Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Socal Post-acute Care during CMS and state inspections, most recent first.
Cluttered Dumpster Area: The facility failed to keep the garbage disposal area free of clutter when cardboard boxes and empty plastic containers were left around the main dumpster. During observation, the area was found to be littered with garbage, and the MD stated the boxes and containers should not have been left there. The facility policy required garbage storage areas to remain clean and free of surrounding litter.
Infection Control Failures With PPE and Hand Hygiene: A resident on contact precautions with C. diff, severe cognitive impairment, and extensive ADL dependence had two pillows placed in the handwashing sink in the room, and a family member was not ensured to wear required PPE. In addition, a CNA fed residents without hand hygiene between residents, and two CNAs were observed entering and exiting resident rooms and moving a shower chair between rooms without performing hand hygiene, despite the facility's hand hygiene and C. diff policies.
Failure to Assess Self-Administration of Bedside Medications: A resident with DM and bilateral AKA had moderate impaired cognition on the MDS, yet the IDT did not document an assessment for self-administration of bedside meds. The resident kept artificial tears and Tums at the bedside and stated he used them as needed, while an LVN and the DON confirmed there was no documented self-administration assessment or order authorizing bedside meds.
Call Light Not Within Reach: A resident with muscle weakness, Down syndrome, reduced mobility, severely impaired cognition, and dependence in multiple ADLs had a fall care plan intervention to keep the call light within reach. During observation, the call light was found behind the headboard and out of reach. A CNA stated she forgot to place it next to the resident's hands, and the DON confirmed the care plan required the call light to be within reach for the resident to call for assistance.
Advance directive information was not documented as provided for multiple residents. One resident with intact cognition and another with capacity to make medical decisions had no record of being offered an AD, and a signed acknowledgement form was incomplete. Two other residents with dementia or impaired cognition also had no documented evidence that AD information was given, and the SSD verified the forms were incomplete.
MDS assessments did not accurately reflect the current status of two residents. One resident with dementia, hemiplegia, and severely impaired cognition was documented in the MDS as needing partial/moderate or supervision assistance with several ADLs, but observation and CNA documentation showed total/dependent care, Hoyer lift transfers, and no longer walking. Another resident with COPD, CHF, osteoarthritis, and difficulty walking had an MDS that did not show ordered restorative ROM exercises, even though the order required passive ROM to both lower extremities. The MDSC stated the omissions were overlooked, and the DON stated the MDS must accurately reflect each resident’s current condition.
Care plan not updated after Ativan was discontinued. A resident with Alzheimer’s disease, dementia, and anxiety disorder had a care plan that still listed Ativan and nursing monitoring for sedation/drowsiness, even though the active order list showed no current Ativan order. The MDSC confirmed the resident was not currently receiving Ativan and stated the care plan section should have been removed because it was inactive.
A resident with DM and bilateral AKA reported intermittent diarrhea for about two months, but the condition was not assessed, monitored, or evaluated by nursing staff. The resident said staff knew about the issue but he still did not know why it was happening and it kept him from attending the activity room. An LVN later stated she was unaware of the diarrhea, and the DON said licensed nurses were not aware of the episodes and that CNAs should report subtle changes using the stop and watch tool.
A resident with hemiplegia, CVA, and a left elbow contracture did not receive ordered RNA services, including passive ROM to the left upper extremity and application of an elbow extension splint and resting hand splint. The resident stated he had not been getting ROM exercises and did not know when the splints were last used; a CNA had not observed the treatments, and an RNA noted the resident’s left upper extremity was stiff and that the resident had complained the exercises and splinting had not been provided in a while.
Unlabeled IV Bag During Infusion Therapy: A resident receiving IV hydration had a bag of D5 0.45% NaCl connected to IV tubing without the required label showing the resident's name and the date/time the infusion was started. The resident said she did not know how long the IV had been in place or who started it. RN and DON stated the bag should have been labeled per facility policy.
Failure to Check Ordered Vital Signs Before Administering Antihypertensive Medication: An LVN prepared to give Doxazosin Mesylate via G-tube to a resident with HTN, diabetes, and a prior CVA without first checking the ordered BP and HR parameters. The physician’s order required the medication to be held if SBP was below 110 or HR was below 60, and the LVN stated she forgot to verify the vital signs before administration. The DON confirmed the LVN did not follow the ordered procedure.
Incomplete Psychotherapeutic Drug Informed Consent Documentation: A resident with Alzheimer’s disease, dementia, and anxiety disorder was ordered Rexulti for agitation, but the informed consent form was not fully completed. The form lacked the MD’s signature date and did not identify the responsible party or the date consent was verified after the MDSC said consent was confirmed by phone. The MRD stated the required documentation was missing, and the facility policy required the nurse to record the name and date when consent was verified.
The facility failed to keep the kitchen freezer at 0 F or below. Observations showed the freezer at 18 F and 22 F, then 30 F on a later check. Review of the Cold Storage Temperature Log and the Food Receiving and Storage P&P confirmed the freezer was required to keep frozen foods solid at 0 F or below, and the DFS stated the same.
Call Lights Not Within Reach for Two Residents: Two residents were observed in bed with their call lights out of reach, one tied to the bed and one on the floor. RN review of the facility P&P, "Answering the Call Light," stated call lights must be accessible when a resident is in bed, at the toilet, in the shower or bathing, and from the floor; RN stated it is the entire staff's responsibility to ensure call lights are within residents' reach.
Inaccurate Daily Nurse Staffing Postings: The facility failed to post accurate daily staffing information showing the actual hours worked per shift by RN, LVN, and CNA. The Nursing Personnel on Duty posting instead showed a combined total of all nursing staff hours per shift, and the DON stated the posting was inaccurate because it did not identify the type and category of nursing staff providing care.
