Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Coast Global Medical Center D/p Snf during CMS and state inspections, most recent first.
A facility failed to follow physician orders and care plans for residents with seizure disorder and total dependence for transfers. Surveyors observed one resident with only partially padded side rails, another resident with side rails elevated when not providing care and a bed not kept in the lowest position, a third resident with an unpadded side rail despite an order for padded rails, and a totally dependent resident transferred by one CNA alone using a Hoyer lift even though two-person assistance was ordered and required.
Respiratory care orders were not followed for multiple residents receiving ventilator or oxygen therapy. A resident on continuous trach oxygen was found disconnected during a Hoyer lift transfer, another resident’s ventilator high-pressure alarm was set above the facility’s policy range, a third resident’s oxygen flowmeter was set below the ordered LPM and would not adjust properly, and a fourth resident’s ventilator circuit and in-line suction changes were not documented as ordered. Staff interviews confirmed the ordered settings and care were not consistently provided.
The facility failed to follow its infection surveillance policy by limiting McGeer's criteria review to residents who were prescribed antimicrobials, leaving out residents with signs and symptoms of infection who were not on antibiotics. The surveillance logs and McGeer's forms also contained inaccurate infection determinations for several residents, including mismatched pneumonia, bronchitis, and bloodstream infection findings. In addition, a clean linen cart was observed uncovered with residents' linens inside and towels and a razor stored on top of the cart, contrary to the facility's linen handling policy.
Failure to Use Privacy Covers for Urinary Drainage Bags: Two residents with suprapubic catheters were observed in bed with urinary drainage bags hanging openly from the bed or side rail without privacy bags/covers in place. An LVN verified the findings for both residents, and the DON stated that drainage bags should be placed inside privacy bags to provide dignity.
Resident room areas were observed in disrepair for four residents. One resident had an exposed emergency outlet with chipped paint and wall debris behind the bed, another had chipped paint and unpainted wall areas at the foot of the bed, and two residents had scratched, chipped, and peeled wall surfaces behind their beds. The DON verified the findings and stated the rooms needed to be presentable and homelike.
A resident with severe cognitive impairment, psychotic disorder, and depression was prescribed Seroquel for psychosis and Zoloft for depression. The facility documented routine psychotropic monitoring, but did not record orthostatic BP checks for the Seroquel order and did not document nonpharmacological interventions or their effectiveness when behaviors were observed with the Zoloft order. The LVN and DON confirmed the missing monitoring and documentation.
Failure to Follow Care Plans for Side Rail Padding and Heel Protectors: A resident with a seizure disorder and two residents with heel protector orders were observed without the interventions directed in their care plans. One resident’s side rails were only partially padded, leaving exposed rail sections, while two residents were in bed without bilateral heel protectors. Staff verified the missing interventions and acknowledged the care plans called for full rail padding and heel protectors while in bed.
Failure to Apply Heel Protectors as Ordered: Three residents with skin breakdown risk had MD orders and care plan interventions requiring bilateral heel protectors while in bed, but observations showed the protectors were not applied and their heels were resting directly on the mattress. RN and CNA staff verified the findings, and one CNA stated a resident’s heel protectors were off being washed while the heels should have been offloaded with pillows until available.
Failure to provide ordered RNA ROM services. A resident with upper body contractures and limited ROM had physician orders for RNA to provide ROM exercises to both upper and lower extremities 5 days a week, but the record showed multiple missed services because only one RNA was often scheduled, and sometimes none were scheduled. RNA and the DSD verified the resident did not receive the ordered services as planned.
Failure to document and maintain peripheral IV care: A resident with a peripheral IV in the left leg had an undated dressing, no documented IV insertion or daily site assessments, and no care plan for IV use and monitoring. Staff confirmed the IV had been kept because it was difficult to restart, but the record lacked the required documentation and care planning for the IV site.
A medication error rate of 7.69% was identified after surveyors observed an LPN administer liquid potassium chloride via GT without diluting it, despite the label requiring dilution, and hold an antihypertensive medication even though the resident’s SBP was not below the ordered hold parameter. The nurse confirmed both errors during the observation and record review.
Unclean medication cart containers were found in two of four med carts. Each cart had plastic containers in the top drawer holding alcohol pads, lancets, insulin syringes, and one also had a pill splitter, and both containers had brownish/blackish stains and an unknown substance on the bottom. An LVN verified the findings and stated the containers needed to be cleaned for infection control.
Kitchen food safety and sanitation were deficient when surveyors found an opened food item in the freezer without date marking, dirty utensil bins, damaged and wet kitchen utensils, expired or undated food items, and black-brown buildup in the cafeteria ice machine. The RD verified the findings, and staff stated the ice machine was used to obtain ice chips for residents, including a resident with a GT feeding and another resident who was NPO except for ice chips.
Incomplete POLST and Advance Directive Discrepancy: A resident’s POLST was incomplete because the advance directive section was left blank even though the responsible party had signed the form and an Advance Directive Acknowledgement indicated yes to formulating an advance directive. The resident had no capacity to make decisions, the MDS coded no advance directive, and the record lacked documentation that the discrepancy was clarified; the SSW stated the responsible party had selected yes in error and that the resident had no advance directive.
Inaccurate MDS Coding for Antipsychotic GDR: A resident with psychotic disorder was receiving routine antipsychotic medication, but the quarterly MDS was coded to show a GDR had not been attempted and that the physician documented it as clinically contraindicated. Record review instead showed a physician GDR note stating the dose was due to be decreased, and the MDS Coordinator could not find documentation supporting the contraindication and verified the MDS was coded inaccurately.
A resident’s comprehensive care plan was not revised to match a physician order for vent circuit set-up changes every two weeks and as needed if visibly soiled or malfunctioning. The existing care plan addressed airway clearance and infection risk related to a long-term trach, but it only included changing the vent circuit set-up as needed when visibly soiled or malfunctioning. The RT verified the current order, and the DON acknowledged the importance of revising the care plan to reflect the ordered interventions.
The facility failed to protect the confidentiality of 27 residents' PHI when a computer displaying sensitive information was left unattended in a hallway. The facility's policy requires that medical records be kept confidential and accessed only by authorized users. Interviews confirmed that computer screens should be locked when not in use.
The facility's assessment failed to involve direct care staff, residents, or their representatives, and lacked plans for staffing resources, recruitment, retention, and contingency for staffing needs. The DON/Interim CNO and Director of Sub-Acute Unit confirmed the assessment was outdated and did not follow CMS's 2024 guidance.
