Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seal Beach Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a hx of stroke and aphasia received a haircut without prior notification to the responsible party. The DON verified CNA 3 did not follow the facility’s haircut process, which required residents to be placed on a list for the beautician. The responsible party, who made decisions for the resident, filed a grievance after stating she was not consulted before the resident’s hair was cut.
A resident with limited arm mobility and poor bed mobility had the call light left out of reach after care, including being found on the floor during observation. The resident stated the bed remote and call light were not within reach after a CNA changed disposable underwear, and staff later confirmed the call light had been on the floor and may not have been clipped to the bed. The resident's care plan directed staff to keep personal items and the call light within reach.
A facility failed to report an allegation of resident-to-resident physical abuse to the appropriate agencies after a resident said another resident told him to shut up, used profanity, and hit his hands and feet. The RN later said the resident recanted and claimed he made up the allegation for a room change, and the DON and Administrator stated the report was not made because the allegation was not pursued after the recantation.
A resident alleged that another resident used profanity, told him to shut up, and hit his hands and feet after he was unable to reach his call light and bed remote. Staff documented the complaint and noted no visible injury, but one nurse stopped the abuse investigation after believing the resident recanted, and the DON and Administrator said they did not report the allegation to the appropriate agencies within the required time frame.
Excessive noise and room disrepair affected multiple residents when a resident’s loud TV and repeated screaming continued to disturb nearby rooms, and staff were aware of the complaints but did not resolve them or notify SSD. Several residents reported difficulty sleeping because of the noise, and a resident’s room also had chipped paint and a non-penetrating hole near the bed that the resident said did not look good.
Respiratory care deficiencies were identified when a resident used CPAP without a physician order or care plan, one resident’s oxygen cannula was repeatedly found on the chin instead of the nose, and other residents’ oxygen setups were missing required humidification or had tubing that was unlabeled and undated. Staff observations and record review confirmed that ordered oxygen therapy was not consistently provided as prescribed, and that required labeling and equipment setup were not in place for several residents.
Fortified Diet Menu Items Not Provided as Ordered: The facility did not follow its therapeutic menu for residents on fortified/high protein diets. During meal observations, two residents’ lunch trays did not show the required melted margarine, and a resident’s breakfast tray did not include the required whole milk. Staff, including the Dietary Services Supervisor and RD, confirmed the therapeutic spreadsheet should have been followed and that the resident did not receive the ordered fortified diet items.
Incomplete medical records and MAR documentation were identified for several residents. A resident’s POLST was left incomplete and did not list the designated health care agent, two residents had multiple missing MAR entries for ordered assessments, medications, and interventions, and another resident’s COVID-19 vaccine record did not include a signed declination or completed consent form showing refusal.
Infection control practices were not followed during medication administration when an LVN failed to perform hand hygiene between a GT med pass and a Lovenox injection, and another LVN returned multi-dose inhalers to the cart without sanitizing them. The facility also housed a resident with active C-diff in the same room as another resident with a C-diff history, inaccurately reported several UTIs as meeting criteria in the QA process, and observed a resident’s foley drainage bag touching the floor.
Failure to Notify Physician for Antibiotic Reassessment: The facility did not follow its antibiotic stewardship process for three residents who received antibiotics for UTIs that did not meet McGeer's criteria. An IP reviewed the records and verified that the residents' symptoms did not support a true UTI, yet the physician was not notified to reassess the need for continued antibiotic therapy. One resident received ertapenem IV and later meropenem IV, another received Cipro PO, and a third was identified on the infection surveillance report as having a UTI without supporting documentation in the chart.
A resident’s call light was found on the floor beside the bed and out of reach, despite facility policy requiring it to be accessible when the resident is in bed. The resident stated staff always left it on the floor, and a CNA initially did not notice it during a room visit. When the CNA later saw the call light, the resident leaned halfway out of bed to reach it. The resident had a fall-risk care plan that included keeping the call light within reach and answering promptly.
The facility failed to keep copies of advance directives in the medical records for two residents. Records showed both residents had advance directives and that staff requested copies, but the documents were not found in the chart or EHR, and the SSD confirmed there was no documentation of follow-up to obtain them. Both residents had capacity to make medical decisions, and the DON acknowledged the findings.
A resident with bipolar disorder, schizoaffective disorder, and Alzheimer’s disease was receiving valproic acid for mood stabilization, but the facility did not routinely document behavior monitoring as required by the care plan. Staff observed the resident repeatedly shouting out for help, and interviews confirmed the resident’s behaviors were ongoing while the MAR lacked documentation showing the monitoring was completed.
A resident was observed with positioning pillows on both sides of the bed, and an LPN stated the pillows had been requested by a family member for comfort. Staff were unsure whether a care plan had been developed, and record review confirmed there was no care plan or monitoring for the pillows despite facility P&P requiring a comprehensive, person-centered care plan with measurable objectives and timetables.
Low Air Loss Mattress Left in Static Mode: A resident with an unstageable sacral pressure ulcer was observed in bed on a low air loss mattress set to normal pressure and static mode. The resident said he believed he had a bed sore and received daily treatment. An LVN and the DON both confirmed the mattress should not be in static mode while the resident was in bed, and the DON acknowledged the setting was inaccurate.
A resident who was GT dependent and lacked decision-making capacity was observed receiving enteral feeding with the HOB at 22 degrees, below the facility’s required 30-45 degree position. An LVN also administered medication through the GT while the HOB remained at 22 degrees, and later confirmed the HOB was not elevated to at least 30 degrees during feeding and med administration.
IV therapy maintenance was not kept consistent with policy for two residents. One resident’s IV heplock dressing remained dated beyond the 7-day change interval, and another resident’s 0.9% NS IV bag was still hanging beyond 24 hours. RN and DON interviews confirmed the findings, and facility policy required dressing changes at least every 7 days and IV solutions not to hang longer than 24 hours.
A CNA removed a resident's nasal cannula during a transfer and then placed the cannula from the oxygen concentrator back on the resident, even though only LVNs and RNs were allowed to change oxygen delivery from a portable cylinder to a concentrator. The resident had an order for continuous O2 at 2 LPM via NC, and the CNA's skills checklist showed tubing care competency but not competency for oxygen administration or switching oxygen sources.
Medications were not administered as ordered for three residents. One resident’s glipizide, Mobic, and pantoprazole were documented as not given even though pharmacy labels showed the meds had been filled and the DON said they should have been available. An LPN was observed cutting a divalproex delayed-release tablet in half before giving it to a resident who said the tablet was too large to swallow, and an IV antibiotic dose for another resident was incomplete because solution remained in the bottle after administration.
A resident’s Medline Remedy antifungal powder was found on the bedside table, and the resident said staff had left it there since the prior night and had applied it to his arm. An LVN confirmed the bottle should not have been left at the bedside, and the DON verified there was no physician order for the antifungal powder and that staff should not apply medication without an order or leave it unattended.
Kitchen food-contact surfaces were not maintained and cleaned properly when six plastic food bowls were observed with numerous cuts, scratches, and permanent staining. The Dietary Services Supervisor acknowledged the bowls should not be used in that condition, and records showed 173 residents received food prepared in the kitchen.
Staff were not educated on safe food handling for food brought in by family or visitors. CNA 3 said outside food was labeled, dated, refrigerated, and reheated in a microwave, but she had not received training and did not know the proper reheating temp. LVN 2 also did not know the correct temp and said no thermometer was available, while CNA 4 said food was reheated to 140 degrees. The DSD stated staff had received an in-service, but later confirmed no education on safe food handling practices was provided and that 140 degrees F applied to food service, not reheating food.
Dumpster Lid Not Kept Closed and Refuse Found Around Bin: The green food scraps dumpster bin had an ill-fitting lid with a gap, and flies were observed inside when the lid was opened. Surveyors also found old equipment, cardboard boxes, scraps of wood, a black plastic trash can, a crate, a mop, trash, and paper scattered on and around the dumpster area. The Dietary Services Supervisor acknowledged the findings.
Loose Bed Grab Bars: A resident’s bilateral bed grab bars were found to be loosely installed and moving sideways, backward, and forward while the resident used them daily to get out of bed and reposition. The Maintenance Director verified that the screws at the bases of both grab bars were loosely attached to the bed frame, and the facility’s maintenance policy required equipment to be kept safe, operable, and free from hazards.
Dirty Resident Fan: A resident's portable fan was observed with heavy dust and lint while positioned beside the bed and blowing toward the resident's face. The resident said he did not know when it was last cleaned, and an LVN verified the fan's condition and stated it should have been cleaned. The facility P&P described a clean, sanitary, and orderly environment as part of a homelike setting.
A cognitively intact resident with anxiety and depression, who had expressed fear about having another heart attack, returned a meal tray that was not to her liking and received a newly prepared tray from dietary staff. While walking back to the room, the resident and a dietary aide spoke loudly, and the resident called the aide names. When the aide later returned with yogurt, the resident yelled at the aide, who responded by yelling, cursing, and making derogatory comments, including calling the resident "crazy." CNAs overheard the profanity and observed the resident crying and distressed, and documentation showed the resident experienced increased anxiety and brief situational emotional distress related to the altercation.