Two residents who had undergone orthopedic surgery did not receive proper care during transfers due to CNAs lacking competency and knowledge of required precautions. One resident suffered a new fracture after staff failed to follow transfer instructions, while another had physician orders disregarded regarding positioning. Staff interviews and record reviews revealed that CNAs had not been assessed for competency in transferring residents with recent orthopedic procedures, and facility policies requiring individualized transfer methods and demonstrated competencies were not followed.
Two residents experienced deficiencies in medication management, including a missing bubble pack of Dilaudid for a resident with amputations and neuropathy, and improper administration and documentation of Alprazolam for a resident with dementia. Staff failed to consistently verify medication quantities and document administration as required, leading to discrepancies between medication records and actual counts.
A resident with dementia and osteoarthritis experienced a fall and reported ankle pain, leading to a physician-ordered x-ray. The facility failed to follow up with the radiology company to obtain the x-ray results, resulting in a delay of several days before the fracture was identified and the physician was notified. Multiple nurses did not communicate or escalate the missing report, and the DON was unaware of the issue until after the delay, contrary to facility policy requiring timely notification of changes in condition and test results.
The facility failed to manage its trash disposal, resulting in an overflowing trash bin and scattered trash in the parking lot, visible from residents' windows. The Dietary Director and Maintenance Director acknowledged the issue, noting that trash should be in the container to prevent attracting pests. The Director of Nursing reviewed the facility's policy, emphasizing the need for a clean and homelike environment.
The facility failed to label an open pack of ground beef in the freezer with an opening date, as required by its policy. The Dietary Director acknowledged the oversight, noting the potential risk of food-borne illnesses if residents consume the unlabeled meat. The DON emphasized the importance of labeling to prevent serving expired food, which could lead to health issues for the 54 residents receiving meals from the facility's kitchen.
A resident's Advance Directive Acknowledgment Form was not completed upon admission, despite the resident's inability to make decisions due to medical conditions. The Social Services Designee confirmed the oversight, which could lead to misinformation about the resident's medical care and treatment preferences.
A facility failed to ensure a resident with diabetes received appropriate care upon readmission from a hospital. The resident did not receive necessary insulin and blood sugar monitoring due to a lack of verification of discharge orders with the attending physician. The Director of Nursing confirmed the absence of orders, and interviews revealed that the admitting nurse did not verify the continuation of insulin orders, despite the resident's history of diabetes management.
A facility failed to ensure the accuracy of the MDS for a resident with diabetes mellitus, leading to the absence of physician orders for diabetes management. Despite the resident's MDS indicating an active diagnosis of diabetes and insulin administration, there were no current orders for diabetic management upon readmission. The DON confirmed the lack of orders and the MDSN admitted to miscoding the MDS, highlighting a failure to accurately assess the resident's status.
A facility failed to update a resident's care plan for diabetes management upon readmission, resulting in the absence of physician orders for insulin and blood sugar checks. Despite having a history of diabetes mellitus, the care plan was not revised to reflect current orders, potentially impacting the resident's treatment. The DON confirmed the oversight, highlighting the need for clarification with the physician to ensure proper diabetes management.
A facility failed to conduct a comprehensive nutritional assessment for a resident with diabetes mellitus, leading to the absence of appropriate dietary orders upon readmission. The resident, who had been receiving insulin prior to readmission, did not have orders for diabetic management, which the DON confirmed could result in uncontrolled blood sugar levels. The CD missed the diabetes diagnosis during the nutritional assessment, leading to an incorrect diet being prescribed.
A resident with chronic respiratory failure was not receiving the correct oxygen flow rate as ordered by their physician. The resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed 2 to 4 LPM range. This was confirmed by an LVN and acknowledged by the DON, who emphasized the importance of correct oxygen dosing to prevent hyperoxygenation. The facility's policy on oxygen administration was reviewed, but the deficiency in practice was evident.
A facility failed to ensure that a physician responded to a consultant pharmacist's recommendation for lab monitoring for a resident with Type 2 diabetes and major depressive disorder. Despite the pharmacist's suggestion for a Basic Metabolic Panel, there was no documented response from the physician, and the Director of Nurses confirmed the lack of communication. This deficiency highlights a failure to adhere to the facility's policy on medication regimen reviews.
A facility failed to limit PRN orders for Ativan to 14 days for a resident with anxiety, lacking a stop date or rationale for extension. The resident's order, initiated without an end date, was not evaluated by the attending physician as required by facility policy, increasing the risk of adverse effects.
A facility failed to maintain infection control by not ensuring proper PPE use and disposal in a resident's Enhanced Barrier Precautions (EBP) room. An LVN was unaware of PPE requirements during high-contact care and disposed of soiled PPE outside the resident's room, contrary to facility policy. Interviews with the DON and infection prevention nurse confirmed the importance of proper PPE use and disposal to prevent infection spread.
A resident with dementia and high fall risk experienced two unwitnessed falls shortly after admission, resulting in a head laceration. The facility failed to increase supervision or update the care plan after the first fall, and did not consistently assist with toileting. Staff interviews revealed inadequate monitoring and documentation, and the DON acknowledged the need for more frequent supervision.
A resident dependent on staff for personal hygiene and toilet use was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident reported multiple instances of not receiving timely assistance after activating the call light, leading to feelings of frustration and humiliation. Interviews with staff revealed that call lights were not answered promptly, as required by facility policy.