The facility failed to provide written notification of bed hold rights to three residents or their representatives upon transfer to a hospital. Despite the facility's policy requiring such notification, documentation was missing for all three cases. The Social Service Staff acknowledged the oversight, and the Director of the Sub-Acute Unit confirmed the findings.
The facility failed to provide necessary respiratory care and services for several residents, including unlabeled and unchanged respiratory equipment, unclean tracheostomy sites, and improperly set ventilator alarms. These deficiencies were confirmed through observations and staff interviews, with the Director of the Sub-Acute Unit acknowledging the findings.
The facility failed to maintain an accurate infection control surveillance program and did not properly disinfect shared glucometers, leading to potential infection risks. The infection control data from October to December 2024 was incomplete, and specific cases showed that criteria for true infections were not consistently applied. Additionally, a glucometer was not disinfected according to the manufacturer's instructions, as observed during a procedure, potentially exposing residents to blood-borne pathogens. These issues were confirmed by the Infection Preventionist and the Director of the Sub-Acute Unit.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for residents whose conditions did not meet McGeer's criteria. Despite policies requiring monitoring and intervention, many residents were prescribed antibiotics without proper justification. The Infection Preventionist and Director of the Sub-Acute Unit acknowledged issues with form completion and tracking compliance, resulting in continued inappropriate antibiotic use.
A facility failed to maintain a clean environment for a resident, as evidenced by dry, brownish residues on the resident's enteral feeding pump. Despite the facility's policy on infection control, licensed nurses did not clean the device, which was used to infuse Glucerna 1.2. Observations confirmed the oversight, and the Director of the Sub-Acute Unit acknowledged the responsibility of licensed nurses to maintain cleanliness.
A resident was transferred to an acute care unit without written notification to their representative, violating the requirement to inform them of the transfer, reasons, and appeal rights. The Social Service Staff confirmed that only verbal communication was made, and the Director of the Sub-Acute Unit acknowledged the deficiency.
A facility failed to ensure the accuracy of a PASRR Level 1 assessment for a resident, which inaccurately indicated no serious mental illness or psychotropic medication use. The resident's records showed severe cognitive impairment, a psychotic disorder, and antipsychotic medication use. The discrepancy was confirmed by the Director of the Sub-Acute Unit, revealing a failure in the facility's screening and review procedures.
A resident's low air loss mattress was incorrectly set for a higher weight range than appropriate, potentially affecting pressure ulcer care. The resident, weighing 117.5 pounds, was observed on a mattress set for 265-330 pounds. The error was confirmed by an LVN, who noted the resident's inability to communicate discomfort due to cognitive impairment.
Two residents with limited ROM did not receive RNA services as ordered, including passive ROM exercises and splint applications. Documentation showed missed and inconsistent care, with no physician notification of discrepancies. Staffing issues contributed to the failure to provide the required care.
A resident with a seizure disorder was observed without a required helmet while in a wheelchair, contrary to a physician's order. Staff, including a CNA and an LVN, confirmed the absence of the helmet, which was meant to ensure safety during transfers and while the resident was out of bed. The Director of the Sub-Acute Unit verified the findings and emphasized the importance of adhering to safety protocols.
The facility failed to provide proper care for residents with feeding tubes. A resident's head of bed was not elevated to the required angle before medication administration, risking aspiration. Another resident received enteral feeding at an incorrect rate, and the water flush bag was unlabeled. These issues were acknowledged by the facility's director.
The facility failed to ensure accurate medication administration routes for two residents, leading to errors in administering medications via gastrostomy tube (GT) instead of orally as ordered. The errors were confirmed by nursing staff and the pharmacist, who noted limitations in the electronic health record system. The Director of the Sub-Acute Unit acknowledged the findings.
A facility failed to limit a resident's PRN order for lorazepam to 14 days, as required for psychotropic medications. The absence of physician documentation justifying the extension of this medication was confirmed by staff, including an LVN and the Director of Pharmacy. This oversight could lead to unnecessary medication use, potentially affecting the resident's well-being.
A medication cart in an LTC facility was found unlocked and unattended, containing various medications for multiple residents. The cart's locking mechanism was malfunctioning due to debris obstructing it, allowing unauthorized access to medications. The issue was identified and confirmed by the LVN, Director of Sub-Acute Unit, and Engineering team.
The facility failed to ensure the cook followed the recipe for pureed Swiss steak, potentially affecting a resident's nutritional needs. The cook did not measure the beef broth and used insufficient thickener, contrary to the facility's policy. The RD confirmed the cook should have adhered to the instructions.
The facility failed to follow food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were stored wet, contrary to USDA Food Code requirements. A rack for clean pots and pans was unsanitary, and four cutting boards were heavily marred, hindering proper cleaning. These deficiencies could lead to foodborne illnesses for residents.
A facility failed to maintain accurate and complete documentation for a resident using bilateral soft hand mittens. The Restraint Assessment/Restraint Flowsheet was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Staff interviews confirmed the expectation for accurate documentation, highlighting the potential impact on the resident's care needs.
The facility failed to properly record a resident's personal belongings, as evidenced by incomplete inventory forms and missing items. Interviews confirmed that the inventory process was not consistently followed, leading to difficulties in tracking the resident's belongings.
The facility failed to provide necessary care and services for four residents, including missed showers, improper transfers, and inadequate nail care. Staffing shortages were confirmed by family members and staff, contributing to these deficiencies.
Failure to Follow Orders for Padded Side Rails, Bed Position, and Two-Person Transfers
Penalty
Summary
The facility failed to ensure four residents remained free from accident hazards related to bed rails, bed position, and transfers. The report identified residents with seizure disorders and other significant care needs whose physician orders and care plans were not followed during routine care and transfers. Resident 8 had a seizure disorder and a physician order for a low bed with bilateral padded side rails, with the care plan also directing padded siderails when up in bed. Surveyors observed the resident in bed multiple times with the rails only partially padded, leaving about half of the upper rail exposed. The resident’s upper body, including the head, was not protected by the exposed rail. Staff interviewed during the survey acknowledged that both side rails were not fully padded and stated the exposed railing near the resident’s head could cause injury if the resident had a seizure. Resident 12 had diagnoses including quadriplegia and seizure disorder, and the record showed orders for a low bed with no side rails, with side rails permitted only when providing care and turning the resident. Surveyors repeatedly observed the bilateral side rails elevated while no staff were in the room, and the bed was not in the lowest position during several observations. The resident was also transferred from a shower gurney back to bed by one CNA alone, even though the CNA stated two people should assist with that transfer and the facility’s staff confirmed that two-person assistance was required. Resident 14 had a seizure disorder and a physician order for padded side rails times two when in bed for safety, but surveyors observed the resident in bed with one elevated side rail that was not padded. Resident 25 was totally dependent for transfers and had orders and a care plan for Hoyer lift transfers with two-person assistance, yet a CNA independently transferred the resident from a Geri-chair to bed using a Hoyer lift without another staff member present.
