Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Coast Post Acute during CMS and state inspections, most recent first.
Failure to Offer Advance Directive Option: The facility did not provide the option to formulate an advance directive for five sampled residents. Records showed several residents were informed of the right to develop an advance directive, but documentation did not show the option was actually offered to the resident or RP. One resident had capacity to understand and make decisions, yet the social services assessment documented that no advance directive was in place, the opportunity was not offered, and no educational materials or state form were provided. Interviews with residents and SSD staff confirmed the omission.
Inadequate Water Temperatures in Shower and Sink Areas: Residents in Hallway A reported that shower water was too cool and that adjoining restroom sinks provided only cold water at night. A Maintenance Director measured one shower at 97.2 F to 100.1 F and another at 100.2 F to 106.7 F, while CNAs and an LVN stated the sink water stayed cold during the overnight shift and was used for bathing, hand hygiene, and incontinent care.
The facility failed to manage pain according to physician orders for several residents. One resident received acetaminophen for pain rated above the ordered mild-pain range and without documented nonpharmacological interventions, two residents received hydrocodone-acetaminophen when their pain scores did not match the ordered parameters, and another resident lacked an order covering moderate pain levels. Staff interviews and MAR review confirmed the medications were not always administered as ordered.
Food was not prepared to preserve nutritive value for 233 of 237 residents receiving kitchen-prepared meals. Vegetables, including pureed green peas, were cooked more than an hour before meal service and held in a steamer set at 212 to 220 degrees Fahrenheit. The Dietary Manager and an Assistant Cook confirmed the timing and holding conditions, and the facility policy stated fruits and vegetables were to be cooked to a holding temperature of 140 degrees Fahrenheit.
Kitchen Sanitation and Food-Contact Surface Deficiencies: The facility failed to keep the microwave clean, failed to air dry a blender and pitchers before storage, and had multiple dirty or damaged utensils and cutting boards with residue, fuzzy films, cracks, chips, and deep grooves. The Dietary Manager verified the findings during the kitchen tour.
Incomplete and inaccurate resident record documentation: Surveyors found that several resident records did not match the documented care or resident directives. One resident’s POLST left the Health Care Agent section blank despite an advance directive naming an agent, another resident’s opioid overdose monitoring entries used Y/YES in a way that did not align with the order’s required documentation, an IV antibiotic dose was not documented as given, and a physician progress note was dated after a resident had already been transferred to the hospital.
Infection control practices were not maintained for a decorative water fountain, laundry equipment, shower room caulking, and a glucometer. The fountain had visible green residue and lacked documented monthly monitoring, two washers had residue inside, Shower Room A had black residue on the caulking, and an LVN used a glucometer without disinfecting it before or after checking a resident’s blood glucose and returned it to the med cart unsanitized.
The facility failed to ensure informed consent forms for psychotropic medications included resident-specific reasons for use. For one resident, consents for Ativan, quetiapine, risperidone, and sertraline listed only general drug-class information and did not identify the resident’s diagnosis or manifested behaviors. For another resident, consents for lurasidone and fluoxetine also omitted the reason for use. The DON and an LVN verified the missing information in the records.
Failure to Protect Residents from Physical Abuse: The facility failed to protect two residents from physical abuse when one resident struck another resident during horseplay and another resident slapped a resident while he was using the phone. Records and staff interviews confirmed both incidents, and both involved cognitively intact residents with psychiatric diagnoses, including schizophrenia and schizoaffective disorder.
Incomplete Psychotropic Monitoring Documentation: The facility did not complete or accurately document monthly behavior summaries for a resident receiving Ativan, quetiapine, risperidone, and sertraline, and another resident’s behavior summary for lurasidone HCl and fluoxetine HCl was inaccurate compared with the MAR. The same resident also lacked complete orthostatic BP monitoring documentation, as the required sitting readings were not recorded within the appropriate time frame. The SSD and DON verified the missing and incorrect documentation.
A resident’s quarterly MDS failed to code continuous O2 use and PRN opioid administration, even though the MAR showed both were provided and the MDS Coordinator confirmed the assessment was inaccurate. Another resident’s MDS mis-coded weight loss and a weight-loss regimen despite an 11-lb loss in one month and no physician order for a weight-loss regimen; the MDS Assistant verified the error.