Cluttered Dumpster Area
Penalty
Summary
The facility failed to ensure the garbage disposal area was free of clutter when used cardboard boxes and empty plastic containers were left surrounding the dumpster. During a concurrent observation and interview on 3/3/2026 at 7:42 AM with the Maintenance Director at the facility's garbage disposal area, the ground was cluttered with garbage, including constructed and deconstructed cardboard boxes stacked next to the main dumpster and at least ten empty plastic containers stacked directly adjacent to it. The Maintenance Director stated the area around the dumpster should be clear of trash and that the boxes and containers should not have been left there. Review of the facility's policy titled Garbage and Refuse Disposal, dated October 2017, indicated that waste should be kept in containers, stored in a manner inaccessible to pests, and that garbage storage areas should always be clean and free of surrounding litter.
Infection Control Failures With PPE, Hand Hygiene, and Sink Contamination
Penalty
Summary
The facility failed to implement its infection control policy and procedure when two pillows were observed sitting inside the handwashing sink in Resident 64's room, and the Infection Preventionist confirmed the sink should be kept clear because it is for handwashing. Resident 64 had been admitted and readmitted to the facility, with diagnoses including enterocolitis due to C. diff, encephalopathy, and a left below-knee amputation. The resident's MDS indicated a BIMS score of 2, showing severe cognitive impairment, and the resident required extensive assistance with multiple activities of daily living, including toileting hygiene, bathing, dressing, and personal hygiene. The facility also failed to ensure a family member for Resident 64 wore appropriate PPE while in contact with the resident, who was on contact precautions. The DON stated that any staff member passing a room under precautions should ensure visitors are wearing the required PPE. The facility's policy for C. diff stated precautions are taken while caring for residents with CD infection to prevent transmission to other residents, including wearing gloves when handling feces or articles contaminated with feces. In addition, CNA 4 was observed feeding residents in the dining room without performing hand hygiene between residents. The Infection Preventionist stated staff are required to perform hand hygiene before entering a room, before a task, and to prevent the spread of germs and protect resident health. The facility also observed CNA 1 and CNA 2 entering and exiting resident rooms, and moving a shower chair between rooms, without performing hand hygiene. Both CNAs acknowledged they forgot to perform hand hygiene and stated staff are supposed to do so every time they come in and out of resident rooms. The facility's hand hygiene policy stated all personnel shall follow hand hygiene procedures and perform hand hygiene before and after direct contact with residents and objects nearby residents.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team assessed whether Resident 16 could self-administer medications and keep medications at the bedside. Resident 16 was admitted with diagnoses including diabetes mellitus and bilateral above-the-knee amputations, and the history and physical stated the resident had the capacity to understand and make decisions. However, the Minimum Data Set dated 2/18/2026 indicated moderate impaired cognition and the resident required varying levels of assistance with dressing, bathing, and toileting hygiene. The record showed a physician order for artificial tears ophthalmic solution to be given as needed for dry, itchy eyes, but there was no documented assessment for self-administration of the eye drops or Tums tablets found at the bedside. During observation and interview, Resident 16 stated he kept eye drops at the bedside and used them for eye allergies, and also kept Tums in the nightstand drawer and took them as needed. An LVN stated there was no documented evidence that the resident had been assessed for self-administration of the eye drops and Tums, and the DON stated there was no assessment indicating the resident had been assessed for self-administration medication.
Call Light Not Within Reach
Penalty
Summary
The facility failed to follow its policy and procedure titled Answering the Call Light for one sampled resident whose call light was not within reach. Resident 8 was admitted with diagnoses including muscle weakness, Down syndrome, and reduced mobility. The resident's H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and dependence in bed mobility, eating, and personal hygiene. The resident's fall care plan, initiated on 7/29/2025 and revised on 7/31/2025, included an intervention for staff to keep the call light within reach. During an observation on 3/3/2026 at 8:40 AM, Resident 8's call light device was observed behind the headboard and out of reach. In a concurrent observation and interview, CNA 3 stated the call light was not within the resident's reach because it was behind the headboard and said it should have been placed close to the resident's hands; the CNA also stated she forgot to place it next to the resident's hands before leaving the room. The DON later reviewed the fall care plan and stated that staff were to place the call light within the resident's reach and that call lights are used by residents to call for assistance into the room.
Advance Directive Information Not Provided or Documented
Penalty
Summary
The facility failed to follow its policies and procedures regarding advance directives for four sampled residents. For Resident 47, the admission record showed diagnoses including difficulty walking, urinary tract infection, and muscle weakness. The history and physical stated the resident had the capacity to make needs known but could not make decisions, while the MDS indicated intact cognition. Review of the resident’s physical and electronic records did not show documented evidence that information to formulate an advance directive was provided, and the resident stated she did not recall ever being offered the opportunity to create one. LVN 2 and the SSD both stated the records did not show that Resident 47 was offered the opportunity to formulate an advance directive, and the SSD stated this should be offered upon admission. For Resident 39, the admission record listed diagnoses including hyperlipidemia, pneumonia, and hypertension. The history and physical did not state whether the resident had the capacity to understand and make decisions, while a physician progress note later stated the resident had the capacity to make medical decisions and the MDS indicated intact cognition. The resident’s records did not show documented evidence that information to formulate an advance directive was provided. A form titled Advance Directive Acknowledgement in the physical record had no initials or signature to show the resident received or reviewed it, and LVN 2 stated the form was incomplete and the records had no documented evidence that the resident was offered the opportunity to formulate an advance directive. The resident stated no one from the facility had offered information to create an advance directive, and the SSD stated she had not offered the resident the opportunity to formulate one. For Resident 20, the admission record listed diagnoses including dementia, psychosis, and diabetes mellitus, and the MDS indicated moderately impaired cognition. The records did not show documented evidence that the resident received information to formulate an advance directive, and the resident stated she did not understand what an advance directive is. For Resident 22, the admission and readmission records listed diagnoses including metabolic encephalopathy, dementia, and hemiplegia, and the MDS indicated severely impaired cognition. The records also did not show documented evidence that the resident received information to formulate an advance directive. The SSD verified that the advance directive was incomplete and should have been filled out completely with all statements completed and explained with information given to the resident’s responsible party.