Respiratory Care Orders Not Followed
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who were receiving ventilator or oxygen therapy. The report identified deficiencies involving Resident 7, Resident 10, Resident 12, and Resident 25, each of whom had physician orders and care plans related to respiratory support. The findings were based on observation, interview, medical record review, and review of facility policies and procedures. Resident 25 had a physician order for aerosol mist to the tracheostomy via T-piece or trach mask at 60% FIO2 and a care plan addressing altered respiratory status due to tracheostomy, chronic respiratory failure, and traumatic brain injury. During an observed transfer from a Geri-chair to bed using a Hoyer lift, the resident was suspended on the sling and was not receiving supplemental oxygen. The corrugated breathing tubing was observed disconnected from the tracheostomy piece, and the CNA performing the transfer stated she noticed the tubing was disconnected when the resident was moved onto the lift. RN 5 later reconnected the tubing and obtained an oxygen saturation of 93% while the resident was receiving 60% FIO2. RN 5 stated the resident required continuous oxygen therapy and should not have been without it during the transfer. Resident 10 had a physician order for mechanical ventilator settings including tidal volume 450, assist control 18, FIO2 35%, and PEEP 5. When observed, the resident was connected to a ventilator with an average peak airway pressure of 28 to 30, but the high-pressure alarm was set at 60 cm. RT 2 verified that the alarm setting was not in accordance with the facility policy, which required the high-pressure alarm to be set 15 to 20 cm of water pressure above the resident’s peak airway pressure, and adjusted it to 50. Resident 12 had an order for aerosol mist to the trach via T-piece or trach mask at FIO2 50%. The resident was observed with the cool aerosol adapter set at 50% FIO2/10 LPM, but the oxygen flowmeter attached to the T-piece was set at 8 LPM. RN 4 verified the setting should have been 10 LPM and was unable to adjust the flowmeter above 8 LPM, stating another flowmeter was needed. Resident 7 had physician orders to change the in-line suction catheter of the tracheostomy every Monday, Wednesday, and Friday and to change the ventilator circuit set-up every two weeks and as needed if visibly soiled or malfunctioning. RT 1 stated the ventilator circuit set-up was being changed monthly and was not aware of the two-week order. RT 1 verified there was no documentation showing the ventilator circuit set-up was changed every two weeks, and the documentation for in-line suction catheter changes was incomplete. The Cardiovascular-Pulmonary Manager also verified there was no documentation showing the ventilator circuit set-up was changed per physician order and that documentation for the in-line suction catheter was not always completed.
Infection Surveillance and Linen Handling Failures
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its policy. The Infection Control and Surveillance policy stated the facility would closely monitor all residents who exhibit signs and symptoms of infection, and that the infection control program would develop prevention, surveillance, and control measures, perform surveillance activities to monitor and investigate causes of infections and manner of spread, and analyze clusters of infections and changes in prevalent organisms. The policy also stated that when a resident exhibited signs and symptoms of suspected infection, the charge nurse would record the resident on the initial Infection Surveillance Form and the Infection Control Preventionist would gather further data for infection tracking and reporting. Review of the monthly Infection Prevention and Control Surveillance Logs from July 2025 through December 2025 showed infections categorized as HAIs, CAIs, and DNMCs. However, the logs reflected that all residents identified as having an HAI, CAI, or DNMC were also prescribed antimicrobial medications. There was no documented evidence that residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications were included in the monthly surveillance logs. During interview, the Infection Preventionist stated the McGeer's criteria form was only initiated for residents with signs and/or symptoms of infection who were prescribed antimicrobial medications, and that residents who were not prescribed antimicrobial therapy were not included in the surveillance process. Review of McGeer's criteria forms for five residents showed inaccurate determinations of whether infections met criteria for true infection. For one resident, blood stream infection was marked as meeting criteria even though blood cultures showed no growth. For another resident, pneumonia was marked as DNMC even though the chest x-ray, increased sputum production, and temperature of 100.8 degrees F met the criteria documented on the form. For another resident, pneumonia was marked as meeting criteria even though the chest x-ray was unremarkable. For another resident, the surveillance log did not reflect DNMC even though the form indicated the infection did not meet criteria. For another resident, bronchitis was marked as meeting criteria even though only one respiratory sub-criterion was documented when two were required. The Infection Preventionist reviewed these records and verified the McGeer's criteria forms were inaccurate. The facility also failed to follow its linen handling policy. During observation, the clean linen cart was found with residents' gowns and bed linens inside, the cart cover hanging on the side instead of covering the linens, and a plastic bin containing a razor and towels placed on top of the cart with two towels underneath it. The observing LVN verified the findings and stated that clean or used towels should not be stored on top of the cart and that the cart cover should be in place to keep linens clean.
Failure to Use Privacy Covers for Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure dignity and respect for two residents who had suprapubic catheters with urinary drainage bags. Facility policy titled Dignity Bags Utilization stated that each resident who used a urinary catheter with an attached drainage bag would be provided with a dignity bag. Resident 5 had no capacity to understand and make decisions and had an order for a suprapubic catheter to gravity drainage due to urinary stricture. On 1/5/26, Resident 5 was observed lying in bed with the urinary drainage bag hanging on the left side rail and not inside a privacy bag; this was observed twice during the day. During a concurrent interview, an LVN stated the drainage bag should have been stored inside a privacy bag to provide privacy and dignity and verified the finding. Resident 6 had an order for a suprapubic catheter to gravity drainage for urinary retention. On 1/5/26, Resident 6 was observed lying in bed with the urinary drainage bag hanging from the bed, full of urine, and without a privacy cover in place. During a concurrent interview, an LVN verified the finding and stated the drainage bag should have been covered with a privacy cover to ensure dignity. The DON later stated that residents with urinary drainage bags should have the bags placed inside privacy bags to provide dignity, and the CNO, DON, DSD, and IP were informed and acknowledged the findings.