A resident with anxiety and depression, who was cognitively intact and had expressed fear of another heart attack, experienced increased anxiety and brief emotional distress after a dietary aide yelled at them during meal service. A change in condition evaluation was completed and the care plan was updated to include monitoring every shift for 72 hours for changes in routine and symptoms of distress, consistent with facility policy and staff descriptions of required practice. However, nursing staff did not complete the required follow-up assessments and monitoring after the incident, and the ADON confirmed that the resident was not monitored following the verbal abuse allegation and that all assessments were missed on a subsequent day, a finding verified by the DON.
A resident with a gastrostomy tube experienced multiple episodes of tube dislodgement requiring medical intervention, but the facility did not assess or document the causes of these incidents, nor did it update interventions or hold IDT meetings to address the issue. Staff relied mainly on an abdominal binder and signage, with lapses in supervision and communication contributing to the ongoing problem.
A resident with a history of multiple gastrostomy tube (GT) dislodgements did not have an individualized care plan or interventions in place to address and prevent further GT dislodgement, despite repeated incidents and ongoing assessments. The care plan was not updated to reflect the resident's needs, and this was confirmed by the ADON during review.
Surveyors found that both ice machines were not cleaned and sanitized according to the manufacturer's instructions, as the Maintenance Director used a lower concentration and amount of bleach than required and brown residue was observed inside the machines, indicating they were not properly maintained.
Surveyors identified multiple failures in food safety and sanitation, including lack of monitoring for TCS food cooling, improper hand hygiene by kitchen staff, inadequate sanitizing of food contact surfaces, uncleanable kitchen flooring, missing air gap in a food prep sink, unclean and damaged kitchen equipment, improper dry storage practices, and dietary aides wearing large false eyelashes during food preparation. These deficiencies affected a large number of residents receiving meals from the kitchen.
Two residents did not have comprehensive care plans developed to address their individual needs. One resident receiving apixaban for atrial fibrillation did not have a care plan reflecting the use of this anticoagulant, and another resident with cancer, dysphagia, and muscle wasting experienced a 6.5% weight loss in one month without a care plan addressing this significant change. These omissions were confirmed by staff during medical record reviews.
The facility did not follow current professional standards for diabetic diets, continuing to use the outdated 'RCS' (Reduced Concentrated Sweets) terminology across diet orders, care plans, and dietary documentation. The RD acknowledged the inconsistency with current guidelines but had not raised the issue with corporate leadership. Over 50 residents, including a diabetic patient with a recent fracture, were affected by this practice, which persisted due to longstanding facility habits.
A resident who required staff supervision for personal hygiene and grooming did not receive regular nail care, resulting in long, dirty fingernails and self-inflicted skin lesions. Staff confirmed that nail care was their responsibility and that the resident's care plan, which included keeping nails short, was not followed. Documentation showed the last nail care was provided over a month prior, and no further offers were recorded.
A resident admitted with a Stage 3 pressure injury did not receive a low air loss mattress as required, and staff failed to accurately assess new heel blisters and follow a physician's order for a wound consult. The care plan lacked appropriate interventions for bed-bound pressure relief, and staff interviews revealed confusion and lack of follow-up regarding both the mattress and wound consult orders.
A resident with severe cognitive impairment experienced a significant weight loss over one month and was not monitored or assessed as required by facility policy, despite dietary interventions being recommended. Staff and leadership confirmed that the necessary monitoring following the change in condition did not occur.
A resident receiving enteral feeding via GT was not positioned with the head of bed elevated to the required 30-45 degrees during feeding, and the GT feeding bag was not labeled with the date and time it was hung, as required by facility policy. An LVN confirmed both deficiencies during observation and interview.
Multiple residents did not receive safe and appropriate respiratory care due to missing physician orders, lack of care planning, and improper management of respiratory equipment. Staff administered oxygen and performed suctioning without required orders, and respiratory supplies such as oxygen tubing, nebulizer masks, and suction canisters were not dated, labeled, or changed according to policy. Staff interviews confirmed that procedures for labeling, changing, and storing respiratory equipment were not consistently followed.
A resident with a diagnosis of dementia was not properly monitored or had their dementia-related behaviors documented as required by facility policy. Staff observed confusion, agitation, and aggression but did not formally record or assess these behaviors in the medical record, resulting in a lack of documented evidence that appropriate dementia care interventions were being implemented.
The facility did not maintain complete and accurate documentation of controlled medication counts, with missing staff signatures and incomplete records on narcotic count sheets for multiple medication carts. LVNs confirmed that it was their responsibility to perform and document these counts at shift changes, but this was not consistently done, creating the potential for diversion of controlled substances.
Surveyors found that the medication error rate exceeded 5% due to multiple failures by LVNs during medication administration, including cutting unscored tablets, not following physician orders for GT medications, failing to flush between medications, not assessing for loose stools before giving stool softeners, and not providing proper instructions or assessments for residents receiving extended-release or anticoagulant medications.
Surveyors found multiple deficiencies in medication storage and handling, including expired supplies in a treatment cart, staff personal belongings in medication storage rooms, improper segregation of transdermal, topical, oral, and injectable medications, a medication refrigerator outside the required temperature range, and medication carts left unlocked and unattended. Additionally, a resident with severe cognitive impairment had an unlabeled cream at the bedside, and another resident had artificial tears left at the bedside. Staff confirmed these practices did not follow facility policy.
Cooks did not follow established recipes for preparing pureed mandarin chicken and roasted cauliflower, resulting in inconsistent texture and flavor compared to regular menu items. The DTR confirmed the pureed chicken was bland, and the RD verified that recipes should be followed as written. This failure affected 16 residents on pureed diets and risked not meeting their nutritional needs.
A resident admitted under hospice care did not have the required hospice visit calendar or physician certification of terminal illness in their medical record. Multiple LVNs were unable to confirm hospice visit schedules or identify the hospice coordinator, and there was confusion among staff regarding who held this role. The DON later confirmed the social worker as the hospice coordinator and acknowledged the missing documentation.
Two residents were found self-administering medications at their bedside without proper assessment, physician orders, or care plans in place. One resident with decision-making capacity was using multiple eye drop medications without education on correct administration, while another resident with moderately impaired cognition had an antifungal powder at her bedside and no documentation supporting self-administration. Staff were unaware of the presence of these medications, and facility policy requiring IDT assessment and documentation for self-administration was not followed.
Two residents' advance healthcare directives were not properly honored or maintained. One resident's directive, which designated a specific healthcare agent and a choice not to prolong life, was not reflected in the POLST form, which instead authorized CPR and was signed by a different family member. For another resident, the advance directive provided by family was not uploaded or made accessible in the medical record, despite documentation indicating it was received. These failures resulted in the potential for residents' healthcare decisions not being followed.
Several residents with cognitive impairments were found to have personal belongings and other items placed on top of their overbed light fixtures, including picture frames, toys, flower cards, and a piece of wood. Staff confirmed the presence of these items but had not reported or removed them, and maintenance checks or requests were not documented. The deficiency was identified through direct observation and staff interviews.
A CNA did not receive a required annual performance evaluation, as confirmed by facility policy and interviews with the DSD and DON. The last evaluation for the CNA was conducted more than a year prior, and the facility's process for regular review of employee files was not followed.
The facility failed to maintain complete and accurate medical records by not uploading the most current POLST form for a resident, leaving a previous form unvoided, and having multiple missing or incomplete entries for CNA documentation of turning, repositioning, and personal hygiene for several residents, including those with severe cognitive impairment and total dependence on staff. Facility leadership confirmed that documentation was not completed as required by policy.
The facility failed to enforce infection control policies by allowing symptomatic staff to work while awaiting COVID-19 test results, did not maintain clean laundry equipment, and did not consistently implement Enhanced Barrier Precautions for residents with medical devices. Additionally, a resident's meal tray was placed next to a used urinal without proper care plan documentation, and staff confirmed these practices did not follow infection control protocols.