MDS Did Not Accurately Reflect Resident ADLs and Treatments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected Resident 22’s status. Resident 22 had diagnoses including metabolic encephalopathy, dementia, and hemiplegia, and the MDS dated 2/20/2026 described severely impaired cognition and listed partial/moderate assistance or supervision for several ADLs, including personal hygiene, dressing, bathing, toileting hygiene, oral hygiene, eating, and walking 10 feet. However, during observation on 3/3/2026, CNA 2 was providing total care assistance with ADLs, and documentation from CNAs showed dependent assistance for bathing/shower, personal hygiene, oral hygiene, and putting on/taking off footwear. CNA 2 stated the resident had been dependent on ADLs, was usually transferred with a Hoyer lift with 2-person assistance, and was no longer walking. The MDSC stated he believed moderate/maximal assistance meant the resident was dependent on staff for ADLs and therefore overlooked the fall that was not captured on the MDS. The facility also failed to accurately document Resident 42’s ADLs and treatments in the MDS. Resident 42 had diagnoses including COPD, difficulty walking, lack of coordination, osteoarthritis, and CHF. The MDS dated 1/16/2026 indicated the resident was not receiving range of motion exercises, but the Order Summary Report dated 2/12/2026 included an order for the Restorative Nurse Assistant to provide bilateral lower extremity passive range of motion as tolerated once daily, five times a week. The MDSC stated he overlooked the range of motion treatment exercises that were not entered into the current MDS. The DON stated that all resident ADLs and treatments must be accurately documented in the MDS because it is intended to reflect each resident’s current condition, and the facility policy required those completing portions of the MDS to certify the accuracy of the sections they completed.
Care plan not updated after Ativan was discontinued
Penalty
Summary
The facility failed to ensure Resident 10’s care plan was updated to reflect that Ativan had been discontinued. Resident 10 was admitted with diagnoses including Alzheimer’s disease, dementia, and anxiety disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The latest MDS indicated the resident was rarely or never understood. During interview and record review, the MDS Coordinator reviewed Resident 10’s care plan, last revised 3/2/2026, and it still indicated the resident was receiving Ativan to manage anxiety and that nursing staff were to monitor for side effects such as sedation or drowsiness. The MDS Coordinator confirmed that the care plan section meant the resident was currently receiving Ativan either as a scheduled medication or as needed. However, review of the current active order list showed no active order for Ativan, and the MDS Coordinator stated the last active Ativan order had ended in 2024. He stated the Ativan care plan should have been removed because there was no current order, and that inactive care plans should be removed in a timely manner to keep the care plan accurate.
Failure to Assess and Monitor Resident With Ongoing Diarrhea
Penalty
Summary
The facility failed to assess, monitor, and evaluate a resident who reported having diarrhea on and off for the past two months. Resident 16 was admitted and later readmitted with diagnoses including DM and bilateral above-the-knee amputations. The resident’s H&P dated 6/16/2025 stated that he had the capacity to understand and make decisions, and the MDS dated 2/18/2026 indicated moderate impaired cognition and varying levels of assistance needed with dressing, bathing, and toileting hygiene. During an interview on 3/2/2026, Resident 16 stated that staff were aware of his intermittent diarrhea, but he still did not know why it was happening, and he said the issue kept him from going to the activity room. On 3/4/2026, an LVN stated she was not aware of the diarrhea and would notify the physician of the change in condition. On 3/5/2026, the DON stated the licensed nurses were not aware of the episodes of diarrhea and said CNA staff need to recognize subtle changes in residents’ condition and report them to the physician. The facility policy dated 3/2018 stated that CNAs would be trained to recognize subtle but significant changes and use the stop and watch early warning tool to communicate changes to the nurse.
Failure to Provide Ordered ROM and Splinting
Penalty
Summary
The facility failed to complete Restorative Nursing Assistant (RNA) treatments per physician orders for one resident by not providing ordered range of motion exercises to the affected joints. The resident was admitted and readmitted with diagnoses including hemiplegia and hemiparesis, cerebrovascular accident, and contracture of the left elbow. The Minimum Data Set indicated the resident’s cognition was intact and that the resident required varying levels of assistance with activities of daily living, including total dependence for footwear and assistance with bathing, dressing, toileting hygiene, oral hygiene, and eating. The care plan directed staff to minimize the risk of further loss of range of motion and included use of a left elbow extension splint, a resting hand splint, and passive range of motion exercises to the left upper extremity. Physician orders required the RNA program to apply the elbow extension splint six times a week for up to two hours, the resting hand splint six times a week for up to three hours, and passive range of motion to the left upper extremity six times a week or as tolerated. During interviews, the resident stated he had not received range of motion exercises and did not know when the splints were last applied. A CNA stated he had not seen the splints applied or observed range of motion exercises, and an RNA stated the resident’s left upper extremity was stiff and that the resident had complained he had not received exercises or splinting in a while.