A facility failed to complete a PASRR Resident Review/status change for a resident after schizophrenia was documented in the chart. The resident’s admission record, H&P, and MDS all reflected schizophrenia, but the record lacked evidence that a PASRR resident review or status change was submitted after the diagnosis was updated; the MDS Coordinator acknowledged the omission, and the Administrator was informed.
A resident’s comprehensive care plan was not revised to reflect current weight management needs and physician-ordered interventions. The resident had orders for Glucerna if meals were refused, a carbohydrate controlled diet, and diabetic snacks, but the significant weight loss care plan did not document these interventions. RN and the DON verified the omission during record review.
A resident refused ordered CBC labs, but the chart did not show that the physician was notified. Another resident was admitted with HSV blisters and lesions on the buttocks, yet no skin assessment was documented when the resident refused a body check. A third resident received repeated insulin injections in the same abdominal sites instead of rotated sites as ordered, and RN verification confirmed the sites were not rotated.
A resident with cognitive impairment and unilateral extremity impairment had a physician order for a resting hand splint to the R hand for up to 3 hours daily, 5 days a week, with skin checks and premedication if needed. Staff observed the splint off the resident and on the bedside drawer during one observation, and RNA documentation did not show when the splint was applied or removed or how long it was tolerated; the RNA stated he did not document those times.
A resident with a GT, dysphagia, Parkinson's disease, and failure to thrive was observed lying flat in bed while receiving enteral feeding and water via pump, despite orders and care plan directions to keep the HOB elevated during feeding. The water bag connected to the pump was also not labeled with the resident's name, date, and time, and an LPN confirmed both the unlabeled bag and the resident's flat positioning during the feeding.
Failure to Change Oxygen Tubing as Ordered: A resident receiving continuous O2 via nasal cannula had tubing at the bedside that was dated beyond the weekly change interval ordered by the MD. An LVN verified the tubing should have been discarded and changed, and the DON stated the tubing should be changed every seven days and labeled with the date for infection control purposes.
A resident with diabetes had insulin glargine documented as held on multiple occasions even though the DON stated it was administered as ordered, and a second resident's PRN Norco was signed out on the controlled drug record but not documented on the MAR. Facility policy required medications to be given per MD order and controlled meds to be documented on both the accountability record and MAR.
Improper Medication Storage and Labeling: The facility stored oral meds with external-use meds in one medication cart, including tablets, eye drops, an injection, a patch, and topical gel in the same compartments. Another cart contained unlabeled eye drops in an unlabeled Ziplock bag for a recently admitted resident, and two opened multidose insulin vials without open dates, which the LVN confirmed were not properly labeled or dated.
The facility failed to keep required documentation showing staff were educated on the risks and benefits of the COVID-19 vaccine and that the vaccine was offered to staff who declined it. The IP stated she tracked staff vaccination status, but the record for an CNA showed conflicting information, with a prior dose documented while the tracking log also listed the CNA as refused and left the vaccination date blank. The IP confirmed there was no documentation that the CNA was offered the vaccine or provided the required education.
Glucometer calibration and QC were not documented for one glucometer on Medication Cart D, and the QC log was blank for the scheduled check. LVN and DON verified that the 11-7 shift was responsible for nightly/daily calibration and QC to support accurate blood sugar readings.
Failure to Protect Residents from Physical Abuse: The facility failed to protect residents from physical abuse by other residents. One resident was punched in the cheek by another resident while speaking with staff, resulting in a small cut, and another resident was struck on the head by a different resident. Records showed both aggressors had behavioral or psychiatric histories, including schizoaffective disorder, and staff interviews confirmed the assaults occurred without provocation.
Failure to Follow Infection Control Practices During Resident Care: A CNA handled a resident’s tube syringe after it fell to the floor, touched clean linens with it, returned it to the bedside table, and did not perform hand hygiene or disinfect the bedside table. An LVN also picked up a call light from the floor and placed it on a resident’s lap without disinfecting it or performing hand hygiene. Staff confirmed the items were dirty/contaminated and acknowledged the missed infection control steps.
A resident with functional cognition pushed and kicked another resident in the abdomen, causing the resident to fall and report pain. The aggressive resident had a history of horseplaying, poor boundaries, and poor judgment, but the care plan did not address those behaviors. The resident was also on q15-minute checks for unpredictable and aggressive behavior, and required monitoring entries were missing. Staff interviews showed the assault was not interrupted until after the other resident was already on the floor.