Resident Room Walls and Outlet Left in Disrepair
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for four of 14 final sampled residents. In Room C, Resident 5 was observed lying in bed with the emergency outlet on the wall behind the head of the bed exposed, with an opening above the red wall plate, chipped paint, and wall debris. In Room A, Resident 12 was observed lying in bed with the wall at the foot of the bed in disrepair, including chipped paint and unpainted areas. In Room B, Residents 14 and 25 were observed with the walls behind their beds in disrepair, including scratches, chipped drywall, and peeled paint. During concurrent interviews, the DON verified the findings for Rooms A, B, and C and stated the resident rooms needed to be in good repair and presentable. The CNO, DON, DSD, and IP were later informed and acknowledged the findings.
Psychotropic Medication Monitoring and Behavior Documentation Deficiencies
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication-related monitoring deficiencies. Resident 18 had severe cognitive impairment and diagnoses including psychotic disorder and depression. The resident had a physician order for Seroquel 150 mg via GT every 12 hours for psychosis manifested by striking out to staff, and the care plan identified postural hypotension as a side effect to monitor. Although routine psychotropic medication forms documented that no adverse reactions were observed each shift, the medical record did not show documentation that orthostatic blood pressure monitoring was performed for the Seroquel use. During interview and record review, the LVN stated that orthostatic hypotension should be monitored by obtaining blood pressure readings in different positions and comparing them, and acknowledged that Resident 18 was able to move from lying to sitting and should have been monitored in that way. The LVN also stated that the resident’s blood pressure was obtained every shift, but not in different positions, and that the record did not contain orthostatic blood pressure monitoring for the resident’s Seroquel use. The DON later confirmed that the facility was not checking Resident 18 for orthostatic hypotension. The facility also failed to document nonpharmacological interventions and their effectiveness for observed behaviors related to Zoloft use. Resident 18 had a physician order for Zoloft 50 mg via GT daily for depression manifested by self-isolation. The routine psychotropic medication record showed observed behaviors on two occasions, but the back of the form did not document the nonpharmacological interventions implemented or whether they were effective. The LVN and DON both stated that when the behavior was observed, nonpharmacological interventions should be implemented and documented on the psychotropic medication flow sheet, and the DON verified that the documentation was missing.
Failure to Follow Care Plans for Side Rail Padding and Heel Protectors
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident 8, Resident 14, and Resident 22 as written. Resident 8 had a care plan for seizure-related injury risk that included padding both side rails, but repeated observations on multiple days showed the side rails were only partially padded, leaving half of the upper rail exposed. During interview, CNA 2 stated the purpose of both padded side rails was to prevent injury and verified the rails were not fully padded. RN 2 later acknowledged the bed rails were partially padded and stated the entire side rails should have been padded in accordance with the care plan. Resident 14 had physician orders for padded side rails when in bed due to seizure disorder and for bilateral heel protectors while in bed. The resident’s care plan also directed padded side rails for safety related to seizure activity and application of bilateral heel protectors while in bed. On observation, Resident 14 was lying in bed with an elevated right side rail that was not padded, and the resident’s heels were resting directly on the mattress without heel protectors. RN 1 verified both findings and stated the side rail should have been padded and the heel protectors should have been applied while the resident was in bed in accordance with the care plan. Resident 22 had a physician order to apply bilateral heel protectors while in bed, and the care plan for actual skin breakdown included providing the ordered treatment. On observation, Resident 22 was lying in bed with heels resting directly on the mattress and no heel protectors in place. CNA 4 verified the finding and stated the heel protectors should always have been applied while the resident was in bed in accordance with the care plan.
Failure to Apply Heel Protectors as Ordered
Penalty
Summary
The facility failed to ensure bilateral heel protectors were applied while three residents were in bed, despite physician orders and care plan interventions requiring their use. The deficiency involved Residents 5, 14, and 22, all of whom were identified as being at risk for skin breakdown or pressure injuries. Facility policy titled Skin Care Management stated that prevention techniques included pressure reduction mattress use, heel protectors, and turning residents every two hours. Resident 14 had a physician’s order to apply bilateral heel protectors while in bed and a care plan that included the same intervention. During observations, Resident 14 was found lying in bed with both heels resting directly on the mattress and the heel protectors not applied. RN 1 later verified the observation and stated the heel protectors should have been applied while the resident was in bed to prevent pressure injuries. Resident 22 also had a physician’s order to apply bilateral heel protectors while in bed and had left ankle redness with a wound treatment order for the left ankle. During observations, Resident 22 was lying in bed with both heels resting directly on the mattress and the heel protectors not applied. CNA 4 verified the findings and stated the heel protectors should always be applied while the resident was in bed. Resident 5 had a care plan addressing risk for skin breakdown with interventions to offload the heels and apply bilateral heel protectors while in bed, and a physician’s order for the same. Resident 5 was observed in bed without the heel protectors on multiple occasions, with both heels resting on the mattress; CNA 3 stated the heel protectors were not applied because they were soiled and being washed, and that the heels should have been offloaded with pillows until the protectors were available.
Failure to Provide Ordered RNA Range of Motion Services
Penalty
Summary
The facility failed to provide RNA services per the physician’s order for Resident 3, who had documented upper body contractures and limited range of motion. The resident’s care plan included interventions for RNA to perform range of motion exercises as ordered by the physician, and the physician’s order report showed orders for RNA to provide range of motion to both upper extremities daily five times a week for 30 days and to both lower extremities daily five times a week for 30 days. Review of the RNA schedules for December 2025 and January 2026 showed multiple dates when no RNA was scheduled. Medical record review showed Resident 3 did not receive RNA services on several dates in December 2025 and January 2026, and RNA 1 verified the resident did not receive services per the physician’s order on those dates. RNA 1 stated there was only one RNA providing services to all residents on the floor, and the DSD verified there were supposed to be two RNAs scheduled Monday through Friday but sometimes only one or none were scheduled. The DON was informed and verified Resident 3 was not always given RNA services per physician’s orders.
Failure to Document and Maintain Peripheral IV Care
Penalty
Summary
The facility failed to provide the necessary care and services to maintain IV access for one resident who had a peripheral IV in the left lower leg. On observation, the IV dressing was undated, and the licensed nurse confirmed it was not labeled with the date and initials. The resident’s medical record did not show documentation of the IV insertion, removal, or daily assessment of the IV site, and the resident’s plan of care did not include a care plan problem for the use and maintenance of the peripheral IV. The resident was admitted with no capacity to understand and make decisions. A nurse stated the IV had been started because the physician initially wanted antibiotics for leukocytosis, but the physician later waited for culture and sensitivity results before prescribing antibiotics. The nurse also stated the IV was kept because it was difficult to start a peripheral IV on the resident. Facility staff, including the DON, confirmed that the IV site should have been documented and assessed every shift for patency and signs of infection, phlebitis, infiltration, or swelling, and that a care plan should have been developed for the peripheral IV.