Unlabeled IV Bag During Infusion Therapy
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not followed for one resident who was receiving IV medications at the facility. The resident was admitted with diagnoses that included hyperlipidemia, pneumonia, and hypertension. The resident's H&P did not indicate whether the resident had the capacity to understand and make decisions, but a physician progress note later stated that the resident had the capacity to make medical decisions, and the MDS indicated intact cognition. The resident required substantial assistance with some transfers and partial assistance with rolling in bed and personal hygiene. A physician order dated 2/27/2026 directed Dextrose-NaCl 5-0.45% to be infused at 35 ml/hr intravenously for hydration until 3/2/2026, with a total of 2 liters. During observation, the resident was lying in bed with IV tubing connected to the right arm and attached to a 1000 mL bag of clear liquid labeled 5% Dextrose and 0.45% Sodium Chloride, with about 200 mL remaining. The bag did not have a label showing the resident's name or the date and time the bag was opened and initially administered. The resident stated she did not know how long the IV had been connected or who placed it. RN 1 stated the bag should have been labeled with the resident's name, infusion rate, and the date and time the infusion was started, and said the lack of labeling could pose a risk for infection because staff would not know if the bag was old and needed to be replaced or disposed of. The DON stated IV bags must be labeled with the resident's name, date of initiation, and the name of the nurse who started the infusion, and that an unlabeled bag could place the resident at risk for IV-related complications such as infections and phlebitis. The facility policy also stated staff are to complete an Infusion Therapy Solution/Additive label and place it on the IV bag.
Failure to Check Ordered Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to follow physician-ordered monitoring parameters before administering Doxazosin Mesylate to Resident 63. Resident 63 was admitted with diagnoses including cerebral infarction, diabetes, and hypertension, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive status and the resident required assistance with personal hygiene, toileting, bathing, and dressing. The physician’s order directed staff to administer Doxazosin Mesylate 1 mg via G-tube daily for hypertension and to hold the medication if systolic blood pressure was less than 110 or heart rate was below 60. During a medication pass, LVN 1 prepared the medication and was about to administer it via G-tube without first checking the resident’s blood pressure and heart rate. LVN 1 stated she forgot to check the vital signs before giving the medication and acknowledged that the medication could have been given without verifying whether the resident met the ordered parameters. The MAR also reflected the instruction to hold the medication if SBP was less than 110 or heart rate was lower than 60. The DON stated LVN 1 did not follow procedure and should have checked blood pressure and heart rate before administering Doxazosin Mesylate.
Incomplete Psychotherapeutic Drug Informed Consent Documentation
Penalty
Summary
The facility failed to ensure that Resident 10’s psychotherapeutic drug informed consent form for Rexulti was completed. Resident 10 was admitted with diagnoses including Alzheimer’s disease, dementia, and anxiety disorder, and the record showed the resident did not have capacity to understand and make decisions. The MDS also indicated the resident was rarely or never understood, and the care plan directed nurses to administer Rexulti as ordered for Alzheimer’s dementia-related agitation. The physician’s order dated 1/28/2026 showed Rexulti 2 mg each morning was prescribed. During a concurrent interview and record review, the Psychotherapeutic Drug Informed Consent Form for Rexulti did not include the date of the physician’s signature, the name of the responsible party who confirmed consent, or the date consent was verified. The MDSC stated he had called the responsible party and confirmed consent over the phone, but he forgot to document the name of the responsible party and the date of the call. The MRD stated the physician should have dated the signature and the licensed vocational nurse should have documented the responsible party’s name and the date consent was confirmed, and that she was responsible for auditing paper forms before they were uploaded to the EMR. The facility policy required the licensed nurse to sign the consent form if the resident or representative signature could not be obtained and to list the date and name of the person with whom informed consent was verified.
Freezer Temperature Not Maintained at Required Level
Penalty
Summary
The facility failed to ensure the kitchen freezer was maintained at 0 degrees Fahrenheit (F) and below, per its policy and procedure. During observations in the kitchen, the freezer thermometer read 18 F and the exterior digital thermometer read 22 F on 3/2/2026, and the following day the freezer thermometer read 30 F. During interview and record review with the Director of Food Services, the Cold Storage Temperature Log showed the freezer readings are to be 0 F or lower. The facility policy titled, Food Receiving and Storage, dated October 2017, stated the freezer must keep frozen foods solid and that wrappers of frozen foods must stay intact until thawing. The Director of Food Services stated the freezer must keep foods frozen solid at 0 F or below.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two of four sampled residents, Resident 17 and Resident 33. During observation on 3/2/2026, Resident 17 was lying in bed with a sling on the right arm, and the call light was behind the resident and tied to the bottom right side of the bed, not within reach. During a separate observation the same day, Resident 33 was lying in bed with the head elevated at a 45-degree angle, and the call light was behind the resident on the floor, not within reach. During a concurrent interview and record review on 3/5/2026, RN 1 reviewed the facility policy titled "Answering the Call Light," dated September 2022, which stated the call light is to be accessible to the resident when in bed, from the toilet, from the shower or bathing, and from the floor. RN 1 stated it is the entire staff's responsibility to ensure all call lights are within residents' reach.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate nurse staffing information showing the actual hours worked per shift by RN, LVN, and CNA from 2/23/2026 through 3/3/2026, as required by its policy titled Posting Direct Care Daily Staffing Number. Instead of listing the actual time worked for each nursing category and type, the Nursing Personnel on Duty posting showed a combined total of all nursing staff hours per shift. During a concurrent interview and record review on 3/4/2026 at 8:36 AM, the DON stated the posting reflected combined total actual hours worked per shift of all nursing staff and not by category or type. The DON further stated the posting was inaccurate because it should identify what type and category of nursing staff worked, since that determines what kind of nursing care is provided to residents. On 3/5/2026 at 8:40 AM, the DON stated the daily nursing postings are intended to inform residents, responsible parties, and visitors about the type, category, and hours of nursing care provided per shift, and that the postings must be accurate to prevent misinformation and confusion.
