternate food of similar nutritive value, and menu alternates should be planned and available for all meals. However, this policy was not followed for Resident 75, leading to the deficiency. The RD and DSS acknowledged the importance of honoring the resident's food preferences to prevent potential weight loss and ensure the resident's satisfaction with her meals.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, leading to potential risks of infection spread. Resident 189, who exhibited symptoms of a respiratory infection, including a productive cough and fever, was not placed on isolation precautions as required by the facility's policy. Despite the presence of symptoms and pending test results for COVID-19, influenza, and RSV, Resident 189 was observed not on contact or droplet isolation. The Infection Prevention Nurse confirmed that Resident 189 should have been isolated to prevent the spread of infection. Additionally, the facility did not ensure that Resident 23's nasal cannula, used for oxygen administration, was kept off the floor. Observations on two separate occasions revealed the nasal cannula touching the floor, which posed a risk of bacterial contamination and potential respiratory infection for Resident 23. The Licensed Vocational Nurse and the Infection Prevention Nurse both acknowledged that the nasal cannula should not have been in contact with the floor, as it could lead to infections such as pneumonia. The facility's failure to adhere to its own infection control policies for both residents highlights deficiencies in maintaining a safe environment. The lack of isolation precautions for Resident 189 and improper handling of medical equipment for Resident 23 could have contributed to the spread of infections within the facility, affecting both residents and staff.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pico Rivera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Rancho Vista Health Care Center | 0.7 mi | ★★★★★ | 23 | 0 |
| Rio Hondo Subacute & Nursing Center | 1.2 mi | — | 78 | 0 |
| Socal Post-acute Care | 1.4 mi | ★★★★★ | 22 | 0 |
| Colonial Gardens Nursing Home | 1.7 mi | ★★★★★ | 14 | 0 |
| Montebello Care Center | 2.2 mi | ★★★★★ | 24 | 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.