Medication Error Rate Above Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; surveyors calculated the rate at 7.69%. During an observation, interview, and concurrent medical record review for one resident, a licensed nurse administered 7.5 mL of liquid potassium chloride 10 mEq via GT without diluting it, even though the bottle label stated to dilute prior to administration. The nurse verified the label and acknowledged that the potassium chloride had not been diluted before it was given. The same resident had a physician’s order for amlodipine 5 mg daily via GT for hypertension with instructions to hold the medication only if systolic blood pressure was less than 100 mmHg. The resident’s blood pressure was documented as 100/75 mmHg, but the nurse held the amlodipine anyway and later stated this was an error. The nurse verified that the resident’s systolic blood pressure was not less than 100 mmHg when the medication was withheld.
Unclean Medication Cart Containers
Penalty
Summary
The facility failed to ensure that two of four medication carts were clean. During observation and interview, Medication Cart A and Medication Cart B each had two plastic containers in the top drawer that held alcohol pads, lancets, insulin syringes, and, in Cart B, a pill splitter. The bottoms of both containers were observed with brownish/blackish stains and an unknown brownish/blackish substance. LVN 5 and LVN 8 each verified the findings and stated the containers needed to be cleaned for infection control because the items stored in them were used to provide resident care. The facility's Infection Control Program and Surveillance policy dated 9/2025 was reviewed and stated the facility maintains an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections.
Kitchen Food Safety and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen during survey observations and interviews. On an initial kitchen tour with the RD, surveyors observed an opened bag of chocolate covered pastries stored in the walk-in freezer without an open date. The Dietary Assistant stated the frozen pastries were a personal food item from dietary staff and should not have been stored in the freezer. The RD verified the finding. Surveyors also observed multiple sanitation and equipment concerns in the kitchen. Two bins containing clean kitchen utensils had debris and white particles or grayish debris with a pepper packet at the bottom. In addition, two blue-handled scoopers had discolored and chipped handles, three black-handled and one gray-handled portion servers had melted handles, and two spatulas were discolored, cracked, and chipped. Two gray-handled scoopers were also observed stored wet inside a bin with other clean kitchen utensils, despite the facility policy requiring flatware to air dry before storage. The RD verified these findings. Food storage and ice machine sanitation concerns were also identified. One bin labeled lentil had a use-by date of 12/30/25, and one bin labeled jasmine rice was not labeled with a use-by date. During inspection of the cafeteria ice machine, the inner shoot had blackish-brown buildup surrounding the exit spout, and the Director of the Facility identified the substance as dark, black-brown buildup. The ice from this machine was used for residents with orders for ice chips, including one resident with a GT feeding who could receive ice chips for oral gratification and another resident who was NPO except for ice chips. LVNs stated they obtained or provided the ice chips from the cafeteria ice machine.
Incomplete POLST and Unresolved Advance Directive Discrepancy
Penalty
Summary
The facility failed to ensure the medical record for one sampled resident was accurate because the resident’s POLST was incomplete. Resident 5 was admitted to the facility and had an Advance Directive Acknowledgement dated 10/24/22 showing the responsible party selected yes to formulating an advance directive. The POLST dated 10/24/22 was signed by the responsible party, but section D regarding advance directive information was left blank. Resident 5’s H&P dated 10/13/25 stated the resident had no capacity to understand and make decisions, and the MDS assessment coded the resident as having no advance directive. The medical record did not show documentation that the discrepancy regarding the resident’s advance directive was clarified. During interview and concurrent record review, the Social Service Worker stated the resident had no advance directive and verified the findings, stating the POLST should be complete and accurate. The Social Service Worker also stated she spoke with the responsible party and verified the resident had no advance directive and that the responsible party selected yes in error, but she was unable to find documentation showing the issue was clarified with the responsible party. The CNO, DON, DSD, and IP were informed and acknowledged the findings.
Inaccurate MDS Coding for Antipsychotic GDR
Penalty
Summary
The facility failed to ensure Resident 18’s MDS assessment was completed accurately. Resident 18 was admitted with a diagnosis of psychotic disorder and was receiving an antipsychotic medication on a routine basis since admission. Review of the quarterly MDS showed the resident’s gradual dose reduction (GDR) section was coded to indicate that a GDR had not been attempted and that a GDR had been documented by the physician as clinically contraindicated. However, review of the resident’s progress notes showed a physician note titled GDR Meeting documenting that Resident 18 was due for a GDR and that the Seroquel dose was to be decreased to 100 mg BID. Further review of the physician progress notes did not show documentation that the GDR was clinically contraindicated. The Clinical Summary Report showed an active order for Seroquel 150 mg via GT every 12 hours for psychosis as manifested by striking out to staff. During interview and record review, the MDS Coordinator was unable to locate documentation supporting the contraindication and verified that the MDS had been coded inaccurately.
Care Plan Not Revised to Match Ventilator Circuit Order
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident to reflect a physician’s order for changing the ventilator circuit set-up every two weeks and as needed if visibly soiled or malfunctioning. The resident’s care plan, dated 4/18/22, addressed potential alteration in gas exchange related to ineffective airway clearance and risk for infection related to long term trach tube status and colonization, and the approach plan included changing the ventilator circuit set-up as needed when visibly soiled or malfunctioning. However, the physician’s order report showed a later order dated 5/31/23 directing that the vent circuit set-up be changed every two weeks and as needed if visibly soiled or malfunctioning. During interview and concurrent record review, the RT verified the current physician’s order, and the DON was informed of the findings and stated that revising the care plan was important to ensure goals were being met, interventions were being implemented, and monitoring was occurring to determine whether changes were needed.
Failure to Protect Residents' PHI
Penalty
Summary
The facility failed to maintain the confidentiality of residents' Protected Health Information (PHI) for 27 residents. During an observation in Hallway 1, a computer was found displaying the names, dates of birth, and ages of all residents currently residing in the facility. This computer was left unattended, and multiple staff members were observed walking past it without securing the information. The facility's policy on confidentiality, revised in August 2023, mandates that medical records are to be kept confidential and accessed only by authorized users on a need-to-know basis. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed that the computer screens should be locked when not in use to prevent unauthorized access to resident information.