Care Plan Did Not Address Behavioral Concerns: A resident with functional cognition had repeated documentation of childlike behavior, horseplaying, poor boundaries, poor insight, and poor judgment, along with difficulty being redirected and disruptive behavior. The record also showed an incident where the resident pushed another resident, but the care plan did not include a problem addressing these behavioral concerns, and the DON acknowledged a care plan should have been created.
The facility did not conduct thorough investigations into two separate abuse allegations, as required by policy. In both cases, potential resident witnesses who may have observed the incidents were not interviewed, and there was no documentation explaining the omission. The DON confirmed that these interviews should have been conducted to ensure a complete investigation.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
Two residents' Out on Pass Logs were found to have missing entries, including times of departure and return as well as nurse initials, despite facility policy requiring complete and accurate documentation. The DON confirmed that nurses were expected to sign the log, and both the DON and Administrator acknowledged the incomplete records during the survey.
Two residents with histories of aggressive behavior engaged in a physical altercation in their shared room, resulting in minor injuries. Both had documented behavioral issues, including aggression and responding to internal stimuli, and staff were aware of these risks. The facility did not effectively intervene to prevent the incident, as required by its abuse prevention policy.
A resident's medical record lacked a signed admission physician's order in the EHR after readmission and discharge to a hospital. The signed order was not found during review, and when later produced, it was signed after the fact and pre-dated, resulting in inaccurate documentation.
A resident with a documented history of aggressive behavior pushed another resident into a wall after being bumped in the hallway, causing facial injuries and a cervical spine injury. Despite prior incidents and requests for separation, the two residents were not adequately separated, and staff did not intervene effectively to prevent the altercation.
The facility did not report suspected abuse and resident-to-resident altercations to authorities within the required timeframe. Incidents included a resident with visible injuries after alleged physical abuse by staff, another resident reporting verbal abuse by staff, and two residents involved in repeated physical altercations, with one sustaining injuries. Facility leadership acknowledged that these incidents were not reported as required by policy.
The facility did not follow its abuse investigation policies for multiple residents, including failing to remove a staff member accused of assault, not interviewing witnesses, delaying the start of investigations, and not separating residents involved in repeated altercations. These actions resulted in unaddressed allegations and visible injuries among residents.
Surveyors found that the facility did not develop or update care plans for three residents: one with repeated falls and physician-ordered floor mats, another with severe unaddressed weight loss, and a third who sustained facial abrasions after an altercation. The DON and Registered Dietician confirmed that these care needs were not reflected in the residents' care plans.
A resident sustained facial and neck bruising, swelling, and scratches after staff used manual restraint during a de-escalation incident involving aggressive behavior over access to water. Staff and DON confirmed the injuries occurred during a physical struggle when attempts at therapeutic communication failed, and the resident was restrained on the ground.
A LTC facility failed to ensure safe IV therapy for four residents, leading to potential complications. A resident's IV tubing contained air bubbles, another's midline dressing was not labeled or monitored, a third resident's PIV line was not discontinued after therapy, and a fourth's PIV site was undated. These deficiencies risked infection and other complications.
The facility failed to maintain food safety and sanitation standards, with observations of trash and clutter in food preparation areas, unclean equipment, and unlabeled personal food items in residents' rooms. These deficiencies posed a risk of foodborne illnesses for residents consuming food prepared in the facility.
A facility failed to obtain informed consents for the administration of psychotropic medications to a resident upon readmission. The medications, including olanzapine, quetiapine, and valproic acid, were prescribed for managing psychosis and mood lability. Facility staff confirmed the absence of informed consents in the resident's medical record, despite policy requirements for obtaining and verifying consent prior to medication administration.
A facility failed to maintain a copy of a resident's advance directive in their medical record, as required by their policies. Despite the resident having an advance directive, there was no documentation in the medical record, nor evidence of follow-up to obtain it. The Social Services Assistant confirmed the absence of the document and the lack of follow-up documentation, which was acknowledged by the Director of Nursing.
The facility failed to accurately complete PASRR Level 1 assessments for two residents, leading to a risk of inappropriate care. One resident had diagnoses of major depressive disorder and schizoaffective disorder, with prescriptions for quetiapine and lorazepam, while another had mood disorder and psychosis, with prescriptions for quetiapine and olanzapine. The MDS Coordinator confirmed the errors in the assessments.