Failure to Notify Responsible Party Before Resident Haircut
Penalty
Summary
The facility failed to ensure that Resident 5’s responsible party was notified before the resident received grooming services. Resident 5 was admitted with diagnoses including a history of stroke and aphasia, and Family Member 1 was listed as the care conference contact and stated she made decisions for the resident. Family Member 1 reported she was upset that Resident 5’s hair was cut without consulting her, and she stated she knew Resident 5 preferred to keep her hair long because the resident was a cancer survivor and liked having her hair down to her back. The DON verified that CNA 3 did not follow the facility’s process for arranging haircuts. The facility’s process was for residents who wanted a haircut to be placed on a list for the beautician who comes to the facility, but Resident 5 was not placed on that list. The grievance record showed Family Member 1 filed a grievance because Resident 5’s hair was cut without notification, and it documented that CNA 3 did not consult with Family Member 1 before the haircut. The DON stated she was not informed that CNA 3 was going to cut Resident 5’s hair.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs was provided for one resident when the resident's call light was not kept within reach. The resident stated that after a CNA changed the resident's disposable underwear, the bed remote and call light were left out of reach, with the bed remote placed to one side of the head and the call light to the other side. The resident reported limited mobility in both arms and stated the resident could not raise the arms high enough to reach the bed remote when it was left beside the head. During a later observation, the resident was seen lying in bed with the call light on the floor to the left side of the bed. The resident stated that the call light had been left near the resident earlier that morning and that the resident could press it if it was placed close enough. A CNA verified the call light was on the floor that morning and stated it had not been noticed until breakfast was brought. Another CNA stated he had been assigned to the resident overnight and said he placed the call light over the resident's abdomen before leaving the room, but acknowledged he might not have clipped it to the bed before leaving. The resident's record showed care plans directing staff to place personal items within reach, assist with repositioning, and ensure the call light was within reach; the resident was bedbound, had decreased strength, poor mobility, and no cognitive impairment.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident physical abuse was reported to the appropriate agencies for one of five sampled residents. Resident 3 stated that after a CNA forgot to place the resident’s bed remote and call light nearby, the resident began yelling for help and Resident 4 told the resident to shut up, used profanity, and hit the resident’s hands and feet. Resident 3 reported the incident to staff, and the medical record documented that during a blood glucose check the resident said he felt unsafe because Resident 4 got up and started hitting his hand while he was looking for his bed control and cell phone. The RN supervisor was notified immediately, and Resident 3 was assessed with no skin marks, discoloration, or skin tear noted. Resident 4 acknowledged telling Resident 3 to shut up and stated he moved to Resident 3’s bed and moved the resident’s feet because the resident was yelling and had awakened him. RN 1 stated Resident 3 later recanted the allegation and said he made it up because he wanted a room change, and RN 1 did not continue the abuse investigation because of that recantation. The Administrator and DON stated the allegation was not reported to the appropriate agencies within the required time frame because the resident recanted within 45 minutes, and after that recantation the abuse investigation was stopped and the allegation was not reported.
Failure to Fully Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident physical abuse was fully investigated for one resident. The resident reported that another resident told him to shut up, used profanity toward him, and hit his hands and feet after the resident’s bed remote and call light were not placed within reach following care. The resident stated he reported the incident to a male nurse and later told surveyors he never recanted the allegation and gave the same account to staff and agencies that asked him about it. The medical record showed that during a blood glucose check, the resident reported feeling unsafe because the other resident got up, walked to his bed, and started hitting his hand while he was making noise looking for his bed control and cell phone. The RN supervisor was notified immediately, and the resident was assessed with no skin marks, discoloration, or skin tear noted. Staff interviews showed one nurse believed the resident recanted and therefore did not continue the abuse investigation, while another staff member stated the resident reported being punched and was moved to another room to separate the residents. The Administrator and DON stated they stopped the investigation after the resident recanted and did not report the allegation to the appropriate agencies within the required time frame.
Excessive Noise and Room Disrepair
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for several residents by allowing excessive noise to continue in multiple rooms and by leaving a resident’s room in disrepair. The facility’s policy stated residents should be provided a safe, clean, comfortable, and homelike environment with comfortable sound levels and personalized surroundings. Surveyors found that residents in nearby rooms were disturbed by loud television volume and repeated screaming from a resident in one room, and that staff were aware of the noise concerns but did not resolve them or notify social services to initiate a grievance. Resident 50 stated that the resident in the adjacent room frequently screamed and kept the television volume excessively loud at all times, including during the night, which prevented sleep and rest. Resident 204 also reported being affected by the loud television noise and stated staff had not taken action. Staff interviews showed a CNA had notified the charge nurse once or twice, and an LVN reported the concern to the night shift nurse, but neither followed up or initiated a grievance. The SSD stated staff should notify social services when aware of excessive noise concerns, but she had not been notified of these complaints. Surveyors also observed Resident 79 repeatedly yelling out and screaming from bed, including shouting for help multiple times, which disturbed nearby residents in adjacent rooms. Residents 93 and 142 stated they preferred their door closed because they could hear the yelling and had difficulty sleeping. Family members of Resident 177 stated they heard the screaming episodes and removed hearing aids before leaving the room so the resident would not be bothered. In addition, Resident 22’s room had a large area of chipped paint and a non-penetrating hole on the wall near the bed, and the resident stated it was huge and did not look good. The Maintenance Director verified the damage and stated he had not known a repair was needed for that room.
Respiratory Care and Oxygen Administration Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care and services for multiple residents, including failure to administer oxygen in accordance with physician orders, failure to properly label and date oxygen tubing, failure to connect oxygen to a humidifier as ordered, and failure to obtain an order or develop a care plan for CPAP use. Surveyors identified these issues during observations, interviews, and medical record reviews involving Residents 5, 38, 96, 116, and 166. Resident 116 was observed with a CPAP machine and mask stored at the bedside. The resident stated the CPAP had been used since admission and that staff assisted with placing the mask on at night and removing it in the morning. The resident’s representative stated the CPAP had been obtained from an outside clinic before admission. Review of the medical record showed no physician order for CPAP and no care plan addressing its use. An LVN confirmed the CPAP was present, and also confirmed there was no physician order and no care plan for it. Resident 5 was observed receiving oxygen at 2 LPM via nasal cannula, but the cannula was on the resident’s chin rather than the nose. The resident had severe cognitive impairment and required substantial staff assistance with activities of daily living. The physician had ordered oxygen at 2 LPM continuously every shift and oxygen saturation monitoring every shift. On a later observation, the cannula was again on the resident’s chin, and the LVN verified the resident was not receiving oxygen as ordered. The LVN checked the oxygen saturation, which was 85% without oxygen, then repositioned the cannula correctly and the saturation increased to 90% with oxygen. The LVN stated the resident had a habit of removing the cannula, but documentation showing physician notification or care plan intervention was not provided. Resident 96 was observed receiving oxygen via nasal cannula from an oxygen concentrator without a humidifier bottle attached, despite a physician order for oxygen and weekly humidifier changes. Resident 38 had physician orders for continuous oxygen and weekly change of the nasal cannula with the resident’s name and date, but both the portable oxygen tubing and the concentrator tubing were observed unlabeled and undated. Resident 166 was observed using portable oxygen via nasal cannula, and the tubing was not labeled with a date despite an order to change the nasal cannula weekly with name and date labeling. Staff members confirmed the unlabeled or undated tubing and, in the case of Resident 96, the absence of the humidifier bottle.
Fortified Diet Menu Items Not Provided as Ordered
Penalty
Summary
The facility failed to follow its fortified diet menus for residents receiving a fortified/high protein diet. The facility’s matrix showed 173 residents consumed food prepared in the kitchen, and the facility’s Enhanced Diet policy stated the diet was based on the regular diet with whole milk instead of 2% and included enhanced menu items. The facility’s therapeutic spreadsheets for the week specified that fortified/high protein diets were to receive one ounce of melted margarine at lunch and eight ounces of whole milk at breakfast. During a lunch observation, Resident 3 and Resident 109 both had fortified/high protein meal trays, but the trays did not show the one ounce of melted margarine that should have been added. The Dietary Aide stated the fortified/high protein diet gets whole milk, but Resident 3 was given an alternative high protein nourishment and Resident 109 was given chocolate milk. During a breakfast observation, Resident 10’s tray ticket listed a fortified/high protein diet, but the tray contained juice, cereal, a puree breakfast slider, and puree hashbrowns with no whole milk. The Dietary Services Supervisor confirmed the therapeutic spreadsheet should have been followed and verified that Resident 10 did not receive whole milk or an appropriate substitute, and the RD confirmed the diet was not fortified.
Incomplete Medical Records and MAR Documentation
Penalty
Summary
The facility failed to ensure Resident 16’s medical record was accurate because the resident’s POLST form was incomplete. The POLST, dated 6/10/25, referenced the resident’s AHCD dated 7/8/25, but the form was left blank for the health care agent’s name and telephone number. The resident’s AHCD identified Health Care Agent 1 as the chosen health care agent, and the SSD verified that the POLST did not reflect that designated agent. The facility also failed to ensure MAR documentation was complete for Resident 59 and Resident 201. For Resident 59, the June 2026 MAR did not document multiple ordered assessments and interventions on the 11-7 shift, including monitoring for sleep hours, medication side effects, opioid overdose signs, pain level, nonpharmacological pain interventions, behavioral interventions, oxygen saturation, and continuous oxygen administration. The DON reviewed the MAR and verified the documentation was missing and should have been completed. For Resident 201, the June 2026 MAR did not show documentation for several ordered monitoring tasks on the 7-3 shift, including administration or holding of celecoxib before discontinuation, orthostatic hypotension monitoring, intake and output, monitoring for paranoid feelings, side effects and adverse reactions for lurasidone and risperidone, hyperglycemia and hypoglycemia monitoring, opioid overdose monitoring, pain assessment, nonpharmacological pain and behavioral interventions, inability to process external stimuli causing stress, and monitoring for depression and venlafaxine side effects. The DON verified the missing documentation. The facility also failed to maintain complete COVID-19 vaccine records for Resident 93; the record showed the resident had not received the vaccine, but there was no signed declination or completed consent form documenting the resident’s refusal.