Facility Assessment Lacks Comprehensive Planning and Stakeholder Involvement
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during regular operations and emergencies. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, the assessment lacked a detailed plan for staffing resources, particularly for weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Director of Nursing (DON)/Interim Chief Nursing Officer (CNO) and the Director of the Sub-Acute Unit confirmed that the facility assessment was outdated, based on regulations from 2016, and did not incorporate the revised guidance issued by CMS in 2024. They acknowledged the absence of active involvement from key stakeholders and the lack of necessary plans and resources to ensure adequate care for residents, particularly during weekends and unforeseen staffing shortages.
Failure to Provide Bed Hold Notification to Residents' Representatives
Penalty
Summary
The facility failed to notify three residents or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in July 2005, mandates that residents be informed of their right to a bed hold upon admission and when transferred to an acute care facility or during therapeutic leave. However, for Residents 2, 17, and 27, there was no documented evidence that their representatives were provided with a copy of the Bed Hold Notification form when the residents were transferred to the hospital. Resident 27 was transferred to the hospital on January 22, 2025, but the Social Service Staff acknowledged that the bed hold notification was not given or mailed to the resident's responsible party. Similarly, Resident 17 was transferred on January 16, 2025, and the Social Service Staff confirmed that the notification was not provided because the family member did not request it. For Resident 2, although the representative was informed by phone about the bed hold, there was no written documentation provided. The Director of the Sub-Acute Unit acknowledged these findings during interviews conducted on January 23, 2025.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care and services for several residents, as evidenced by multiple observations and interviews. For Resident 18, the Trach-Bar aerosol tubing set-up was not labeled with the date, and there was no documentation that the aerosol set-up was changed weekly as required. Similarly, Resident 26's yanker was not labeled with the opened date, and the T-Bar aerosol set-up was also undated. Resident 28's T-Bar aerosol tubing set-up and sterile water connected to the oxygen flowmeter were not labeled with the opened date, and the yanker was not changed according to the facility's policy. The facility also failed to change the suction canister and tubing as per policy for Residents 2 and 8, and the yankauer tube was not labeled for these residents. Additionally, Resident 8's tracheostomy site was not clean, and the tracheostomy dressing was not changed as required. Resident 6's ventilator machine alarms were not set for high pressure alarms, and there was no documentation that the alarms were checked every shift as per the physician's order. The care plans for respiratory status did not include interventions for monitoring the mechanical ventilator and settings, posing a risk of delayed intervention in emergencies. Furthermore, Resident 27's set-up bag was not changed weekly as required. The facility's policies and procedures for oxygen therapy and changing disposable equipment were not followed, leading to potential negative effects on the residents' medical conditions. Interviews with staff, including licensed nurses and respiratory therapists, confirmed these deficiencies, and the Director of the Sub-Acute Unit acknowledged the findings.
Infection Control Deficiencies in Surveillance and Equipment Disinfection
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by deficiencies in maintaining an accurate infection control surveillance program and improper disinfection practices. The infection control surveillance data from October to December 2024 was incomplete and inaccurate, failing to determine whether residents' infections met McGeer's criteria for true infections. Specific cases, such as those of Residents 2, 14, 17, 26, and 27, showed that the section on the form to indicate whether the infection met the criteria for a true infection was not selected, leading to potential mismanagement of infections. Additionally, the facility did not adhere to proper disinfection protocols for shared medical equipment, specifically glucometers. An observation revealed that a glucometer was not cleaned and disinfected according to the manufacturer's instructions after use on a resident. The Licensed Vocational Nurse (LVN) responsible for the procedure did not ensure the glucometer remained wet for the required two minutes with the disinfectant wipe, as per the manufacturer's guidelines, potentially exposing residents to blood-borne pathogens. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed these findings. The IP acknowledged the incomplete surveillance data and the failure to apply McGeer's criteria consistently. The Director of the Sub-Acute Unit was informed of the improper disinfection practices and acknowledged the potential risk of infection transmission due to these lapses in protocol.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, leading to the inappropriate use of antibiotics for residents whose conditions did not meet the McGeer's criteria for true infections. The facility's policy required that culture and sensitivity results be monitored by the pharmacy, with interventions to inform physicians of results and recommendations for antibiotic therapy. However, the facility's Infection Control Surveillance Dashboard revealed that a significant number of residents were prescribed antibiotics for infections that did not meet the McGeer's criteria over a three-month period. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit revealed that the licensed nurses were responsible for completing the Healthcare Associated Infections (HAI) forms, which were then reviewed by the IP to determine if the McGeer's criteria were met. However, the forms were not accurately completed, as selections for the type of infection or criteria for infection were often not made. This led to the continuation of antibiotic treatments without proper justification, as seen in the cases of Resident 27 and Resident 28, who were prescribed antibiotics without meeting the necessary criteria. The Director of the Sub-Acute Unit acknowledged the high prevalence of antibiotic use that did not meet the McGeer's criteria and admitted to incorrectly tracking antibiotic stewardship compliance. Despite discussions in QAPI meetings and awareness by the Medical Director, the facility did not take effective action to address the issue, resulting in continued inappropriate antibiotic use and a failure to adhere to the established antibiotic stewardship program.
Failure to Maintain Clean Enteral Feeding Pump
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident 26, as evidenced by the presence of multiple dry, brownish residues on the resident's enteral feeding pump device. Observations conducted on two consecutive days revealed that the enteral feeding pump was not cleaned, despite being used to infuse Glucerna 1.2 at a rate of 90 ml/hr. Licensed nurses, who were responsible for the cleaning and daily upkeep of the enteral feeding pump, did not notice or address the stains on the device. This oversight was confirmed by both LVN 6 and RN 3 during interviews and concurrent observations. The facility's policy on Environmental Services/Infection Control, reviewed in August 2023, emphasizes the importance of removing soil and dust from surfaces to prevent nosocomial infections. However, the policy was not adhered to in this instance, as the enteral feeding pump remained unclean. The Director of the Sub-Acute Unit acknowledged that the residents' rooms and environment should be clean and comfortable, and confirmed that the licensed nurses were responsible for cleaning the enteral feeding pump. The failure to maintain the cleanliness of the enteral feeding pump device had the potential to negatively impact Resident 26's safety and quality of life.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the transfer and discharge of the resident to an acute care unit. The resident, who lacked the capacity to understand and make decisions, was transferred based on a physician's order, which included a bed hold for seven days. Although the resident's representative was verbally informed and agreed to the transfer, the facility did not provide the required written notice detailing the transfer, the reasons for it, and the resident's rights to appeal the decision. The deficiency was identified during a review of the resident's medical records, which lacked documentation of the written notification. The Social Service Staff, responsible for issuing such notifications, confirmed that the notice was not provided in writing, acknowledging that only verbal communication was made. The Director of the Sub-Acute Unit was informed of these findings, which highlighted the facility's failure to comply with the requirement to notify residents and their representatives in writing about transfers and discharges, including their appeal rights.
