Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 San Jacinto Valley Post Acute during CMS and state inspections, most recent first.
The facility failed to keep an exit door unobstructed and unlocked as required, when a nurse, unable to reset a new door alarm and occupied with admissions, secured the former main entrance door handles with a zip tie instead of contacting on-call maintenance. Two residents, both alert and with decision-making capacity (one with a history of TIA and another with paraplegia), reported seeing the door zip tied on multiple occasions and one took a photograph, stating it did not feel safe because the tie could only be removed by cutting it. The Maintenance Director and ADM later acknowledged that the photographed door was zip tied contrary to policy and that this could delay egress, despite the facility’s written policy stating emergency exits are for rapid evacuation and must remain unlocked at all times.
Failure to Update Fall Care Plans and Conduct IDT Reviews: The facility failed to fully implement and re-evaluate fall-prevention interventions for two residents with significant fall histories and cognitive impairment. One resident had multiple falls and the record lacked documented medication regimen reviews and IDT review of the fall interventions. Another resident, with dementia and a history of falls, had repeated falls with no documented care plan updates for some falls and no documented IDT meetings for several fall events.
BP meds were administered contrary to prescriber hold parameters for three residents with HTN and related cardiac diagnoses. MARs showed metoprolol, lisinopril, losartan, and metoprolol tartrate were given when SBP or pulse were below ordered thresholds, and the DON verified the orders were not followed.
Expired medications were found stored with active stock in two medication storage areas. An unopened house supply bottle of glucosamine sulfate was kept in a med room after its expiration date, and an opened vial of acetylcysteine for a resident remained in a med cart beyond the manufacturer’s discard time. An LPN confirmed both items were expired and should have been removed from active medication storage.
Unlabeled roast beef was found stored in the freezer and readily available for use without an open date, use-by date, or expiration date. The DS stated all food in the refrigerator or freezer should be labeled and dated, and the facility policy required all food items in the storeroom, refrigerator, and freezer to be labeled and dated.
Two residents received psychotropic medications without the required documented clinical basis. A resident with dementia and anxiety was given mirtazapine for depression even though the record did not show a documented depression diagnosis before the drug was started, and the MD later stated the indication should have reflected poor oral intake rather than depression. Another resident received PRN temazepam for insomnia beyond the 14-day limit, with frequent MAR use but no documented clinical rationale in the IDT psychotherapeutic reviews; the DON confirmed the extended use lacked documentation.
Inaccurate MDS Diagnosis Without Psychiatric Evaluation: A resident’s MDS coded schizophrenia without any documented psychiatric evaluation to support the diagnosis. The resident’s PASRR was negative for serious mental illness, the admission record listed schizophrenia, and the MDS showed moderately impaired cognition and an active schizophrenia diagnosis. The MDS Coordinator and DON both stated no psych consult or evaluation had been completed, and the diagnosis was not validated before being coded.
A resident with chronic pain and multiple serious neurologic and musculoskeletal conditions received scheduled oxycodone, but pain assessments were not consistently documented with administration. The care plan and facility P&P required ongoing pain monitoring and documentation, yet the resident had only limited pain entries across the review period. The DON and CP both confirmed that residents on scheduled narcotic pain meds require routine pain assessments to evaluate effectiveness and ongoing need.
A resident with a history of stroke, falls, and moderate cognitive impairment was discharged to a room and board facility without proper assessment or verification of care needs. The resident, who required assistance with mobility and ADLs, was placed in an inaccessible environment, lacked caregiver support, experienced multiple falls, and was ultimately hospitalized due to inadequate care.
A resident's bank card and ID card were not properly documented or safeguarded after admission, despite staff awareness of their presence. The resident chose to keep these valuables at her bedside, and the facility's inventory and waiver processes did not specify or monitor the items retained. During the resident's stay, her bank cards and ID went missing, and unauthorized transactions occurred, highlighting a failure in the facility's system for protecting personal belongings.