A resident with severe cognitive impairment was not provided with an individualized and ongoing activity program, as required by the facility's policy. Observations showed the resident lying awake in bed without engagement in preferred activities like watching TV or listening to music. The Activity Director admitted to scheduling room visits only three times a week due to insufficient staff, and the Participation Record showed gaps in activity provision. Interviews confirmed the lack of daily activities for the resident, which was acknowledged by the DON and Administrator.
A resident with severely impaired cognition did not receive proper gastrostomy tube (GT) care as the LVN failed to check GT placement before administering medications and water, contrary to facility policy. The LVN also used improper technique by pushing the syringe's plunger instead of allowing gravity flow, potentially risking complications. The DON acknowledged these findings.
The facility failed to provide appropriate respiratory care for two residents. A resident's humidifier was not labeled or dated, and there was no physician's order for oxygen use. Another resident received oxygen at a rate exceeding the physician's order. These deficiencies were confirmed by staff and acknowledged by the Administrator.
The facility failed to provide adequate pharmaceutical services, leading to discrepancies in controlled medication reconciliation for three residents and one medication cart. A resident's oxycodone administration was not documented in the MAR, another resident's digoxin was administered without checking the apical pulse, and a medication cart had missing narcotic shift count signatures. Additionally, a resident's medication count sheets were inaccurately maintained, with errors in tablet strength and missing co-signatures for wastage.
The facility failed to monitor two residents for the use of psychotropic medications. One resident was not monitored for orthostatic blood pressure as ordered, with identical readings suggesting incorrect documentation. Another resident was given quetiapine without documented non-pharmacological interventions or behavioral monitoring, and no AIMS assessment was completed. These actions did not adhere to the facility's policies, potentially impacting the residents' well-being.
A facility's medication error rate was found to be 25.93%, significantly above the acceptable threshold. An LVN administered medications via GT with residue left in cups and used the wrong form of Keppra. An RN prepared an IV antibiotic with air bubbles in the tubing, requiring intervention to ensure safe administration. Both staff acknowledged the errors.
The facility failed to properly store, label, and dispose of medications, with expired items found in Medication Rooms A and C, and Medication Cart B. Treatment Carts A and B also contained expired items and cleanliness issues. These deficiencies were verified by LVNs and acknowledged by the DON.
The facility failed to properly dispose of waste, with food residues and trash found near dumpsters and in storage areas, posing pest risks. Two soiled linen barrels were uncovered and overfilled with trash, contrary to facility policy requiring tight-fitting lids. The Maintenance Director and Administrator acknowledged these deficiencies.
The facility failed to implement proper infection control practices, including the use of PPE and hand hygiene during medication administration for residents with indwelling medical devices. Additionally, a shared restroom was found to be unsanitary, posing a risk for infection transmission. These deficiencies were acknowledged by facility staff.
The facility failed to document medication administration for two residents, leading to incomplete medical records. A resident's piperacillin-tazobactam administration was not recorded on multiple occasions, and another resident's monitoring for antipsychotic side effects and schizoaffective disorder episodes was not documented. These lapses were confirmed by staff and acknowledged by the DON and Administrator.
Failure to Offer Advance Directive Option
Penalty
Summary
The facility failed to provide the option to formulate an advance directive for five sampled residents: Residents 10, 158, 163, 169, and 213. The facility’s policy stated that residents would be given information about advance directives upon admission and, if no advance directive existed, would be provided an opportunity to complete one upon resident request. Survey review found that this opportunity was not provided or documented for the five residents reviewed. Resident 213’s record showed the resident was informed of the right to develop an advance directive, but the record did not show the facility provided the resident or responsible party the opportunity to formulate one. Resident 213 had a full LPS conservatorship status, was cognitively intact on the MDS, and had a diagnosis of schizoaffective disorder. Similar findings were identified for Resident 169, whose record showed full LPS conservatorship status, cognitive intactness on the MDS, and a diagnosis of schizoaffective disorder, but no documentation that the resident or responsible party was offered the opportunity to formulate an advance directive. Resident 158’s record showed the resident was informed of the right to develop an advance directive, but the resident refused to sign the acknowledgement and the record did not show the facility provided the resident or responsible party the opportunity to formulate one. Resident 158 stated during interview that the facility did not provide information or the option to form an advance directive. Resident 163’s record also showed the resident was informed of the right to develop an advance directive, but no documentation showed the resident or responsible party was offered the opportunity to formulate one; the resident stated the facility did not provide information or the option to form an advance directive. Resident 10’s record showed the resident had capacity to understand and make decisions, yet the social services assessment documented that an advance directive was not in place, the opportunity to complete one was not offered, and no educational materials, including the state form, were provided. The SSD and SSD-STP acknowledged that the residents were not offered the option to formulate advance directives.