Inaccurate PASRR Level 1 Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level 1 assessment for a resident, which is a federal requirement to prevent inappropriate placement in nursing homes. The assessment inaccurately indicated that the resident did not have a diagnosed serious mental illness or symptoms of psychosis, and was not prescribed psychotropic medications for serious mental illness. However, the resident's medical records revealed severe cognitive impairment, a psychotic disorder, and the use of antipsychotic medications, including Zyprexa and Seroquel. The discrepancy was identified during a review of the resident's medical records and confirmed through interviews with the Director of the Sub-Acute Unit. The Director acknowledged that the PASRR Level 1 screenings were completed by the discharging facility and reviewed for accuracy by the MDS nurse, DSD, or the Director of Sub-Acute Unit. Despite this process, the assessment for the resident was found to be inaccurate, highlighting a failure in the facility's screening and review procedures.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, identified as Resident 24, was observed on multiple occasions lying on a low air loss mattress set to a comfort level corresponding to a weight range of 265-330 pounds, while the resident's actual weight was 117.5 pounds. This discrepancy was confirmed by LVN 4, who acknowledged that the mattress should have been set to light 2, appropriate for the resident's weight. Resident 24 was admitted to the facility with a physician's order for a Blue-Chip Power Pro Elite Mattress for wound management. The resident was totally dependent on staff for bed mobility and had severely impaired cognitive skills, making it impossible for them to communicate discomfort. The resident had a pressure ulcer of unknown depth on the left buttocks, documented the day before the observations. The Director of the Sub-Acute Unit was informed of these findings, acknowledging the incorrect mattress setting.
Failure to Provide Ordered RNA Services for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered by the physician for two residents with limited range of motion (ROM). Resident 2 was observed without the necessary splints and had missed four days of RNA services, which included passive ROM exercises and knee splint application. The facility's documentation did not provide any explanation for the missed services, and it was noted that staffing issues contributed to the inability to provide the required care. Resident 18 also did not receive RNA services as ordered. The resident's care plan included passive and active ROM exercises and the application of various splints. However, documentation showed inconsistencies in the application of these splints, with some days missing entirely and others exceeding the prescribed duration. There was no evidence that the physician was informed of these discrepancies or that the resident's inability to tolerate the splints was communicated. Interviews with facility staff, including LVNs and the Director of the Sub-Acute Unit, confirmed the findings. The staff acknowledged the challenges in providing RNA services due to insufficient staffing, which resulted in the failure to administer care as ordered by the physician. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the issues.
Failure to Provide Required Helmet for Resident Safety
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 11, was free from accident hazards by not providing a helmet protective device as per the physician's order. On multiple occasions, Resident 11 was observed in a wheelchair without the required helmet, which was ordered for safety when the resident was out of bed. The medical record review confirmed the physician's order dated 10/28/24, which specified the use of a helmet during transfers and while the resident was in a wheelchair. Despite this, the helmet was not available in the resident's personal belongings, and staff members, including a CNA and an LVN, confirmed the absence of the helmet. Interviews with staff members, including a CNA, the Activity Coordinator, and an LVN, revealed a lack of awareness and adherence to the safety precautions outlined in the care plan for Resident 11. The CNA acknowledged the need for two-person assistance with a mechanical lift but did not mention the helmet requirement. The Activity Coordinator, familiar with the resident's participation in activities, also did not observe the resident wearing a helmet. The LVN verified the physician's order for the helmet but admitted that the resident did not have one during transfers or while in the wheelchair. The Director of the Sub-Acute Unit confirmed the findings and expressed an expectation for staff to observe safety protocols at all times.
Deficiencies in Feeding Tube Care and Administration
Penalty
Summary
The facility failed to provide appropriate care for residents with feeding tubes, as evidenced by two specific incidents involving Resident 12 and Resident 18. For Resident 12, the facility did not ensure that the head of the bed (HOB) was elevated to the required 30 to 45 degrees before administering medication via a gastrostomy tube (GT). During an observation, a licensed vocational nurse (LVN) elevated the HOB to less than 30 degrees, contrary to the physician's order, which could potentially lead to aspiration. The LVN admitted to estimating the angle due to the absence of a measuring device on the bed. In the case of Resident 18, the facility failed to administer enteral feeding according to the physician's orders. The resident was supposed to receive Vital 1.5 at 55 ml per hour, but the feeding pump was set to infuse Pivot 1.5 at 60 ml per hour. Additionally, the water flush bag was not labeled with the resident's name or the ordered rate, which is against the facility's policy. The LVN responsible for the administration acknowledged the discrepancies and admitted to not verifying the physician's order before starting the feeding. Both incidents were acknowledged by the Director of the Sub-Acute Unit, who confirmed that the facility's policies were not followed. The director stated that licensed nurses are expected to review physician orders and ensure correct administration rates, and that all feeding and flush bags should be properly labeled with the resident's details and the ordered rate.