A resident did not receive potassium chloride as prescribed, leading to potential hypokalemia. The medication records and remaining packets indicated missed doses, with no documentation of refusals. The DON confirmed the medication should have been administered as ordered.
A facility failed to implement infection prevention protocols during a medication pass involving two residents. An LVN did not perform hand hygiene between resident care and did not disinfect a BP cuff before and after use. The LVN acknowledged the oversight, and the DON confirmed the necessity of these actions to prevent infection spread. Facility policies and CDC guidelines emphasize the importance of hand hygiene and disinfection of non-critical items.
A resident's urinary catheter drainage bag was not covered with a dignity bag, violating their right to dignity and respect. Staff interviews confirmed the facility's policy required covering the bag to prevent embarrassment. The resident had moderate cognitive impairment and multiple health conditions. Despite the policy, the dignity bag was not used.
A facility failed to develop a care plan for a resident's surgical site and left hip dressing following hip surgery. Despite a physician's order to leave the Aquacel dressing unchanged for seven days, there was no documented assessment or monitoring of the site. The RN Supervisor confirmed that a care plan should have been initiated, as required by facility policy.
Two residents were found with medications at their bedside without physician orders, violating facility policy. One resident used Voltaren cream and Magnesium Ashwagandha tablets for pain without authorization, while another took Calcium Carbonate tablets for heartburn. Staff confirmed that medications should not be left at the bedside and require physician verification.
A resident with intermittent decision-making capacity and an oxygen concentrator was found with a lighter, violating the facility's smoking policy. Staff interviews revealed inconsistencies in policy enforcement, as the resident's lighter had been confiscated before, but she obtained a new one. The facility's policy prohibits residents from keeping lighting materials due to safety concerns.
The facility failed to discard expired food items, including a pitcher of water and a thickened liquid, both past their use-by-dates, found in the refrigerator. The Dietary Supervisor confirmed these items were intended for resident use and should have been discarded according to the facility's storage policy.
A LTC facility failed to implement infection control practices for three residents. A resident's nebulizer was improperly stored, another was not placed under Enhanced Barrier Precautions (EBP) despite having a colostomy, and a Physical Therapy Assistant did not follow EBP protocol while assisting a resident with an indwelling urinary catheter. These lapses were acknowledged by staff, including the Infection Preventionist and Director of Nursing.
A resident with a history of Myocardial Infarction and Type 2 Diabetes Mellitus experienced a fall, but the facility failed to notify the resident's family. The incident was documented, and the medical doctor was informed, but the family was not contacted, contrary to the facility's protocols. The Director of Nursing acknowledged this oversight during a review.
A resident with thyroid cancer and dementia experienced worsening pressure ulcers due to inconsistent documentation and lack of coordination in wound care. The facility failed to document the pressure ulcer consistently, and the wound care was not coordinated with the wound care team, leading to the resident receiving multiple treatments without proper collaboration. This deficiency in care potentially delayed the healing of the resident's pressure injuries.
A facility failed to ensure a resident was transferred with the required two-person assist using a Hoyer lift. Despite the resident's care plan and facility policy stating that two staff members are needed for safe transfers, a CNA transferred the resident alone, potentially risking injury. The resident had multiple diagnoses, including a stroke and diabetes mellitus type 2.