Inadequate Water Temperatures in Shower and Sink Areas
Penalty
Summary
The facility failed to ensure comfortable water temperatures for residents in Hallway A. Resident 49 stated the shower water in Shower Room A was too cold, and Resident 114 also stated the shower water was too cool and she wanted it warmer. During observation, the Maintenance Director tested Shower Room A and found Shower 2 reached only 97.2 F and then increased to a maximum of 100.1 F, which he described as lukewarm and below the 104 F he said it should be. Shower 3 initially measured 100.2 F and then increased to 106.7 F, which he stated was appropriate. CNA 4 stated that when she recently showered Resident 49, the resident asked for hotter water, but the shower lever was already turned all the way to hot and the water would not get hot. Resident 64 stated her scheduled shower had not yet occurred, but the shower temperature had been cool for a few weeks. Residents 73, 107, 114, 144, and 184, along with CNAs and an LVN, reported that the adjoining restroom sinks in Hallway A did not provide hot water at night. Resident 114 stated that between about 2300 and 0500 there was no hot water in her room sink and that CNAs had to use cold water when cleaning her after bowel movements. Resident 184 stated the hot water was turned off at night and that the sink water stayed cold. CNA 5 and CNA 6, both working the 2300 to 0700 shift, stated the water on Hallway A was usually cold at the beginning of their shift and did not get warm until around 0500, so they had to clean residents with cold water after incontinent episodes. LVN 11 stated the plumbing was old and that the water had to be run for a while to get warm, but then clarified that the water was always cold when she washed her hands. Resident 107 stated she only got cold water at night in her restroom sink, and Resident 73 stated the CNAs used the sink water to clean him up at night and it was always cold.
Pain medications given outside ordered parameters and missing pain-level coverage
Penalty
Summary
The facility failed to provide necessary pain management care and services for four residents. The report identified that pain medications were administered outside of ordered pain parameters, nonpharmacological interventions were not provided before medication administration, and one resident did not have an order covering all pain levels. The facility’s pain management policy stated that residents receiving pain interventions would be monitored for effectiveness and side effects, and that nonpharmacological interventions, effectiveness of PRN medications, and physician notification would be documented. For one resident, acetaminophen 325 mg was given after the resident reported generalized pain at a level of 6 on a 0 to 10 scale, even though the order was for mild pain only, defined as 1 to 4. The nurse did not offer or provide any nonpharmacological interventions before giving the medication, and the medication was administered outside the ordered parameters without notifying the physician. The resident’s record showed capacity to make his own medical decisions. For another resident, hydrocodone-acetaminophen 5-325 mg was administered multiple times when the documented pain level was outside the ordered range. The resident had an earlier order for moderate pain at 5 to 7, later changed to severe pain at 8 to 10, yet the MAR showed doses given for pain levels of 8 when the moderate-pain order was active and for pain levels of 7 after the severe-pain order was in place. Staff interviews confirmed the medication was to be given only within the physician’s ordered pain parameters. A third resident received hydrocodone-acetaminophen 10-325 mg for a pain level of 4 even though the order was for pain levels of 5 to 10. Another resident had orders for acetaminophen for mild pain and hydrocodone-acetaminophen for severe pain, but the record did not show any physician order for pain levels of 5 to 7. The resident’s MAR showed repeated use of hydrocodone-acetaminophen for severe pain, and no PRN acetaminophen was documented as given. The DON acknowledged that there should have been an order covering pain levels of 5 to 7.
Food Held Too Long at High Temperature Reduced Nutritive Value
Penalty
Summary
The facility failed to ensure food prepared for residents was cooked to preserve nutritive value for 233 of 237 residents receiving food prepared in the kitchen. The deficiency involved vegetables that were cooked more than one hour before meal service and held in the steamer with the temperature set between 212 and 220 degrees Fahrenheit. The facility’s Diet Type Report dated 7/27/26 showed that 233 of 237 residents consumed food prepared in the kitchen. The facility’s Food Preparation and Service policy stated that fresh, frozen, or canned fruits and vegetables are cooked to a holding temperature of 140 degrees Fahrenheit. On 7/28/26 at 0936 hours, the Dietary Manager stated puree preparation had been completed by the cook and tray line started at 1030 hours, and verified the vegetables were prepared more than one hour before meal service. On 7/28/26 at 1040 hours, an observation of the steam table with the Assistant Cook showed covered serving pans containing cream of rice, pureed pork and tortilla taco, pureed chicken, and pureed green peas vegetables. The Assistant Cook acknowledged the findings and stated puree preparation was started after returning from lunch at 0900 hours and that the pureed green peas were kept on the steamer at 212 to 220 degrees Fahrenheit.