Infection Control Failures in Medication Handling, C-diff Isolation, UTI Reporting, and Foley Care
Penalty
Summary
Infection control practices were not followed during medication administration for a resident receiving GT medications and a Lovenox injection. After administering the GT medication, the LVN removed gloves and then donned a new pair to give the subcutaneous Lovenox injection, but did not perform hand hygiene between the two tasks. The LVN later confirmed that hand hygiene should have been performed after the GT medication and before putting on new gloves for the injection. In another medication pass, an LVN administered inhaled medications to a resident with COPD-related treatment needs and then returned both multi-dose inhalers to the medication cart without sanitizing them first. The LVN administered Incruse Ellipta and fluticasone propionate inhalers, performed hand hygiene around the medication pass, but did not clean either inhaler before storing them. The LVN acknowledged the omission and stated both inhalers should have been sanitized before being placed back in the cart. The facility also failed to properly manage C-diff isolation and cohorting. One resident had active C-diff and another resident in the same room had a history of C-diff. The room was observed under contact isolation, but the resident with active infection was housed with the other resident rather than being isolated as described in the facility’s guidance. The infection prevention staff confirmed that the resident with symptoms on one date was not isolated, that the resident later tested positive for C-diff, and that the resident remained in the shared room because a private room was not available at the time. The infection control program also inaccurately reported UTI data for three residents. The infection prevention staff stated that the facility used Loeb’s criteria and McGeer’s criteria to determine whether infections met criteria, but the records for three residents did not show completed infection screening evaluations and did not support that their symptoms met McGeer’s criteria for UTI. Despite this, the residents’ UTIs were reported as meeting criteria and were presented to the monthly QA Committee. In addition, a resident with an indwelling foley catheter was observed with the drainage bag touching the floor, and the LVN confirmed the bag should not have been on the floor.
Failure to Notify Physician for Antibiotic Reassessment
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not ensuring physician notification for three residents who received antibiotics for infections that did not meet McGeer's criteria. The facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes stated that all clinical infections treated with antibiotics would be reviewed by the IP, who would identify situations not consistent with appropriate antibiotic use and notify the provider. During interview and record review, the IP stated the facility uses McGeer's criteria to determine whether a resident has a true infection and that, when infections do not meet those criteria, the physician is notified to reassess the need for antibiotics. Resident 65 received ertapenem sodium IV for a UTI in April 2026 and later meropenem IV for ESBL in the urine in May 2026, and the records did not show that the resident's symptoms met McGeer's criteria for a UTI. Resident 130 received Cipro 500 mg by mouth twice daily for a UTI in April 2026, and the record also failed to show symptoms meeting McGeer's criteria. Resident 176 was listed on the Infection Surveillance Report as having a UTI, but the medical record failed to show symptoms meeting McGeer's criteria. For all three residents, the IP verified that the infections did not meet McGeer's criteria and that the physician had not been notified to reassess the need for antibiotics.
Call Light Left Out of Resident’s Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 8 by not keeping the resident’s call light within reach. Facility policy titled "Answering the Call Light" stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the door. During an observation and interview, Resident 8 was lying in bed with the call light on the floor on the left side of the bed, about two feet away and out of reach. Resident 8 stated the call light was always on the floor and staff did not pick it up. A CNA entered the room to assist the resident’s roommate but did not notice Resident 8’s call light on the floor and left the room. On a later observation, the CNA verified the call light was out of reach and was about to pick it up when Resident 8 leaned to the left side of the bed to reach it, leaving the resident halfway out of bed. The CNA told the resident not to reach because he could fall out of bed, then assisted the resident to retrieve the call light, cleaned it, and placed it on the bed. Resident 8’s care plan for fall risk, initiated due to a history of falls, included keeping the call light within reach and answering promptly. The DON later verified the call light should have been within reach for the resident to use when needed.
Missing Advance Directives in Medical Records
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for two sampled residents, Residents 50 and 154. Facility policy stated that if a resident or the resident’s representative had executed an advance directive, copies were to be obtained and maintained in the same section of the resident medical record and be readily retrievable by staff. For Resident 50, the record showed the resident had an advance directive and that the facility had requested a copy, but no copy was found in the medical record or EHR. The SSD confirmed there was no documentation showing follow-up to obtain the document, and the resident stated he had an advance directive and would ask his family to bring a copy during their next visit. For Resident 154, the record also showed the resident had an advance directive and that the facility requested a copy from the resident’s daughter, but no copy was maintained in the medical record or uploaded to the EHR. The SSD confirmed the absence of the document and stated the follow-up with the family member should have been documented and the advance directive obtained. Both residents had H&P documentation showing they had the capacity to make medical decisions, and the DON acknowledged the findings.
Failure to Document Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to follow the resident’s plan of care and failed to document behavior monitoring for one resident who was receiving valproic acid for bipolar disorder and recurrent behavior fluctuations. The resident’s medical record showed diagnoses of bipolar disorder, schizoaffective disorder, and Alzheimer’s disease, and the resident was receiving valproic acid 250 mg twice daily, later increased to 250 mg every morning and 500 mg every evening for bipolar disorder manifested by recurrent behavior fluctuations from depressed to manic behaviors. The care plan included monitoring and recording the resident’s mood to determine whether problems may be related to external causes, including medications and treatments. The record did not show routine monitoring and documentation of the resident’s behaviors targeted by valproic acid. The resident was observed shouting out for help repeatedly on multiple occasions, and staff interviews described the resident as constantly calling out for help and sometimes disruptive to a roommate. During interviews and record review, the ADON confirmed the care plan called for behavior monitoring and that it was not routinely completed, and the LVN reviewed the MAR and verified there was no documentation showing the behavior monitoring tracking was completed.
Failure to Care Plan Positioning Pillow Use
Penalty
Summary
Resident 112 was observed in bed with a positioning pillow device on the mattress at the right side of the bed during the initial tour. On a later observation, LVN 2 verified that Resident 112 had positioning pillow devices on both sides of the bed and stated that the resident's family member had requested the pillows for comfort. LVN 2 was unsure whether a care plan had been developed for the use of the positioning pillow devices and said she would check the resident's record. Review of Resident 112's medical record did not show a care plan for the use of positioning pillow devices had been initiated. During an interview and concurrent record review, ADON 2 reviewed the record and verified there was no care plan or monitoring completed for the resident's use of the positioning pillow devices. The facility's P&P stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident.
Low Air Loss Mattress Left in Static Mode
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents reviewed for pressure injuries. Resident 97 was observed in bed on a low air loss mattress that was set to normal pressure and in static mode. The resident stated he believed he had a bed sore and said he received treatment every day, but he did not know the stage of the sore. The resident had been admitted to the facility and had physician orders allowing a low air loss mattress, including an order dated 5/29/26 for a low air loss mattress due to an unstageable pressure ulcer of the sacral region. The facility's operator's manual for the mattress system stated static mode provides a firm surface and prevents bottoming out when sitting. During a concurrent observation and interview, an LVN verified the mattress was in static mode and stated it should not be on static mode while the resident was in bed; static mode should only be used during care and when getting the resident out of bed. The DON also stated the static mode should not be on when a resident is in bed and lying on a low air loss mattress, and that it was only used during ADL care and transfer. The DON acknowledged the mattress setting for Resident 97 was inaccurate.
Improper Head-of-Bed Positioning During GT Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube. Resident 202 was admitted and later readmitted to the facility, had a care plan addressing the feeding tube and aspiration risk, and was documented as GT dependent with no capacity to make decisions. The resident’s care plan included elevating the head of the bed to a 30-45 degree angle during feeding, and the facility’s policy for enteral tube feeding via gravity bag also directed that the head of the bed be positioned at 30-45 degrees unless medically contraindicated. During observation, Resident 202 was seen receiving enteral feeding via the GT while the head of the bed was at 22 degrees. During a medication administration observation, LVN 8 paused the feeding and administered medication through the GT while the head of the bed remained at 22 degrees, and did not elevate it to more than 30 degrees before giving the medication. In a concurrent interview, LVN 8 confirmed the head of the bed should be elevated to at least 30 degrees during enteral feeding and medication administration via GT, and the DON later acknowledged the findings and stated the head of the bed should be elevated to more than 30 degrees during GT feeding and medication administration.
IV Therapy Maintenance Lapses
Penalty
Summary
The facility failed to maintain IV vascular access devices consistent with professional standards of practice for two residents. For one resident, an IV heplock on the right arm was observed with a dressing dated 6/16, and the dressing was still dated 6/16 during a later observation the same day. RN 1 verified that the dressing should have been changed at least every seven days and when soiled, and the DON later acknowledged the finding. The facility policy stated that dressing changes are to be performed at least every 7 days and as needed. For another resident, an IV fluid bag of 0.9% Sodium Chloride was observed running at 50 ml/hr with a label dated 6/28/26 at 1800 hours. The resident had orders for IV hydration, including an order dated 6/29/26 for 50 ml/hr for one liter for one day. RN 1 verified that the IV fluid bag was dated 6/28/26 and stated IV bags should be changed every 24 hours. The facility policy stated that no IV solution will hang for a period greater than 24 hours, and the DON acknowledged the finding.