Exit Door Zip Tied, Obstructing Required Means of Egress
Penalty
Summary
The deficiency involves the facility’s failure to ensure an exit door (EXD 1) remained readily accessible and unobstructed, as required by its policy that exit doors remain unlocked at all times. Two residents, both awake, alert, and with documented capacity to understand and make decisions, reported that EXD 1 had been zip tied on two separate occasions. One resident, with a history including transient ischemic attack, stated he had seen the door handles secured with three zip ties on one occasion and again two days prior to the survey with a black zip tie, and that staff were not supposed to zip tie the door because residents could not get out in an emergency. Another resident, with paraplegia, reported that EXD 1 was zip tied approximately one to two weeks earlier and again on a recent evening, and that he took a photograph of the door; he stated that when the door was zip tied, it did not feel safe in the event of a fire and that the only way to remove the zip tie was to cut it. During interviews and review of the photograph of EXD 1, the Maintenance Director confirmed that the photo showed the lobby area with EXD 1 zip tied and acknowledged that the door should not be zip tied and that doing so could lead to delayed egress. The Administrator stated that a night shift staff member had decided to zip tie EXD 1 because of concern that residents might exit through that door, and acknowledged that this was not facility policy. The Registered Nurse on the PM shift explained that EXD 1, a former main entrance with alarms, had its alarm deactivated when he discovered a delivery driver already inside and the outside gate open; unable to reset the new alarm and while performing two admissions, he placed a black zip tie on the door handles as an immediate measure. He did not contact on-call maintenance as he usually would and stated that exit doors should be accessible in case of an emergency. The facility’s own policy on exits or means of egress, dated July 2024, states that the facility has emergency exits for rapid evacuation and that exit doors remain unlocked at all times.
Failure to Update Fall Care Plans and Conduct IDT Reviews
Penalty
Summary
The facility failed to implement, review, and re-evaluate care plan interventions intended to prevent falls for two residents. Resident 20 was admitted with diagnoses including muscle weakness, gastrostomy, and encephalopathy, and the history and physical indicated he did not have the capacity to understand and make decisions. His BIMS score was 9, indicating moderate cognitive impairment. The record showed three falls within 23 days, with change-of-condition notes dated December 28, 2025, January 5, 2026, and January 20, 2026. The care plan included interventions such as keeping the bed low, keeping the call light and personal items within reach, anticipating needs, educating the resident to call for assistance, and medication regimen review as indicated. For Resident 20, there was no documented evidence that the medication regimen review was conducted as listed in the care plan after the December 30, 2025, and January 20, 2026 fall-related care plan entries. There was also no documented evidence that the care plan interventions were reviewed and updated by the IDT for effectiveness after the resident experienced multiple falls. During interview, the RN and DON both stated that a medication regimen review should have been completed and that an IDT meeting should have been held for the January 20, 2026 fall. Resident 86 was admitted with diagnoses including healing left femur fracture, history of falls, cerebral infarction, and dementia. The history and physical indicated intermittent capacity to make decisions, and the BIMS score was 0, indicating the resident was rarely or never understood. The record showed five falls within 44 days, with change-of-condition notes dated December 12, 2025, December 28, 2025, December 29, 2025, December 31, 2025, and January 25, 2026. There was no documented evidence of a care plan update for the falls dated December 12, 2025, and December 31, 2025, and no documented evidence that IDT meetings were conducted for the falls dated December 12, 2025; December 31, 2025; and January 25, 2026. The RN and DON stated that care plan updates and IDT meetings should have occurred for these falls.
BP Medications Given Despite Holding Parameters
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services when blood pressure medications with holding parameters were administered contrary to physician orders for three residents. Resident 2 had a diagnosis of hypertension and a care plan directing staff to administer medications as ordered and monitor blood pressure; the physician ordered metoprolol tartrate 50 mg twice daily with instructions to hold if systolic blood pressure was less than 110 or pulse was less than 60. The January 2026 MAR showed metoprolol was given on January 6, 2026 at 0900 when the systolic blood pressure was 108. Resident 3 had diagnoses including hypertension, hyperlipidemia, and coronary artery disease, and the physician ordered lisinopril 10 mg daily with instructions to hold if systolic blood pressure was less than 110 or pulse was less than 65. The January 2026 MAR showed lisinopril was administered on January 12, 2026 at 0900 when the pulse was 60 and on January 28, 2026 at 0900 when the pulse was 63. Resident 109 had diagnoses including hypertension, atrial fibrillation, and hyperlipidemia, and orders dated January 27, 2026 directed losartan potassium 50 mg daily to be held if systolic blood pressure was less than 110 or pulse was less than 65, and metoprolol tartrate 25 mg daily to be held if systolic blood pressure was less than 110 or pulse was less than 60. The MAR showed losartan was administered when systolic blood pressure was 106, 101, and 98, and metoprolol was administered when systolic blood pressure was 98. During a concurrent interview and record review, the DON verified the medications were documented as administered despite the holding parameters in the physician orders and stated they should have been held.