Kitchen Sanitation and Food-Contact Surface Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during an initial tour and concurrent interview with the Dietary Manager. The kitchen microwave used to warm residents’ food was observed dirty, with dry, crusted food residue in the door and dry food splatters inside the microwave, and the Dietary Manager verified the finding. The facility also failed to ensure food preparation equipment and utensils were properly air dried before storage. One heavy-duty blender used for puree preparation and four clear pitchers stored on shelves were observed wet with visible water inside. The Dietary Manager verified that the blender and pitchers should have been air dried. In addition, multiple kitchen utensils and food-contact items were observed dirty or in poor condition. Several spatulas, scoops, knives, and a dough cutter had dry, crusted residue, watermarks, and fuzzy films. One stainless steel whisk had a partially cracked handle, one knife had a partially melted handle, and one rubber spatula had chipped and cracked edges. Two green, three yellow, two white, and one red cutting boards were observed fuzzy, heavily marred, and had deep grooves and pits. The Dietary Manager verified these findings.
Incomplete and inaccurate resident record documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for multiple residents. Review of the facility policy stated documentation in the medical record must be objective, complete, and accurate. Surveyors identified inaccurate or incomplete documentation involving advance directives, medication administration records, monitoring records, and a physician progress note across several resident records. For one resident, the POLST showed that an advance directive was available and reviewed, but the section for the Health Care Agent was left blank even though the resident’s advance directive named a designated agent for health care decisions. The resident’s H&P also noted fluctuating capacity to understand and make decisions. For another resident, the MAR for opioid overdose monitoring contained entries of YES or Y on multiple shifts, while the order required staff to document N if the resident was monitored and none of the listed symptoms were observed, or Y if symptoms were observed. A nurse stated that Y or YES meant symptoms were present and N meant symptoms were not present, and the DON stated the documentation should reflect whether the resident was monitored and whether symptoms were present. Surveyors also found that a resident’s IV administration record did not show whether ertapenem was administered on one scheduled day during a 10-day IV antibiotic course for UTI. In another record, a physician progress note was dated after the resident had already been transferred to the acute care hospital and had not returned to the facility. The report also noted a POLST section marked as advance directive not available for a resident whose social services assessment showed the resident did not have an advance directive and had declined to formulate one, and the facility acknowledged the findings during interviews.
Infection Control Failures With Water Fountain, Laundry Equipment, Shower Caulking, and Glucometer
Penalty
Summary
The facility failed to maintain infection control practices related to a decorative water fountain at the entrance of the facility. The facility's Legionella Water Management Program stated that if a decorative water fountain was installed, monthly control measures were to be implemented and each check was to be documented with the date and time, including testing for legionella bacteria and monitoring preventive measures. During observation, the fountain was found running with green built-up residue behind the plexiglass on the right-side border. The MD confirmed the fountain was present, and Housekeeping Staff 1 stated he placed three MaxBlue Tabs into the fountain every three months but did not keep documentation of checks or additions and did not test the water to determine whether this was sufficient to prevent growth of waterborne pathogens and other contaminants. The facility also failed to maintain two of four washing machines in a clean and sanitary condition, with residue observed inside Washing Machine #2 and Washing Machine #4 in the laundry room. In Shower Room A, black residue was observed on the vertical line of white caulking at the corners where the walls met, and wiping the caulking with a paper towel left a black substance on the towel. In addition, during medication administration for a resident, an LVN was observed using a glucometer without sanitizing it before use and then placing it back on the medication cart without sanitizing it after the blood glucose check. The LVN later verified that the glucometer had not been disinfected before or after the check, and the DON was informed of the findings.