Improper Oxygen Administration by CNA
Penalty
Summary
The facility failed to ensure that oxygen was administered only by appropriately licensed nursing staff for one resident who had a physician's order for oxygen at 2 LPM via nasal cannula continuously. On 6/30/26, the resident was observed in a wheelchair with a nasal cannula in use, and later that day CNAs 2 and 5 were at the resident's bedside as the resident was transferred from the wheelchair to bed. CNA 2 removed the resident's nasal cannula to complete the transfer, then placed the nasal cannula attached to the oxygen concentrator back on the resident. When asked about the resident's oxygen, CNA 2 deferred to the nurse, and LVN 4 later stated that only LVNs and RNs could change oxygen delivery from a portable oxygen cylinder to an oxygen concentrator. The DSD stated that only LVNs and RNs could make that change and that CNAs were only able to readjust the nasal cannula if it slipped or fix an ear loop. The DSD also stated CNA in-services were completed on 2/2/26 and 5/4/26 regarding CNA scope of practice and that CNAs could not touch the oxygen except to adjust the ear loop if it slipped off. Review of CNA 2's skills checklist showed competency for oxygen tubing care, but it did not show review for oxygen administration or changing oxygen supply from a portable oxygen cylinder to the oxygen concentrator.
Medications Not Administered as Ordered
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for three residents. For one resident, glipizide, Mobic, and pantoprazole were ordered but were coded as not administered on the MAR, with documentation showing the medications were pending delivery or not arrived even though pharmacy labels showed the medications had already been filled and the DON stated they should have been available. The DON also stated that if medications did not arrive timely, licensed staff were expected to follow up with the pharmacy. For another resident, an LVN was observed preparing divalproex sodium delayed-release 500 mg tablets and cutting the tablet into two halves with a pill cutter before administering it. The resident stated the tablet was too large to swallow, and the LVN confirmed he cut the delayed-release tablet each time it was given. The LVN acknowledged the tablet should not have been cut and stated the physician should have been notified for a different formulation. The pharmacist consultant stated the delayed-release tablet should not be cut because it would alter the medication's intended therapeutic effect. For a third resident receiving IV piperacillin-tazobactam for right lower extremity cellulitis and strep septicemia, surveyors observed the IV bottle still containing approximately one-quarter of the solution during the initial tour. The resident stated this was not the first time and described seeing liquid remaining after the nurse removed the connection. RN 1 reviewed the bottle and stated the full dose had not been given because almost one-quarter of the solution remained in the bottle. The DON later acknowledged the findings.
Medication Left at Bedside Without Order
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for one sampled resident, Resident 187. During observation on 6/30/26 at 0935 hours, a bottle of Medline Remedy antifungal powder was found on the resident’s bedside table while the resident was lying in bed. Resident 187 stated the staff had left the medication on the bedside table since the previous night and said he did not apply the medication himself; instead, staff applied it to his arm. At 0940 hours, LVN 6 was called to the room, verified the bottle was present at the bedside, and stated it should not have been left there. The LVN removed the bottle from the room. Review of the resident’s record showed Resident 187 was cognitively intact, and the Order Summary Report dated 7/2/26 did not show a physician’s order for Medline Remedy antifungal powder. On 7/3/26 at 1019 hours, the DON reviewed the findings and confirmed the resident did not have a physician’s order for the antifungal powder and that staff should not apply medication without an order or leave medication unattended at the bedside.
Kitchen Food-Contact Surfaces Not Maintained
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen when kitchen equipment was not maintained and cleaned properly. During an observation in the main kitchen, six plastic food bowls were found with numerous cuts, scratches, and permanent staining. The Dietary Services Supervisor acknowledged that the bowls should not be used in that condition. The deficiency was identified during an observation and concurrent interview with the Dietary Services Supervisor. Facility records showed that 173 residents consumed food prepared in the kitchen. The report cites USDA Food Code 2022 standards for food-contact surfaces and utensils, including requirements that materials be safe, durable, nonabsorbent, smooth, easily cleanable, and resistant to scratching and other damage, and that food-contact surfaces and utensils be clean to sight and touch.
Staff Not Educated on Safe Reheating of Food Brought From Home
Penalty
Summary
The facility failed to ensure staff were educated on safe food handling for food brought in by family and other visitors. The facility had a policy titled "Foods Brought by Family/Visitors" dated August 2024, which stated staff would strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents and would assist residents in accessing and consuming their personal food. However, review of the in-service materials and the policy showed that the safe reheating temperature for outside food was not included. During interviews, CNA 3 stated family members and friends may bring food from home, that it should be labeled, dated, and stored in the refrigerator, and that she reheats residents' food from outside sources in the microwave. CNA 3 stated she had not received training on safe food handling and did not know the proper reheating temperature. LVN 2 stated CNAs reheat residents' food from outside sources in the staff lounge, was unaware of the proper reheating temperature, and said a thermometer was not available to verify food temperature. CNA 4 stated food from home is labeled, dated, and placed in the refrigerator, and if it needs to be reheated, staff will reheat it to 140 degrees. The DSD stated CNAs reheat food brought from home to 140 degrees F and staff had received an in-service, but later confirmed she did not provide education to staff regarding safe food handling practices and clarified that 140 degrees F applies to food service, not reheating food.
Dumpster Lid Not Kept Closed and Refuse Found Around Bin
Penalty
Summary
The facility failed to ensure the lid of an outside garbage dumpster bin was tightly closed. During observation and interview, the green food scraps dumpster bin was found with an ill-fitting lid and a gap of about three inches between the lid and the bin. When the Dietary Services Supervisor opened the lid, flies were observed inside the bin. Additional refuse, including old equipment, cardboard boxes, scraps of wood, a black plastic trash can, a crate, a mop, trash, and paper, was found on and around the dumpster area and beneath the bin. Review of the facility policy titled Food-Related Garbage and Refuse Disposal stated that outside dumpsters provided by garbage pickup services are to be kept closed and free of surrounding litter. The Dietary Services Supervisor acknowledged the findings.
Loose Bed Grab Bars
Penalty
Summary
The facility failed to ensure the bilateral grab bars attached to Resident 137’s bed were properly installed. During an observation, Resident 137 was awake and lying in bed and stated she used the grab bars daily to get out of bed and reposition herself from lying to sitting, but that they were moving. The resident also stated they could have been fixed so they would be firm and not move. On inspection, the two grab bars were observed to move sideways, backward, and forward. The Maintenance Director verified the movement and determined that the screws at the bases of both grab bars were loosely attached to the bed frame. The resident was admitted to the facility on 12/26/24, and the facility’s maintenance policy stated that equipment was to be maintained in a safe and operable manner and free from hazards.
Dirty Resident Fan
Penalty
Summary
The facility failed to ensure resident equipment was maintained in a clean and sanitary condition for one of 35 sampled residents, Resident 15. On 6/30/26 at 0912 hours, Resident 15 was observed lying in bed with a portable fan positioned on the left side of the bed and blowing air toward the resident's face. Heavy dust and lint were visibly accumulated on the fan. Resident 15 stated he did not know when the fan was last cleaned. During a concurrent observation and interview on 6/30/26 at 0630 hours, LVN 6 verified the fan's condition and stated it had collected dust and lint and should have been cleaned. The facility's P&P titled Homelike Environment dated 2/2021 stated staff and management maximize, to the extent possible, characteristics of the facility that reflect a personalized, home like setting, including a clean, sanitary, and orderly environment.
Verbal Abuse of a Cognitively Intact Resident by Dietary Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. The facility’s Abuse Prevention Program policy stated that residents have the right to be free from abuse. The involved resident had diagnoses including anxiety disorder and depression, was cognitively intact, and had expressed increased anxiety about having another heart attack. On the date of the incident, the resident returned to the kitchen because the meal tray provided was not to her liking, and kitchen staff prepared a new tray. A dietary aide carried the new tray and walked back to the resident’s room with the resident, during which staff overheard them talking loudly and heard the resident call the aide names. When the dietary aide later returned to the resident’s room to bring yogurt, the resident yelled at the aide, and the aide responded by yelling, cursing, and making derogatory comments toward the resident, including calling her “crazy.” CNA witnesses reported hearing the aide curse at the resident, and one CNA observed the resident crying and not understanding why the aide acted that way. A Change in Condition Evaluation documented that the resident experienced increased anxiety and brief situational emotional distress related to the altercation with the dietary aide, though she returned to baseline with reassurance. The facility’s internal conclusion acknowledged that staff should not respond with profanity toward a resident regardless of the resident’s behavior, and the DON verified the findings.