Expired Medications Stored With Active Stock
Penalty
Summary
The facility failed to ensure proper storage of medications in accordance with its policies and procedures and manufacturer specifications. During inspection of the North Medication Room, an unopened bottle of glucosamine sulfate 750 mg was found stored with house supply medications even though the manufacturer expiration date was October 2025. LVN 1 confirmed the bottle was expired and stated expired medications should be separated from house supply medications and either placed in a designated medication cabinet for disposition or discarded in the pharmaceutical waste bin after being documented in the Medication Disposition Log for Non-controlled Medications. During inspection of the Middle Medication Cart, an opened and used vial of acetylcysteine solution 20% 30 mL was found stored with active medications even though the vial had been opened on December 28, 2025 and the manufacturer label stated to discard the opened container after 96 hours. The vial still contained remaining solution and was labeled for Resident 97, whose MAR showed the medication was administered from December 27, 2025 through January 26, 2026. LVN 1 confirmed the vial was opened, used, and expired but remained in the cart with active medications, and stated it should have been disposed of in the pharmaceutical waste bin. The DON later confirmed the findings and stated expired medications should have been removed from active medication storage and disposed of properly.
Unlabeled Roast Beef Stored in Freezer
Penalty
Summary
Food items readily available for use were found stored in the freezer without an open date, use-by date, or expiration date. During the initial kitchen tour, a whole piece of roast beef, approximately 7 lbs., was observed in the freezer with no label indicating when it was opened or when it should be used or discarded. The Dietary Supervisor stated that all items stored in the refrigerator or freezer should have an open date, use-by date, or expiration date, and stated the roast beef should not have been stored in the freezer without a label and should have been discarded. The facility policy titled, Labeling and Dating of Foods, dated 2023, stated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
Unnecessary Psychotropic Medication Use and Missing Documentation
Penalty
Summary
The facility failed to ensure that two sampled residents were free from unnecessary psychotropic medication use. For Resident 3, mirtazapine 15 mg was ordered on January 10, 2026, for depression manifested by poor oral intake and meal intake of 50% or less. The resident had diagnoses including dementia, anxiety, history of falling, and a right femur fracture, and the record showed severe cognitive impairment with a BIMS score of 3. The care plan and medication order identified depression as the indication for mirtazapine, but the hospital discharge record, H&P, SBAR summary, and MDS active diagnoses did not document depression before the medication was started. Resident 3’s record also showed that the first physician progress note documenting depression as a diagnosis was dated January 26, 2026, after mirtazapine had already been initiated. The psychiatric NP’s initial evaluation documented dementia and anxiety and stated to continue mirtazapine as ordered by the PCP, while the NP later stated anxiety-related symptoms stood out during the assessment and that mirtazapine had already been ordered by the primary care physician. During interview, the MD stated the resident’s poor oral intake was related to multiple factors, including dementia, a recent GI bleeding issue, and sundowning behaviors, and agreed sundowning was associated with dementia rather than depression. The MD stated the diagnosis of depression did not accurately reflect the clinical indication and should have reflected poor oral intake or appetite stimulation rather than depression. For Resident 105, temazepam was ordered as needed for insomnia and renewed repeatedly beyond the initial 14-day periods, with the dose later decreased from 30 mg to 15 mg. The MAR showed the PRN temazepam was administered frequently across November 2025, December 2025, and January 2026. However, the IDT psychotherapeutic review notes dated November 10, 2025, December 1, 2025, and January 5, 2026, did not document a clinical rationale for continued use beyond 14 days. The DON confirmed there was no documented rationale supporting the extended PRN use and stated the medication was continued because the resident continued to request temazepam.