Failure to Ensure CNA Competency in Post-Orthopedic Surgery Transfers
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) were competent in providing appropriate care and services during resident transfers for two residents who had undergone orthopedic surgery. For one resident with a recent left femur fracture and surgery, records indicated that the care plan required immobilization of the affected joints and assistance with transfers. However, during a transfer observed by a family member, two nurses twisted the resident's left leg, resulting in the resident yelling in pain and subsequently being found to have sustained a new fracture, necessitating a second surgery. The family member reported that the physical therapist had provided specific instructions for safe transfers, which were not followed by the staff involved. Another resident, admitted after joint replacement surgery, had physician orders specifying that two folded pillows should be placed under the heel while in bed and that no pillow should be placed under the knee. Despite these orders, a family member observed that nurses repeatedly placed a pillow under the resident's knee, contrary to the physician's instructions. Interviews with CNAs revealed a lack of knowledge regarding the type of surgery the resident had undergone and the necessary precautions for safe transfers. One CNA incorrectly stated that the resident's leg should be crossed during transfers, which was contradicted by the physical therapist, who emphasized the importance of keeping the legs aligned. A review of staff competency files showed that the facility had not conducted skill competencies for CNAs regarding resident transfers, particularly for those who had undergone hip or knee surgery. The Director of Staff Development confirmed that such competencies were not part of the CNA skill competency list. The facility's policies required staff to follow individualized transfer methods as identified in the care plan and to demonstrate specific competencies necessary for resident care, but these requirements were not met in practice.
Failure to Account for and Administer Medications as Ordered
Penalty
Summary
The facility failed to properly account for and administer medications as ordered by physicians for two residents. For one resident with a history of bilateral leg amputations, neuropathy, and significant pain, the facility did not account for a full delivery of Dilaudid 4 mg tablets. Pharmacy records and delivery sheets confirmed that 120 tablets were delivered in two bubble packs, but only one bubble pack and one Controlled Medication Count Sheet (CMCS) were present and accounted for. Staff interviews revealed confusion and lack of verification regarding the number of bubble packs and the corresponding CMCS, with some staff only checking the quantity upon initial receipt and not during subsequent shift counts. The Director of Nursing confirmed that staff were not consistently verifying the total quantity received and remaining, as required by facility policy, which led to a missing bubble pack and incomplete documentation. For another resident with severe cognitive impairment, dementia, and psychosis, the facility failed to administer Alprazolam 0.25 mg as ordered by the physician. The medication was given 55 minutes earlier than prescribed, and this administration was not documented in the Medication Administration Record (MAR), although it was recorded on the CMCS. The resident's care plan required anti-anxiety medications to be administered as ordered, with monitoring for side effects and effectiveness. Staff interviews and record reviews confirmed the discrepancy between the CMCS and the MAR, and the Director of Nursing acknowledged that the failure to document the administration in the MAR was a violation of facility policy. Observations and interviews with nursing staff indicated inconsistent practices in medication counting, documentation, and verification. Staff often focused on the number of medications left rather than the total quantity received, leading to discrepancies and missing medications. Facility policies required reconciliation of controlled substances upon receipt, administration, and at each shift change, but these procedures were not consistently followed. The deficiencies resulted in a lack of accountability for controlled substances and improper administration and documentation of medications.
Delayed Follow-Up on X-Ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services as ordered by the physician and as indicated in facility policy for a resident who experienced a fall and subsequently reported pain. The resident, who had a history of dementia and osteoarthritis and required assistance with daily activities, fell and later complained of ankle pain. An x-ray was ordered by the physician, and the imaging was performed the following day. However, the facility did not follow up with the radiology company to obtain the x-ray results in a timely manner. The x-ray, which revealed a nondisplaced complete transverse fracture of the medial malleolus and distal fibula, was not received by the facility until two days after it was performed. Multiple nursing staff members failed to follow up on the pending x-ray report, and there was a lack of communication and endorsement between shifts regarding the need to obtain the results. One nurse contacted the radiology company and learned of technical issues delaying report delivery but did not escalate the issue to the DON or ensure the physician was notified within the facility's required timeframe. As a result, the physician was not notified of the abnormal x-ray findings until several days after the imaging was performed, delaying the resident's transfer to the hospital for further care. The facility's policy required that changes in a resident's condition and test results be reported to the physician within 24 hours, but this standard was not met in this case.
Overflowing Trash Bin in Facility Parking Lot
Penalty
Summary
The facility failed to ensure that its trash bin was not overflowing, leading to trash being disposed of on the ground in the facility's parking lot. This was observed during a concurrent observation and interview with the Dietary Director (DD) and the Maintenance Director (MNTD). Both directors acknowledged the presence of various types of trash, including open boxes, broken containers, wooden pallets, and broken decorations, scattered on the parking lot floor within view of residents' windows. The DD and MNTD both stated that trash should be disposed of in the trash container and not on the ground, as it could potentially attract animals and bugs. During a concurrent interview and record review with the Director of Nursing (DON), the facility's policy and procedure titled 'Homelike Environment' was reviewed. The policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, which includes a clean, sanitary, and orderly setting. The DON stated that seeing trash outside the window or scattered in the parking lot does not create a homelike environment and could make residents feel like the facility is dirty.
Failure to Label Opened Food Items
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and dating of food items, as evidenced by an observation of an open pack of ground beef in the facility's freezer without an opening date. During an interview, the Dietary Director acknowledged the absence of an opening date on the ground beef, expressing concern about not knowing how long the item had been opened, which could potentially lead to food-borne illnesses if consumed by residents. The Director of Nursing confirmed the importance of labeling opened food items to track their freshness and prevent the serving of expired or old food, which could result in health issues such as food poisoning and vomiting for the 54 residents who receive meals prepared in the facility's kitchen.