Failure to Perform Required Post–Change in Condition Monitoring After Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to provide required nursing assessments and monitoring following a resident’s change in condition related to an incident of verbal abuse. The facility’s Abuse and Neglect – Clinical Protocol policy stated that staff and the physician would monitor individuals who have been abused to address issues regarding their medical condition, mood, and function. The resident involved had diagnoses including anxiety disorder and depression, was documented as cognitively intact, and had previously expressed increased anxiety about having another heart attack. After a dietary aide was observed yelling at the resident, a Change in Condition Evaluation documented that the resident experienced increased anxiety and brief situational emotional distress related to the altercation, and then returned to baseline with reassurance. The resident’s care plan was updated with a problem addressing the verbal abuse incident, including an intervention to monitor the resident for 72 hours for changes in routine and symptoms of distress. Facility staff, including an LVN and the ADON, stated that following a change in condition, nursing staff were supposed to assess and monitor the resident every shift for 72 hours, focusing on the change in condition to ensure proper interventions and to notify the physician if needed. The ADON stated that the purpose of the follow-up assessments for this resident was to ensure the resident felt safe and comfortable and to assess for any pain. The ADON verified that the resident was not monitored following the verbal abuse allegation on the morning of 2/10/26 and that all assessments were missed on 2/11/26, and the DON confirmed these findings.
Failure to Prevent and Investigate Repeated Gastrostomy Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received appropriate care and services to prevent complications related to repeated dislodgement of the GT. The resident experienced multiple incidents of GT dislodgement on at least seven separate occasions, each requiring medical intervention and replacement of the tube. Despite these repeated events, the facility did not conduct assessments or document investigations into the possible causes of the dislodgements, except for one incident. There was also no evidence of updated or modified interventions to prevent further occurrences, and no interdisciplinary team (IDT) meetings were held to address the frequent GT dislodgement. Staff interviews revealed that the primary intervention implemented was the use of an abdominal binder to prevent the resident from pulling at the GT, along with a sign instructing staff to keep the resident's right arm outside the sheets. However, staff also reported that the GT had been pulled out by staff during repositioning and that there were lapses in supervision, such as leaving the resident alone without the abdominal binder during shower preparation. Additionally, the shower team was not consistently informed about high-risk residents prior to showers. The facility's lack of investigation, documentation, and updated interventions contributed to the ongoing issue of GT dislodgement for this resident.
Failure to Develop and Implement Individualized Care Plan for GT Dislodgement
Penalty
Summary
The facility failed to develop and implement an individualized care plan to address and prevent the repeated dislodgement of a resident's gastrostomy tube (GT). Despite multiple documented incidents where the resident's GT became dislodged, the care plan did not include a specific problem statement or interventions aimed at minimizing the risk of further dislodgement. The facility's policy requires that care plans reflect current standards of practice, be person-centered, and be updated as residents' conditions change, but this was not followed in the case of this resident. Medical record review showed several change of condition assessments related to the dislodged GT over a period of time, yet the care plan was not revised to address this recurring issue. During an interview and concurrent record review, the Assistant Director of Nursing (ADON) confirmed that a care plan to prevent GT dislodgement should have been developed for the resident, but was not present. This resulted in the resident not receiving appropriate, consistent, and individualized care to address the risk of GT dislodgement.
Ice Machines Not Cleaned per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that both of its ice machines were cleaned and maintained according to the manufacturer's guidelines. The manufacturer's instructions, posted inside the machines, specified the use of 1.7 fluid ounces of 8.25% sodium hypochlorite (chlorine bleach) for sanitizing. However, the Maintenance Director reported using only 1.5 fluid ounces of 7.5% Clorox bleach for all ice machines, which did not meet the specified concentration or amount required by the manufacturer. Additionally, the facility's own policy and procedure, revised in November 2022, required adherence to the manufacturer's instructions for cleaning and disinfecting ice machines and storage chests. During observations of both ice machines, brown residue was found inside the ice chutes, which was removed with a paper towel, confirming that the machines were not clean. The Maintenance Director acknowledged that the cleaning and sanitizing process did not follow the manufacturer's guidelines and verified the presence of residue. No information about residents or their medical conditions was provided in relation to this deficiency.
Multiple Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines in several critical areas, as observed and documented by surveyors. The cool down process for time/temperature control for safety (TCS) foods was not monitored or documented, and previously cooked foods were kept beyond recommended time limits. Staff interviews confirmed that cooling logs did not include required entries for both cooked and ambient temperature TCS foods, such as tuna and egg salad, and that staff were unaware of proper monitoring procedures. Additionally, food items in the refrigerator were found with missing or outdated labels, and some foods were stored longer than recommended by USDA guidelines. Hand hygiene practices among kitchen staff were inadequate. Two of three cooks failed to wash their hands after activities that could cause contamination, such as retrieving items from storage, touching their clothing, or picking up utensils from the floor. These lapses were observed during food preparation and confirmed in interviews with the Registered Dietitian (RD), who acknowledged that staff must wash hands when changing tasks or after contamination. Furthermore, food preparation surfaces were not properly sanitized, as the concentration of sanitizing solution in use was below the effective level required for food contact surfaces. Staff and management confirmed that the sanitizer was not at the correct concentration and that this issue was not being consistently addressed. The physical environment and equipment in the kitchen also failed to meet sanitation standards. The kitchen floor in front of a freezer was unfinished concrete, making it uncleanable, and a food preparation sink lacked an air gap, creating a risk of backflow contamination. Equipment such as drying racks and meal trays were found to be rusted, chipped, and cracked, and a container in dry storage had a cracked lid. Goods in dry storage were not protected from possible pest contamination. Additionally, two dietary aides were observed wearing large false eyelashes during food preparation, which is not recommended due to the risk of physical contamination. These deficiencies affected a highly susceptible population of 156 residents who consumed food prepared in the facility's kitchen.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use and Significant Weight Loss
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of two residents. For one resident with a diagnosis of paroxysmal atrial fibrillation, a physician ordered apixaban, an anticoagulant medication, but the resident's care plan did not include any interventions or monitoring related to the use of this medication. This omission was confirmed during a medical record review and interview with a licensed nurse, who acknowledged that the care plan should have been updated when the medication was ordered. Another resident, admitted with diagnoses including malignant neoplasm of the esophagus, dysphagia, and muscle wasting, experienced a significant weight loss of 6.5% in one month, as documented in weekly weight records. Despite this notable change, there was no evidence in the resident's care plan that addressed the weight loss. This finding was verified during a review of the medical record with the assistant director of nursing.
Failure to Update Diabetic Diet Terminology to Meet Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following the current diet manual recommendations for diabetic diets. Specifically, the facility continued to use the term "RCS" (Reduced Concentrated Sweets) for diabetic diets, despite guidance from the Academy of Nutrition and Dietetics and the American Diabetes Association indicating that such terminology is outdated and not reflective of current nutrition recommendations. The facility's diet manual, menus, tray cards, and dietary documentation all used the RCS nomenclature, and the Registered Dietitian (RD) confirmed that this terminology was used interchangeably with the Consistent Carbohydrate (CC) diet, even though RCS is not a recognized diet by professional organizations. Interviews with the RD revealed that she was aware of the discrepancy between the terminology used at the facility and current professional standards but had not communicated her concerns to the Corporate RD. The RD stated that the facility had always used the RCS terminology for diabetic diets and continued to do so after the implementation of their electronic health record system. The RD also confirmed that she was responsible for the nutrition care plans of all residents on these diets and that the care plans reflected the diet as ordered, using the RCS terminology. A review of facility records showed that 51 residents were receiving an RCS diet, with various modifications such as fortified, high protein, or renal adjustments. One resident with diabetes and a recent fracture was specifically noted to have an RCS NAS regular consistency diet ordered by the physician, and the RD confirmed that this was documented in the care plan and dietary records. The Director of Nursing (DON) also verified that the RCS nomenclature was used because it had been the facility's longstanding practice.
Failure to Provide Adequate Nail Care Resulting in Self-Inflicted Skin Lesions
Penalty
Summary
A deficiency was identified when a resident who required staff supervision for personal hygiene and grooming did not receive adequate nail care. During observations, the resident was seen scratching her face, neck, and arms, resulting in multiple small red lesions. The resident's fingernails were noted to be long, with black stains and food residue underneath. The care plan for this resident specifically included an intervention to keep fingernails short due to a history of self-inflicted excoriations. However, documentation showed that the last time the resident's fingernails were clipped was over a month prior, and there was no record of nail care being offered since then. Interviews with staff confirmed that providing nail care was a CNA responsibility and that the resident's care plan should have been followed. Both the CNA and LVN verified the resident's nails were long and dirty, which contributed to skin impairment. The ADON acknowledged that failure to provide personal hygiene and grooming, including nail care, could affect the resident's dignity and potentially lead to bacterial growth. The facility's policy required assistance with activities of daily living, including grooming and hygiene, for residents unable to perform these tasks independently.