Inaccurate MDS Diagnosis Without Psychiatric Evaluation
Penalty
Summary
The facility failed to accurately assess Resident 14 when the resident’s MDS included a diagnosis of schizophrenia without documented psychiatric evaluation to support, validate, or verify that diagnosis. Resident 14 was observed on January 26, 2026, lying in bed, awake and alert, and stated she was okay and did not want to be bothered. The resident’s PASRR completed at the general acute care hospital before admission was negative for serious mental illness, intellectual disability, developmental disability, or related conditions. The admission record listed schizophrenia among the resident’s diagnoses, and the History and Physical dated November 18, 2025, stated the resident did not have the capacity to make decisions. The MDS dated November 12, 2025, documented a BIMS score of 12, indicating moderately impaired cognition, and Section I listed schizophrenia as an active diagnosis. The care plan also identified cognitive impairment and schizophrenia. However, the resident’s order summary did not show a referral to psychiatry, and there was no documented evidence that Resident 14 was seen or evaluated by a psychiatrist. During interview, the MDS Coordinator stated the diagnosis was taken from the admission record and that no psychiatric consult or evaluation had been ordered or completed from either the hospital or the facility. The DON also stated there was no psychiatric evaluation and that the diagnosis should not have been coded as schizophrenia without confirmation.
Inconsistent Pain Monitoring With Scheduled Oxycodone
Penalty
Summary
The facility failed to ensure one resident with chronic pain and multiple significant diagnoses, including polyneuropathy, multiple sclerosis, paraplegia, Parkinson's disease, spinal stenosis, a stage 4 pressure ulcer, muscle wasting and atrophy, and acute osteomyelitis, was free of unnecessary drugs when pain assessments were not consistently implemented and documented with scheduled oxycodone administration. The resident had an order for oxycodone 10 mg by mouth four times daily for pain management, and the MAR showed the medication was administered from December 1 through December 21, 2025, and again from December 25, 2025, through January 28, 2026. The resident's pain was documented only seven times in December 2025 and once in January 2026, despite the care plan directing staff to ask and assess pain symptoms, monitor effectiveness of pain medications, and notify the physician if ineffective. The DON verified that residents receiving routine scheduled narcotic pain medications require ongoing pain assessment, monitoring, and documentation, and stated pain assessment should have been performed and documented at least every shift. The CP also stated residents receiving scheduled narcotic pain medications require routine pain assessments to evaluate medication effectiveness and ongoing need. Facility policies required pain to be monitored at least each shift for acute or sub-acute pain or significant changes in chronic pain, and medication administration documentation to include complaints or symptoms for which the drug was given and the results achieved.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe and appropriate discharge for a resident who used a wheelchair and required partial to maximal assistance with mobility and activities of daily living (ADLs). The resident, who had a history of stroke, falls, and moderate cognitive impairment, requested discharge to a room and board setting. The case manager (CM) referred the resident to a third-party agency for placement assistance and relied on the agency's verbal assurance that the placement was appropriate, without verifying the level of caregiver support or the suitability of the physical environment. The facility did not conduct or document its own assessment to determine if the discharge destination could meet the resident's needs, nor did it confirm with the receiving facility the availability of necessary caregiver services or accessible accommodations. Upon discharge, the resident was placed in a room and board facility that required residents to be ambulatory and independent. Contrary to what was communicated, the resident was assigned a bedroom on the second floor, which was inaccessible due to his wheelchair use. As a result, he had to sleep in a common area without privacy and lacked assistance for transfers and toileting. The bathroom was not wheelchair accessible, forcing the resident to use it with the door open. During his stay, the resident experienced multiple falls while attempting to transfer himself, and no documentation indicated that the facility followed up to ensure his safety or well-being after discharge. The room and board owner reported that the resident was not appropriate for their setting and could not be cared for safely. After several days, the resident was transported to a general acute care hospital due to recurrent falls, weakness, and lack of care. Hospital records confirmed the resident was not receiving necessary assistance and had frequent falls. The facility's own policy required individualized discharge planning, verification of the discharge setting's ability to meet the resident's needs, and documentation of discussions and follow-up, none of which were adequately performed in this case.