Incomplete Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgment Form was completed upon admission. The resident, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and abnormalities of gait and mobility, did not have the capacity to understand and make decisions. Despite this, the Advance Directive Acknowledgment form was incomplete and not signed by the resident or their responsible party. During a review, the Social Services Designee confirmed that the form was not completed and acknowledged that it should have been filled out entirely to ensure that the resident's wishes were known in case of an emergency. The facility's policy indicates that residents have the right to formulate an Advance Directive, and these directives should be honored according to state law and facility policy. The failure to complete the form could lead to misinformation regarding medical care and treatment, potentially not honoring the resident's wishes when they or their responsible party are unable to make healthcare decisions.
Failure to Verify Diabetic Management Orders for Readmitted Resident
Penalty
Summary
The facility failed to ensure that Resident 53, who was readmitted from a General Acute Care Hospital (GACH), received treatment and care in accordance with professional standards of practice and the facility's policy. Resident 53, diagnosed with Type 2 diabetes mellitus, did not receive the necessary diabetic management and medications from 12/8/2024 to 1/12/2024. The facility did not verify all appropriate discharge orders from GACH 1 with the attending physician upon the resident's readmission, resulting in a lack of insulin administration and blood sugar monitoring. Upon review of Resident 53's medical records, it was found that prior to readmission, the resident was receiving insulin aspart injections according to a sliding scale for blood sugar management. However, after readmission, there were no physician orders for insulin or blood sugar checks documented in the Order Summary Report. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged that the orders should have been clarified with the attending physician to ensure proper diabetic management. Interviews with the nursing staff revealed that the admitting nurse did not verify the continuation of insulin orders with the attending physician, despite the resident's history of diabetes management. The attending physician, Physician 1, stated that he expected the licensed nurse to inform him of any changes in medication orders. The facility's policy requires that physician orders for immediate care be available at the time of admission to meet the resident's care needs, which was not adhered to in this case.
Inaccurate MDS Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar monitoring. Despite the resident's MDS indicating an active diagnosis of diabetes mellitus and the administration of insulin, the facility's records did not reflect any current orders for diabetic management. The Director of Nursing (DON) confirmed that the resident had a diagnosis of diabetes mellitus but acknowledged the lack of physician orders for insulin or blood sugar checks upon readmission. The DON stated that the purpose of clarifying orders with the physician was to ensure the resident's need for insulin was addressed. However, the DON admitted that there was a failure to clarify these orders with the physician, which could lead to uncontrolled blood sugar levels. The Minimum Data Set Nurse (MDSN) also verified that the resident had an active diagnosis of diabetes mellitus but admitted to miscoding the MDS. The MDSN explained that the MDS assessment should accurately reflect the resident's status for reimbursement purposes. The facility's policy on the accuracy of assessments emphasized the need for assessments to represent an accurate picture of the resident's status, but this was not achieved in this case.
Failure to Revise Care Plan for Diabetes Management
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with diabetes mellitus, which resulted in the absence of physician orders for diabetes management. The resident, who had a history of diabetes mellitus, acute pulmonary edema, and end-stage renal disease, was readmitted to the facility without orders for insulin or blood sugar checks. Despite having an active care plan for diabetes management, the care plan was not updated to reflect the current physician orders, leading to a potential gap in the resident's diabetes treatment. The resident's medical records indicated that prior to readmission, insulin was administered according to a sliding scale. However, upon readmission, the Order Summary Report did not include any orders for insulin or blood sugar monitoring. The Director of Nursing (DON) confirmed the absence of these orders and acknowledged the need for clarification with the physician to ensure proper diabetes management. The facility's policy requires that care plans be revised when a resident is readmitted from a hospital stay. However, the Minimum Data Set Nurse (MDSN) verified that the care plan did not reflect the current physician orders, emphasizing the importance of updating the care plan to guide staff in managing the resident's diabetes. This oversight in revising the care plan could lead to the resident not receiving appropriate treatment for diabetes management.
Failure to Conduct Comprehensive Nutritional Assessment for Diabetic Resident
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment for a resident diagnosed with diabetes mellitus, which could potentially result in the resident not receiving the appropriate diet and nutritional needs. The resident, who had a history of diabetes mellitus, was readmitted to the facility without a proper assessment of her dietary needs related to her condition. The facility's records indicated that the resident had been receiving insulin as per a sliding scale prior to her readmission, but upon her return, there were no orders for insulin or blood sugar checks. The Director of Nursing (DON) confirmed that there were no physician orders for diabetic management upon the resident's readmission, which could lead to uncontrolled blood sugar levels. The DON acknowledged that the orders should have been clarified with the physician to ensure the resident's diabetes was managed appropriately. Additionally, the Consultant Dietitian (CD) admitted to missing the resident's diabetes diagnosis during the nutritional assessment, resulting in an incorrect diet being prescribed. The facility's policy required a nutritional assessment to be conducted by a multidisciplinary team, identifying clinical conditions and risk factors affecting the resident's nutritional status. However, the oversight in recognizing the resident's diabetes diagnosis and the lack of appropriate dietary orders demonstrated a failure in adhering to this policy. This deficiency highlights the need for accurate and comprehensive assessments to ensure residents receive the necessary care for their medical conditions.