Medication Administration Route Errors for Two Residents
Penalty
Summary
The facility failed to ensure accurate physician's orders for two residents, leading to the administration of medications via the incorrect route. For Resident 23, medications were ordered to be administered orally, but were given via gastrostomy tube (GT) by LVN 6. The medical record review revealed discrepancies in the physician's orders, which specified oral administration for medications such as ferrous sulfate, lactobacillus acidophilus, and Phenobarbital. LVN 6 acknowledged the error and indicated that the charge nurse should have verified the route with the physician. RN 4 confirmed the findings and noted limitations in the electronic health record system, which sometimes lacked an option for GT route, requiring manual entry in the comment section. Similarly, Resident 2's medications were also administered via GT despite the physician's order specifying oral administration. LVN 8 confirmed the error and stated that the RN should have contacted the physician to correct the order. The pharmacist verified the oral orders and acknowledged the limitations of the electronic health record system, which sometimes did not provide an option for GT route. The Director of the Sub-Acute Unit was informed and acknowledged the findings.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not limit the PRN order for lorazepam, an antianxiety medication, to 14 days as required. The resident had an order for lorazepam 1 mg intramuscularly every four hours as needed for seizures, but there was no documentation from the physician or prescribing practitioner justifying the extension of this medication beyond the 14-day limit. This lack of documentation and oversight could potentially lead to the unnecessary use of psychotropic medication, which might negatively impact the resident's mental, physical, and psychosocial well-being. Interviews with facility staff, including an LVN and the Director of Pharmacy, confirmed the absence of necessary documentation for the continued use of lorazepam beyond the 14-day period. The LVN verified that the resident last received the PRN lorazepam on a specific date, but there was no physician documentation providing a rationale for its continued use. The Director of Pharmacy acknowledged the requirement for such documentation and confirmed its absence in the resident's medical record. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the deficiency.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of its medication carts, specifically Medication Cart B, was properly locked and secured when unattended. During an observation, the cart was found unlocked and unattended in a hallway near the activity room. The cart contained various medications, including Valsartan, insulin pens, and other medications for multiple residents. The cart's drawers, except for the one with a lock, could be easily opened, allowing potential unauthorized access to the medications. Upon further investigation, it was discovered that the locking mechanism on the right column of drawers was not functioning properly. The LVN responsible for the cart confirmed that it should have been locked, but the drawers could still be opened after the locks were engaged. The Director of the Sub-Acute Unit and the Engineering team confirmed the malfunction and identified debris, including oral swab sticks, obstructing the locking mechanism. After removing the debris and resetting the drawers, the cart was confirmed to be fully locked.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that the cook followed the recipe when preparing pureed Swiss steak, which could potentially affect the nutritional needs of residents. During an observation, the cook, identified as [NAME] 1, was seen preparing the pureed Swiss steak for a resident. The cook measured 4 oz of Swiss steak but did not measure the beef broth before blending it with the steak. Additionally, only one teaspoon of thickener was added, contrary to the facility's policy which required two to three tablespoons per pound of solid food. The facility's policy on pureed diets, dated June 2023, clearly outlined the procedure for preparing pureed meals, including specific measurements for broth and thickener. The Registered Dietitian (RD) confirmed that the cook should have adhered to these instructions. The failure to follow the recipe as per the facility's policy could lead to the residents' nutritional needs not being met, as the consistency and nutritional content of the meal might not align with dietary requirements.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were found stored while still wet, contrary to the USDA Food Code 2022, Section 4-901.11, which requires equipment and utensils to be air-dried before storage to prevent microorganism growth. The Clinical Dietician confirmed these observations, acknowledging that the items should have been air-dried before being stored in the clean dish storage area and the kitchen, respectively. Additionally, a rack used for storing clean pots and pans was found to be in an unsanitary condition, with white water residue and dry dust on four of its bottom shelves. This was verified by the Clinical Dietician, who stated that the rack should have been cleaned. Furthermore, four cutting boards were heavily marred and discolored, which could hinder proper cleaning and sanitization, as per FDA Food Code 2022, Section 4-501.12. The Clinical Dietician confirmed that these cutting boards needed replacement. These deficiencies had the potential to result in foodborne illnesses for the residents receiving kitchen services.
Incomplete Restraint Documentation for Resident
Penalty
Summary
The facility failed to ensure the medical record for one resident was accurate and complete, specifically regarding the Restraint Assessment/Restraint Flowsheet for a resident using bilateral soft hand mittens. The resident was observed with these mittens to prevent pulling out medical tubing, with a physician's order to release them every two hours for 15 minutes to check circulation and skin condition. However, the flowsheet documentation was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Interviews with staff, including an LVN and the Director of the Sub-Acute Unit, confirmed the expectation that the Restraint Assessment/Restraint Flowsheet should be completed accurately for each shift. The LVN verified the incomplete documentation, and the Director emphasized the importance of accurate and complete nursing documentation to reflect the care provided. The failure to document the restraint assessments accurately had the potential to impact the resident's care needs due to the inaccuracy of their medical information.
Failure to Properly Record Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure the proper recording of a resident's personal belongings, as evidenced by incomplete Resident Inventory of Personal Effects forms for one of the sampled residents. The facility's policy and procedure (P&P) titled 'Handling of Personal Effects' requires that all residents' personal belongings be recorded and signed by both staff and the responsible party upon admission and whenever new items are brought in or removed. However, the review of Resident 1's inventory forms showed multiple instances where either the staff or responsible party's signatures were missing, indicating a lack of proper documentation and accountability for the resident's belongings. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the inventory forms were not consistently filled out as required. Additionally, a family member of Resident 1 reported that several personal items, including blankets and clothes, had gone missing since the resident's admission. The family member acknowledged awareness of the procedure but noted that it was not being consistently followed by the staff, making it difficult to track the missing items. The DON confirmed that some of the missing items had been replaced but acknowledged the deficiencies in the inventory process.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that four sampled residents maintained good grooming, personal hygiene, and proper transfers. Resident 1 did not receive scheduled showers and was not transferred out of bed as planned. The medical record review showed that Resident 1, who had a major stroke and was nonverbal, was supposed to receive showers twice a week and be transferred to a wheelchair three times a week. However, the CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Interviews with family members and staff confirmed dissatisfaction with staffing levels, which led to these deficiencies. Resident 2, who was in a vegetative state and dependent on staff for all activities of daily living, also did not receive scheduled showers. The CNA flowsheet and nurses' progress notes for April 2024 showed missed showers on multiple dates. Additionally, Resident 2 was observed with long fingernails, including a jagged-edged right thumb fingernail with black matter underneath. Interviews with staff revealed that nail care was not consistently provided, and the DON confirmed ongoing staffing challenges. Resident 3, who was rarely able to express ideas or understand others, did not receive scheduled showers and was not transferred to a wheelchair as planned. The CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Family members and staff interviews highlighted the facility's staffing shortages, which contributed to these deficiencies. Similarly, Resident 5 was observed with long fingernails, and interviews with staff confirmed that nail care was not consistently provided. The DON acknowledged the staffing issues and the impact on resident care.
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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 Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plaza Healthcare Center | 0.6 mi | ★★★★★ | 5 | 0 |
| South Coast Post Acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Fountain Valley Post Acute | 2.3 mi | ★★★★★ | 34 | 0 |
| French Park Care Center | 3.5 mi | ★★★★★ | 51 | 0 |
| Newport Subacute Healthcare Center | 3.5 mi | ★★★★★ | 50 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.