Failure to Safeguard Resident's Personal Belongings Resulting in Unauthorized Transactions
Penalty
Summary
The facility failed to ensure a system was in place to safeguard personal belongings, specifically a bank card and ID card, for one resident. Upon admission, staff conducted an inventory of the resident's personal belongings, but the inventory list did not specify the presence of bank cards or an ID card, despite staff being aware that the resident had these items. The resident, who was determined to have the capacity to make decisions, chose not to store her valuables in the facility safe and signed a waiver. However, the waiver did not specify which valuables she retained, and staff did not inspect or document the contents of her wallet. During her stay, the resident kept her wallet in her purse at her bedside. Unauthorized transactions were made on the resident's bank cards while she was in the facility, and the cards, along with her ID, went missing. The facility did not have a specific monitoring system for residents who chose to keep their valuables, and the inventory process was not sufficiently detailed to account for all items. Facility policy required itemization and safeguarding of valuables, but these procedures were not fully implemented, resulting in the loss and unauthorized use of the resident's personal property.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a medication ordered by the doctor was administered as prescribed to a resident. During a medication pass observation, it was noted that the resident was supposed to receive potassium chloride oral packets daily, as ordered by the physician to address hypokalemia. However, upon reviewing the medication records and the remaining packets, it was discovered that the medication was not administered consistently. The box of potassium chloride, which should have been empty by a certain date, still contained 15 packets, indicating missed doses. Interviews with the LVN and the Director of Nursing confirmed the discrepancy. The LVN could not provide documentation of any refusals by the resident, and the DON acknowledged that the medication should have been administered as ordered. The facility's policy on administering medications emphasizes the importance of following prescriber orders, which was not adhered to in this case, potentially leading to the resident experiencing low potassium levels.
Inadequate Infection Control During Medication Pass
Penalty
Summary
The facility failed to implement proper infection prevention protocols during a medication pass involving two residents. A Licensed Vocational Nurse (LVN) was observed using an automatic blood pressure (BP) cuff on two residents without performing hand hygiene between resident care and without disinfecting the BP cuff before and after use. The LVN did not perform hand hygiene after preparing and administering medications to both residents. During an interview, the LVN acknowledged the failure to perform hand hygiene and disinfect the BP cuff, stating a lack of awareness regarding the necessity of these actions. The Director of Nursing confirmed that hand hygiene and disinfection of the BP cuff should be performed between resident care to prevent the spread of infection. The facility's policy and procedure documents, as well as CDC guidelines, emphasize the importance of cleansing hands before handling medication and disinfecting non-critical resident-care items, such as BP cuffs, after each use. The failure to adhere to these protocols had the potential to expose vulnerable residents to cross-contamination and infection.
Failure to Cover Urinary Catheter Bag with Dignity Bag
Penalty
Summary
The facility failed to ensure that a urinary catheter drainage bag was covered with a dignity bag for one of the residents, resulting in a violation of the resident's rights to be treated with dignity and respect. On November 4, 2024, Resident 37 was observed with an uncovered urinary catheter drainage bag. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that the facility's policy required the use of a dignity bag to cover the catheter drainage bag to prevent potential embarrassment to the resident. Resident 37, who was admitted with conditions such as Type 2 diabetes, benign prostatic hyperplasia, hypertension, and a cerebrovascular accident, had a moderate cognitive impairment as indicated by a BIMS score of 12. The facility's policy, revised in February 2021, emphasized the importance of promoting dignity and self-esteem by covering urinary catheter bags. Despite this policy, the dignity bag was not used, as confirmed by the Director of Nursing during an interview on November 7, 2024.