Oxygen Flow Rate Mismanagement for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to ensure that a resident with chronic respiratory failure was receiving the appropriate oxygen flow rate as ordered by the attending physician. The resident, who was admitted with diagnoses including chronic respiratory failure and pulmonary embolism, had a physician order to receive oxygen at 2 to 4 liters per minute (LPM) via nasal cannula continuously. However, during an observation, it was noted that the resident's oxygen machine was set at 4.5 LPM, exceeding the prescribed range. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the oxygen setting was not in accordance with the physician's order. The resident's care plan and medication administration record both indicated the need for oxygen therapy at the specified rate, yet the facility's failure to adhere to this order posed a risk of hyperoxygenation. The Director of Nursing (DON) confirmed the importance of administering the correct oxygen dose to prevent potential adverse effects such as hyperoxygenation, which could lead to seizures and injury. The facility's policy on oxygen administration was reviewed, highlighting the need for proper oxygen flow adjustment, but the deficiency in practice was evident in the observed deviation from the prescribed oxygen flow rate.
Failure to Communicate Pharmacist's Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to a recommendation made by the consultant pharmacist regarding laboratory monitoring for a resident. The resident, who was admitted and readmitted to the facility with diagnoses including Type 2 diabetes mellitus and major depressive disorder, had the capacity to understand and make decisions. The consultant pharmacist conducted a medication regimen review and recommended that the resident's primary physician clarify if it was clinically appropriate to perform a Basic Metabolic Panel (BMP) lab test. However, there was no documented response from the attending physician to this recommendation. The Director of Nurses confirmed during an interview that there was no documentation indicating that the facility had informed the resident's physician of the consultant pharmacist's recommendation. The facility's policy on medication regimen reviews, revised in August 2019, states that findings and recommendations should be reported to the director of nursing and the attending physician. The lack of communication and documentation regarding the pharmacist's recommendation represents a deficiency in the facility's adherence to its own policies and procedures.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that PRN orders for the psychotropic medication Ativan were limited to a duration of 14 days and evaluated for continued use for a resident taking psychotropic medications. The resident's physician order for Ativan, which was initiated on 12/17/2024, did not include a stop date. This oversight was identified during a review of the resident's Order Summary Report dated 1/11/2025, which indicated the medication was prescribed to be taken as needed for anxiety-related symptoms without a specified end date. During an interview and concurrent record review with the Director of Nursing (DON), it was confirmed that the Ativan order did not include a stop date or a rationale for extending the medication beyond the 14-day limit. The facility's policy requires that PRN psychotropic medications be renewed every 14 days and evaluated by the resident's attending physician before renewal. The lack of adherence to this policy increased the risk of adverse effects for the resident, who had a history of hemiplegia, hemiparesis, and type 2 diabetes mellitus.
Inadequate PPE Use and Disposal in EBP Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections, as observed in the case of a resident with Enhanced Barrier Precautions (EBP) due to a gastrostomy tube. The Licensed Vocational Nurse (LVN) responsible for the resident was not fully aware of the requirements for wearing personal protective equipment (PPE) during high-contact care activities, such as using the feeding tube. During a medication administration observation, the LVN initially did not have access to an isolation cart with PPE at the entrance of the resident's room and had to find an isolation gown elsewhere. This indicates a lack of proper PPE availability and awareness of EBP protocols. Additionally, the LVN improperly disposed of the soiled PPE by exiting the resident's room and discarding the gown in a soiled linen bin across the hall, rather than in a disposal bin inside the resident's room. This action was contrary to the facility's policy, which required PPE to be disposed of inside the resident's room to prevent the spread of infection. Interviews with the Director of Nursing and the infection prevention nurse confirmed the importance of wearing PPE during high-risk activities and disposing of it properly to protect both staff and residents. The facility's policy and signage also emphasized these practices, highlighting the deficiency in adherence to infection control protocols.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to a resident with dementia, Guillain-Barre syndrome, and a high risk for falls. The resident experienced two unwitnessed falls shortly after admission, resulting in a laceration to the back of the head that required medical attention. The facility did not increase the resident's supervision needs or develop an individualized care plan after the first fall, as required by their policy. The facility also failed to implement the resident's care plan for monitoring and frequent visual checks after the initial fall. The staff did not analyze the risk or identify trends in the resident's fall incidents, which were associated with frequent attempts to get out of bed and an inability to void. The resident required assistance with toileting, but this was not consistently provided, contributing to the falls. Interviews with staff revealed that the facility did not have a system in place to indicate the frequency of monitoring, and documentation of the resident's whereabouts was insufficient. The Director of Nursing acknowledged that the care plan was not updated to reflect the resident's continuous fall risk, and additional interventions such as one-to-one supervision were not implemented, which could have potentially prevented the second fall.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident's ability to perform activities of daily living (ADL) did not diminish. The resident, who was dependent on staff for personal hygiene and toilet use, was left wet with urine for an extended period, contrary to the care plan and facility policies. The resident, who had no cognitive impairment and was at risk for skin breakdown due to incontinence, reported multiple instances of not receiving timely assistance after activating the call light. The resident expressed feelings of frustration and humiliation due to being left in a wet diaper. Interviews with facility staff revealed that the call lights were not answered promptly, as required by the facility's policy. The Interim Director of Nursing acknowledged the incident, stating that the CNA was busy with another resident at the time. The Director of Staff Development emphasized the importance of answering call lights immediately, as delays could pose life-threatening risks. A CNA confirmed finding the resident wet and frustrated, with urine on the floor, after the call light had been activated multiple times without response.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Whittier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pico Rivera Healthcare Center | 1.4 mi | ★★★★★ | 21 | 0 |
| El Rancho Vista Health Care Center | 1.4 mi | ★★★★★ | 23 | 0 |
| Presbyterian Intercomm Hosp Dp/snf | 1.5 mi | ★★★★★ | 0 | 0 |
| The Orchard - Post Acute Care | 1.5 mi | ★★★★★ | 3 | 0 |
| Colonial Gardens Nursing Home | 1.7 mi | ★★★★★ | 14 | 0 |
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