Failure to Provide Pressure Ulcer Prevention and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for a resident admitted with a Stage 3 pressure injury on the sacrum. Despite being identified as high risk for pressure injury on Braden Scale assessments, the resident was not provided with a low air loss mattress as required by facility policy and physician order. Multiple observations confirmed the resident was resting and sleeping in bed without the appropriate pressure-relieving mattress, and staff interviews revealed confusion and lack of follow-up regarding the mattress order, with insurance issues cited as a reason for the delay. The case manager was unaware of the need for the mattress, and the ADON acknowledged the resident should have received one within a month of admission. Additionally, the facility failed to ensure accurate skin assessment for the resident, who developed blisters on both heels. Staff interviews revealed inconsistent understanding of pressure injury staging, with one LVN incorrectly stating that an intact blister on the heel was not a Stage 2 pressure injury, while the ADON confirmed it should be considered as such. The care plan addressed the need for a pressure-relieving device for the wheelchair but did not include an intervention for the bed, despite the resident's decreased mobility and incontinence, which were identified as contributing factors for further skin breakdown. Furthermore, the facility did not follow the physician's order for a wound consult. Although a wound consult was ordered due to the Stage 3 pressure injury, staff interviews and record reviews confirmed that the order was not followed up or completed. The LVN responsible was unaware of the order, and the wound physician had not been consulted for the resident. These failures had the potential to contribute to the deterioration of the resident's existing pressure injuries and the development of new ones.
Failure to Monitor Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to monitor a resident who experienced a significant weight loss of 6.71% in one month. According to the facility's policies and procedures, a weight loss of 5% or more in one month is considered a significant change of condition, requiring assessment and monitoring. The resident, who had severe cognitive impairment, was noted by the registered dietitian to have lost weight likely due to a recent acute care hospitalization, and dietary interventions were recommended, including increased milk intake and weekly monitoring of weights, oral intake, laboratory tests, and skin condition. Despite these recommendations and the facility's own protocols, there was no documented evidence that the resident was assessed or monitored for the significant weight loss. Observations showed the resident consumed only 20% of a lunch meal on one occasion, though intake was higher at breakfast on another day. Interviews with staff confirmed that the required monitoring and assessment following the change in condition did not occur. Facility leadership acknowledged that the resident was not monitored as required after the significant weight loss.
Failure to Ensure Proper Positioning and Labeling During Enteral Feeding
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident receiving enteral feeding. Specifically, the resident was observed in bed with the head of the bed only slightly elevated, not meeting the required 30 to 45 degrees elevation during GT feeding as ordered by the physician and outlined in the facility's policy and procedure. This was confirmed during an observation and interview with an LVN, who verified that the resident's head of bed was not properly elevated while the GT feeding was in progress. Additionally, the GT feeding bag containing Fibersource 1.2 was not labeled with the date and time it was hung, contrary to the facility's policy which requires such labeling to ensure safe administration and monitoring of enteral nutrition. The LVN also confirmed that the feeding bag was missing the required label. These failures were identified through observation, interview, and review of the resident's medical record and facility policies.
Failure to Provide Safe and Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care for multiple residents, as evidenced by a lack of physician orders, incomplete care planning, and improper management of respiratory equipment. For example, one resident was administered oxygen without a physician's order or a corresponding care plan, and suctioning was performed without an order. Observations revealed that respiratory equipment such as suction canisters and catheters were undated, unlabeled, and not stored in set-up bags as required by facility policy. Another resident was found to be receiving oxygen at a rate higher than prescribed by the physician, with undated nasal cannula tubing and a set-up bag that was not changed weekly. Additional residents had respiratory therapy equipment, such as nebulizer masks and oxygen tubing, that were not dated or changed according to the facility's infection control policies. In several cases, the required set-up bags for storing respiratory equipment when not in use were missing, and equipment was not labeled with the resident's name or date as required. Interviews with staff, including LVNs, the Central Supply Manager, and the DON, confirmed that respiratory supplies were not consistently labeled, changed, or stored according to policy. The facility's own policies required weekly changes and proper labeling of respiratory equipment, but these procedures were not followed for several residents. These failures were observed across multiple residents and confirmed through staff interviews and medical record reviews.
Failure to Document and Monitor Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for a resident diagnosed with dementia, as required by its own policies and procedures. The resident, who had a history of dementia and was noted to lack capacity for medical decision-making, was observed to be confused, sometimes agitated, and in need of reminders to eat. Staff interviews revealed that while changes in the resident's behavior, such as agitation and aggression, were verbally reported to the charge nurse, there was no documentation or formal monitoring of these behaviors in the medical record as outlined in the resident's care plan. Review of the resident's care plan indicated that staff were to monitor for changes in condition and behaviors related to dementia and report these findings to the physician. However, both CNA and LVN staff confirmed that they did not document altered behaviors or assess for changes in the resident's thought process, despite observing such behaviors. The lack of documentation and monitoring meant that the resident's dementia-related symptoms and potential changes in condition were not being formally tracked or communicated as required.
Failure to Document and Safeguard Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not maintaining complete and accurate documentation on the Narcotic Card/Bottle Count Sheets for multiple medication carts over several months. Specifically, for Medication Cart C in February and March, and Medication Cart D in February and April, there were numerous instances where required staff signatures were missing for both incoming and outgoing shifts across all three daily shifts. Additionally, there were several occasions where the total number of narcotic cards and bottles was not documented by either on-duty or off-duty staff as required. These deficiencies were confirmed during interviews and concurrent document reviews with licensed vocational nurses, who acknowledged that it was the responsibility of licensed nurses to count and sign for the narcotic cards and bottles at the start of their shifts. The lack of proper documentation and signatures on the count sheets had the potential for controlled substance diversion, as the facility did not ensure that the required procedures for tracking and safeguarding controlled medications were consistently followed.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 23.07%. During medication administration observations, three LVNs were found to have made multiple errors. One LVN cut an unscored vitamin C tablet in half for a resident, contrary to best practices and without a physician's order, resulting in the administration of an inaccurate dose. The same LVN also failed to administer the correct dosages and types of medications to another resident via gastrostomy tube (GT), did not flush the GT between medications, mixed multiple medications together, and did not check for loose stools before administering a stool softener, as required by the physician's order. Another LVN did not follow physician's orders when administering a calcium with vitamin D supplement to a resident, failed to instruct the resident not to chew an extended-release medication, and did not assess for signs of bleeding or bruising prior to administering an anticoagulant. The medication administration record and medication packaging indicated that the extended-release medication should not be chewed or crushed, but the resident was observed breaking the tablet to swallow it more easily, without being advised otherwise by the nurse. A third LVN administered a stool softener to a resident without assessing for loose bowel movements, despite a clear physician's order to hold the medication if the resident had loose stools. In interviews, the LVNs acknowledged the errors and confirmed that they did not follow the required procedures or physician's orders during medication administration. The DON confirmed that nurses are expected to be competent in medication administration and to follow all orders and protocols.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Multiple deficiencies were identified regarding the storage, labeling, and disposal of medications and supplies. Expired treatment supplies, such as culture swabs, were found in a treatment cart, and staff confirmed these items should not have been present. Medication storage rooms contained staff personal belongings, and medications were not properly segregated by type, with transdermal patches stored alongside oral medications and artificial tears stored with oral medications. The medication refrigerator was found to be outside the acceptable temperature range, and staff acknowledged this deviation from policy. Further observations revealed that topical and oral medications were stored together in medication carts, such as antifungal cream with oral tablets and suspensions, and injectable medications were stored with inhalant medications. Discontinued medications were not removed from medication carts, and medication carts were left unlocked and unattended. A white capsule was found on a resident's bed, despite the resident not being authorized for self-administration, and the nurse confirmed the medication should have been administered and not left with the resident. Additional deficiencies included unlabeled and resident-specific creams left at the bedside of a resident with severe cognitive impairment, and artificial tears eye drops were found at another resident's bedside. Staff verified that these items should not have been accessible to residents in this manner. The facility's policies and procedures required medications and biologicals to be stored in locked compartments and maintained under proper conditions, but these were not consistently followed, as evidenced by the findings.
Failure to Follow Pureed Food Preparation Procedures
Penalty
Summary
The facility failed to ensure that cooks followed proper procedures for preparing pureed food, specifically for mandarin chicken and roasted cauliflower. During observation, it was noted that the cook preparing the pureed mandarin chicken did not follow the facility's recipe, which required the addition of mandarin sauce to the chicken before pureeing. Instead, only plain boiled chicken, water, and thickener were used, resulting in a pureed product that was bland and did not match the flavor of the regular texture dish. The dietetic technician registered (DTR) confirmed that the pureed mandarin chicken lacked the same flavor as the regular version. For the pureed roasted cauliflower, the cook did not initially follow the recipe instructions, which required blending the roasted cauliflower before determining if additional liquid or thickener was needed. Instead, the cook added water and thickener before blending, and repeatedly added more water to achieve the correct consistency. The cook acknowledged not following the recipe after being prompted to read the instructions and had to restart the process to comply with the proper method. Interviews with the registered dietitian (RD) confirmed that all recipes should be followed as written. The failure to adhere to established recipes and procedures for pureed foods created a risk for inconsistent products and the potential for not meeting the nutritional needs of the 16 residents who required a pureed diet.