Failure to Develop Care Plan for Surgical Site
Penalty
Summary
The facility failed to develop and implement a care plan for the surgical site and left hip dressing of a resident who had undergone hip surgery. The resident, who was alert and capable of making decisions, had a physician's order specifying that the Aquacel dressing on her left hip should not be changed for seven days. Despite this, there was no documented evidence that the surgical site was assessed or monitored from the time of admission until the survey date. The Registered Nurse Supervisor acknowledged that a care plan should have been initiated to monitor the integrity of the surgical site and dressing. The facility's policy requires care plans to incorporate goals and objectives derived from the resident's comprehensive assessment, but this was not done for the resident in question. The lack of a care plan for the resident's surgical site and dressing was identified as a deficiency during the survey.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for two residents. For one resident, an opened tube of Voltaren cream and an opened bottle of Magnesium Ashwagandha tablets were found on the bedside table. The resident stated that she used these medications daily for pain relief, but there was no physician's order for these medications, and the resident did not have the capacity to make decisions regarding her medication. The LVN confirmed that medications should not be left at the bedside and that residents are not allowed to self-administer medications without a physician's order. For another resident, an opened bottle of Calcium Carbonate tablets was observed on the bedside table. The resident reported taking the tablets daily to prevent heartburn, but there was no physician's order for self-administration. The LVN and the RN Supervisor both stated that residents are not allowed to keep medications at the bedside and that any medications brought from home should be verified with a physician. The facility's policies require that medications be administered by licensed staff unless a resident is assessed and authorized for self-administration.
Resident Found with Lighter Despite Smoking Policy
Penalty
Summary
The facility failed to ensure that a resident who smoked did not have a lighter in her possession, which posed a potential safety risk. During an observation and interview, the resident, who used an oxygen concentrator at night, was found with a pack of cigarettes and a lighter in her pocket. The resident stated she smoked four times a day and was aware not to smoke in her room. However, the presence of the lighter, especially with an oxygen concentrator nearby, presented a significant hazard. Interviews with facility staff, including the Activities Director, Registered Nurse Supervisor, and Director of Nursing, revealed inconsistencies in the enforcement of the facility's smoking policy. The Activities Director acknowledged the safety issue and admitted that the resident's lighter had been confiscated before, but was unsure how the resident obtained a new one. The Registered Nurse Supervisor was unaware that the resident had a lighter, and the Director of Nursing stated that all smoking materials should be kept by the activity department. The resident's care plan indicated a risk for smoking-related injury due to poor safety awareness, and the facility's smoking policy prohibited residents from keeping lighting materials.
Expired Food Items Found in Facility Refrigerator
Penalty
Summary
The facility failed to ensure that expired food items were not stored in the refrigerator, which were readily available for use. During an initial tour of the kitchen, a one-gallon size pitcher of water, dated with a past use-by-date, was observed in the refrigerator. The Dietary Supervisor (DS) confirmed that the water was intended for residents who preferred cold water and acknowledged that it should have been discarded on or before the use-by-date. Additionally, a one-gallon pitcher containing a thickened liquid, also past its use-by-date, was found in the refrigerator. The DS stated that this liquid was used for residents on a diet requiring thickened liquids and confirmed that it should have been discarded on or before the use-by-date. The facility's policy, titled 'Storage of Food and Supplies,' indicated that food and supplies should be stored properly and safely, which was not adhered to in this instance.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three residents. For Resident 69, a hand-held nebulizer mouthpiece was left exposed on the bedside table near the resident's urinal, instead of being stored in a plastic bag after use. This oversight was acknowledged by both the Licensed Vocational Nurse and the Director of Nursing, who confirmed that the nebulizer should have been properly stored to prevent infection. Resident 86 was admitted with a colostomy but was not placed under Enhanced Barrier Precautions (EBP) as required. The room lacked EBP signage and a PPE cart, which was confirmed by the Infection Preventionist. The resident's medical history included a recent bowel surgery, and the failure to implement EBP was recognized as a lapse in infection control measures. For Resident 140, the Physical Therapy Assistant did not wear a gown while performing exercises at the bedside, despite the presence of EBP signage and a PPE cart. The PTA admitted to not noticing the EBP sign, and both the RN Supervisor and the Infection Preventionist confirmed that the EBP protocol was not followed. This oversight occurred despite the resident having an indwelling urinary catheter, which necessitated EBP to prevent cross-contamination.
Failure to Notify Family of Resident's Fall
Penalty
Summary
The facility failed to ensure that the resident's representative was informed of an incident involving a fall for one of the residents, identified as Resident C. During an unannounced visit to investigate a complaint about quality of care, it was found that Resident C, who had been admitted with diagnoses including Myocardial Infarction and Type 2 Diabetes Mellitus, experienced a fall on May 15, 2024. The SBAR form indicated that a CNA found Resident C on the floor next to her bed, lying on her right side, and the resident denied hitting her head. The medical doctor was informed, and the resident was notified, but there were no new orders at that time. Upon review of the facility's protocols and policies, it was noted that the Director of Nursing acknowledged that Resident C's family should have been notified about the fall, and the nurse should have called the family. The facility's protocol on Acute Condition Changes and the policy on Falls/Fall Risk Management both emphasize the importance of involving the resident's family in discussions about the resident's condition and any incidents such as falls. However, in this case, the family was not informed, which could potentially delay their involvement in planning the resident's care.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide consistent and coordinated care for a resident with pressure ulcers, leading to a deficiency in the quality of care. The resident, who was admitted with diagnoses including malignant neoplasm of the thyroid gland and dementia, had a pressure ulcer on the coccyx that was not consistently documented in the medical records. Despite the presence of a pressure wound, the facility's comprehensive skin evaluations on multiple dates did not mention the sacral/coccyx pressure ulcer, indicating a lack of proper documentation and monitoring. The resident's pressure ulcer worsened over time, with measurements indicating an increase in size and severity. The wound care was not coordinated with the wound care team, resulting in the resident receiving two treatments on the same day from different providers without proper collaboration. The Licensed Vocational Nurses (LVNs) involved failed to document the wound's measurements and descriptions accurately, and there was a lack of communication between the facility staff and the hospice nurse, who noted the rapid progression of the pressure ulcer. The facility's policies required coordinated care plans and regular documentation of pressure ulcers, but these were not followed. The hospice nurse reported that the resident's pressure ulcer had worsened significantly, and the facility staff did not adequately document or address the changes in the resident's condition. This lack of coordination and documentation contributed to the inconsistent provision of wound treatment, potentially delaying the healing of the resident's pressure injuries.
Failure to Follow Two-Person Assist Protocol for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was transferred with the required two-person assist using a Hoyer lift. During an unannounced visit, it was observed that a CNA transferred a resident from a Geri-chair to bed using the Hoyer lift without the assistance of another staff member. The CNA confirmed that the Hoyer lift should be operated with two people to safely transfer residents but did not follow this protocol. Interviews with the resident, another CNA, and the Director of Nursing corroborated that the Hoyer lift requires two persons to operate it safely. The resident involved had multiple diagnoses, including a stroke, depression, diabetes mellitus type 2, osteoarthritis, epilepsy, and a contracture in the left knee. The resident's care plan indicated that he required a mechanical lift with two staff members for transfers. The facility's policy also stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. Despite these guidelines, the CNA proceeded with the transfer alone, potentially putting the resident at risk of injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 304 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hemet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devonshire Care Center | 0 mi | ★★★★★ | 4 | 0 |
| Hemet Valley Healthcare Center | 0.1 mi | ★★★★★ | 18 | 0 |
| Meadowbrook Post Acute | 1.4 mi | ★★★★★ | 34 | 0 |
| Ramona Rehabilitation And Post Acute Care Center | 1.7 mi | ★★★★★ | 15 | 1 |
| Hemet Hills Post Acute | 2.3 mi | ★★★★★ | 7 | 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 August 2026) and official state health department websites.