Failure to Maintain Hospice Documentation and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had all necessary documentation and coordination in place. Specifically, the hospice visit calendar and the physician certification of terminal illness were not available in the resident's medical record. Multiple staff members, including LVNs, were unable to confirm the schedule of hospice visits or the identity of the hospice coordinator. The hospice binder did not contain the required calendar for scheduled visits, and staff were unsure about the frequency of hospice visits for the resident. Additionally, there was confusion among staff regarding who was designated as the hospice coordinator, with different staff members identifying either the QA Nurse or the social service department. Interviews with staff revealed a lack of awareness about hospice visit documentation and the process for communicating with the hospice provider. One LVN was unaware of whether hospice had visited regarding a specific equipment request and had to rely on a sign-in sheet for confirmation. Another LVN was unable to provide the physician's certification for hospice benefits when asked. The Director of Nursing later confirmed that the social worker was the hospice coordinator and acknowledged the findings related to missing documentation and unclear staff roles.
Failure to Assess and Care Plan for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly assessed and care planned for self-administration of medications, as required by facility policy. One resident was found with three bottles of eye drops at her bedside, which she self-administered without a physician's order or a documented assessment by the interdisciplinary team (IDT) to determine her ability to safely self-administer these medications. The resident was not provided with education on the correct technique for administering the eye drops, as she reported not knowing how long to keep her eyes closed after application and often opened them immediately after use. Review of her medical record confirmed the absence of a physician's order and a care plan addressing self-administration of these medications, despite her having the capacity to make medical decisions. Another resident was observed with an antifungal powder at her bedside, which she reported possibly using once but could not recall who provided it. This resident's medical record indicated moderately impaired cognition, and there was no physician's order, assessment for self-administration, or care plan for the use of this medication. Staff interviews confirmed that the medication was not authorized to be kept at the bedside and that the resident and her family had not been educated on the facility's protocol regarding self-administration and storage of medications. Facility policy requires that residents may only self-administer medications if the IDT determines it is clinically appropriate and safe, with documentation in the medical record and care plan, and with periodic reassessment. Any medications found at the bedside without authorization are to be removed. In both cases, these procedures were not followed, resulting in unauthorized self-administration of medications without proper assessment, documentation, or education.
Failure to Honor and Maintain Advance Healthcare Directives
Penalty
Summary
The facility failed to honor the advance healthcare directives for two residents, resulting in deficiencies related to the residents' rights to have their healthcare decisions respected. For one resident with severe cognitive impairment, the advance healthcare directive designated a specific family member as the healthcare agent and indicated a preference not to prolong life. However, the resident's medical record contained a POLST form that authorized CPR and artificial nutrition, was signed by a different family member, and incorrectly stated that no advance directive was available. Both the registered nurse and the social services director confirmed that the POLST form did not match the resident's documented wishes or the designated healthcare agent. For another resident who was cognitively intact, the facility failed to maintain a copy of the advance healthcare directive in the medical record. Although the resident's family provided the directive and documentation indicated it was received by the medical records department, the document was not uploaded or made readily retrievable in the electronic health record. Multiple staff interviews confirmed that the advance directive was not available in the resident's record, despite the POLST form indicating it had been reviewed. The facility's policy required that advance directives be obtained, maintained in a consistent and accessible section of the medical record, and that the resident's wishes be communicated to care staff and reflected in the plan of care. These requirements were not met for the two residents, resulting in the potential for their healthcare decisions and treatment preferences not being honored.
Failure to Prevent Accident Hazards Due to Items Placed on Overbed Light Fixtures
Penalty
Summary
The facility failed to ensure that certain resident areas were free from accident hazards, specifically by allowing personal belongings and other items to be placed on top of overbed light fixtures in the rooms of three residents. For one resident, two picture frames, a hat, and two stuffed toys were observed on top of the overhead light fixture. Staff, including an LVN and the Maintenance Director, confirmed these items were present and acknowledged that such placement could weaken the fixture and potentially result in items falling. The Maintenance Director noted that the resident had recently been transferred to the room and that monthly checks were conducted, but no maintenance request had been logged to address the issue. The DON stated that all staff were responsible for checking resident rooms and ensuring safety, but no action had been taken to remove the items or report the hazard. In two other cases, two pop-up flower cards and a piece of wood were found on top of overbed light fixtures in the rooms of residents with severe cognitive impairment. Staff interviews revealed that CNAs had not noticed or addressed the items, and the Maintenance Director confirmed the presence of these hazards during observations. The Maintenance Director also removed a metal drawer slide bracket from one of the fixtures, stating that no items should be placed on top of overbed light fixtures. Medical record reviews indicated that the affected residents had moderate to severe cognitive impairments, which may have limited their ability to recognize or report such hazards.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete annual performance evaluations for one of two reviewed certified nurse aides (CNA 1), as required by its policy. The facility's policy, revised in September 2020, mandates that each employee's job performance be reviewed and evaluated at least annually by department directors and supervisors, with further review by the director of human resources. During an interview and document review, the Director of Staff Development (DSD) confirmed that CNA 1's last performance evaluation was conducted on 11/16/22, and acknowledged that employee files should be reviewed regularly based on the date of hire. The Director of Nursing (DON) also acknowledged that the policy on performance evaluations was not followed.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and professional standards. For one resident, the most current POLST (Physician Orders for Life-Sustaining Treatment) form was not uploaded into the electronic health record, and a previous POLST form indicating a different code status was not voided. This resulted in conflicting information regarding the resident's code status, as the electronic record showed a full code while a physician's order indicated DNR (Do Not Resuscitate). The Medical Records Director confirmed that the current POLST form was not uploaded because she had not yet accessed the binder, and the previous form remained in the record unvoided. Additionally, documentation for turning and repositioning, personal hygiene, oral hygiene, toileting hygiene, and pressure reduction was incomplete or missing for multiple residents, including those with severe cognitive impairment and total dependence on staff for ADL (Activities of Daily Living) care. Reviews of documentation survey reports revealed numerous missing entries across various shifts, with some tasks incorrectly coded as 'not applicable' or left blank. Interviews with the DON and ADON confirmed that CNAs were expected to document care at the end of their shifts and that missing or incorrect documentation could indicate that care was not provided or not properly recorded. The facility's policies required that all procedures and treatments be documented with specific details, including the date, time, care provided, and the staff member responsible. However, for several residents, these requirements were not met, as evidenced by the missing or incomplete documentation in their records. The DON and ADON verified these findings during interviews and acknowledged that the documentation did not meet facility standards.
Infection Control Program Failures and Lapses in Staff Work Restrictions
Penalty
Summary
The facility failed to maintain its infection prevention and control program, resulting in several deficiencies related to the prevention and transmission of communicable diseases. Staff members with symptoms of COVID-19 were not restricted from working while awaiting test results, contrary to facility policy and CDC guidelines. Specifically, a CNA reported symptoms such as sneezing, headache, watery eyes, and back pain, which were communicated to the Director of Staff Development (DSD), but the CNA was allowed to continue working until the end of her shift and returned to work the following day. The CNA later tested positive for COVID-19. Similarly, an LVN who tested positive for COVID-19 continued to work until notified of her result, and there was a lack of immediate communication and follow-up regarding her work restriction. The Infection Preventionist (IP) and DSD did not ensure that symptomatic staff were promptly removed from the schedule, and the Director of Nursing (DON) and Administrator were not made aware of these lapses at the time they occurred. The facility also failed to maintain clean laundry equipment, as observed during an inspection of the laundry room. One washing machine was found with heavy buildup of black, yellow, and white sediments on various parts, despite claims of daily cleaning by the Housekeeping Supervisor. The IP confirmed that such buildup could serve as a breeding ground for bacteria and that equipment should be kept clean to prevent infection. This lack of proper maintenance of laundry equipment posed a risk of contamination for residents' laundry. Additional deficiencies were identified in the implementation of Enhanced Barrier Precautions (EBP) for residents with medical devices such as gastrostomy tubes (GT). During wound care for a resident with a GT, an LVN failed to don a gown before performing care, only putting it on after beginning the procedure. Another resident with a GT did not have EBP signage or precautions in place, despite care plan orders and policy requirements. Furthermore, a resident's meal tray was placed on a bedside table next to a used urinal containing urine, and there was no care plan documentation addressing the resident's preference to keep the urinal at the bedside. Staff interviews confirmed that this practice was not in line with infection control policies.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 5,740 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seal Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alamitos West Health & Rehabilitation | 3 mi | ★★★★★ | 36 | 0 |
| Stanley Healthcare Center | 3.5 mi | ★★★★★ | 22 | 0 |
| Shoreline Healthcare Center | 3.8 mi | ★★★★★ | 23 | 0 |
| Bel Vista Healthcare Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Alamitos Belmont Health And Rehabilitation | 4.1 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.