Incomplete Psychotropic Medication Informed Consent Documentation
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed of the reason for use of psychotropic medications for two sampled residents. The deficiency involved incomplete informed consent documentation for antipsychotic, antidepressant, and anti-anxiety medications, with the forms not including the resident-specific diagnosis and manifested behaviors tied to the medication orders. For Resident 10, the medical record showed capacity to understand and make decisions, and physician orders dated 5/17/26 for Ativan for anxiety manifested by restlessness and inability to relax, quetiapine for bipolar disorder manifested by striking out, risperidone for psychosis manifested by angry outburst without apparent reason, and sertraline for depression manifested by reduced social interaction. The corresponding psychotropic medication disclosure forms stated general reasons and benefits for the drug classes, but did not include Resident 10’s specific diagnosis and manifested behavior for each medication. An LVN reviewed the record and verified the consents did not specify the reason for use including diagnosis and manifested behavior. For Resident 6, the record showed diagnoses of bipolar disorder and major depressive disorder, with physician orders for lurasidone for bipolar disorder manifested by mood swings and fluoxetine for depression manifested by verbalization of feeling sad. The informed consent forms for both medications failed to show the reason for use of the psychotropic medications. The DON reviewed the record and verified that both consents failed to show the reason for use and should have included it.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse involving two separate incidents. The report states that Resident 24 struck Resident 33 while Resident 33 was using the facility telephone, and that Resident 104 struck Resident 204 on the head after an interaction that began as horseplay. The facility’s abuse prohibition policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, injury, or mental anguish, and included hitting, slapping, pinching, or kicking as physical abuse. Resident 104 was cognitively intact and had a diagnosis of schizoaffective disorder. Records show that Resident 104 approached Resident 204, engaged in horseplay by hugging him from behind, and then struck Resident 204 on the head after Resident 204 yelled at him and declined to continue interacting. Interviews with Resident 33 and Mental Health Workers 3 and 4 confirmed that Resident 104 struck Resident 204, and staff notes documented that staff separated the residents after the altercation. Resident 24 was cognitively intact and had a diagnosis of schizophrenia. Records show that Resident 24 struck Resident 33 on the face with an open hand while Resident 33 was on the telephone, with staff documenting that Resident 24 believed Resident 33 was talking about her over the phone. Interviews with RN 2, LVN 2, and Resident 33 confirmed the incident, and the Administrator and DON were informed of the findings.
Incomplete Psychotropic Behavior Monitoring and Orthostatic BP Documentation
Penalty
Summary
The facility failed to ensure that two sampled residents receiving psychotropic medications had accurate behavioral monitoring documentation and required monitoring completed. One resident was prescribed lurasidone HCl and fluoxetine HCl for bipolar disorder and depression, and another resident was prescribed Ativan, quetiapine, risperidone, and sertraline for anxiety, bipolar disorder, psychosis, and depression. The facility’s policy required behavioral monitoring for residents receiving psychotropic medications, including documentation of behavioral triggers, episodes, symptoms, and the resident’s response to interventions. For the resident receiving Ativan, quetiapine, risperidone, and sertraline, the medical record showed physician orders for monthly behavioral summaries tied to the target behaviors for each medication. Although the MAR showed the resident was being monitored for the related behaviors, the record did not contain the monthly behavioral summaries for those medications, and the SSD confirmed the documentation could not be located. For the resident receiving lurasidone HCl and fluoxetine HCl, the June 2026 MAR showed five episodes of mood swings and five episodes of verbalized sadness. However, the OBRA Chemical Reduction and Behavior Management Meeting form dated 7/17/26 recorded zero episodes for both behaviors and listed the month as July instead of June. The SSD verified that the form presented to the IDT was incorrect based on the MAR. In addition, the resident had an order for weekly orthostatic blood pressure monitoring while lying and sitting, but the MAR and blood pressure log did not show the required sitting blood pressures were obtained within the appropriate time frame, and the DON verified the orthostatic monitoring documentation was incomplete.
Inaccurate MDS Coding for Oxygen, Opioid Use, and Weight Loss
Penalty
Summary
Resident 4’s quarterly MDS assessment was coded inaccurately because the facility did not record the resident’s use of continuous oxygen or the administration of PRN hydrocodone-acetaminophen. The resident had a physician’s order for continuous oxygen at 2 LPM via nasal cannula for hypoxia every shift, and the MAR showed oxygen was administered on 6/30/26 during the day, evening, and night shifts. The resident also had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for severe pain, and the MAR showed a dose was given at 0640 hours on 6/30/26. The MDS Coordinator reviewed the record and confirmed the oxygen therapy and opioid medication were not coded on the quarterly assessment, and stated the assessment was inaccurate. Resident 189’s MDS assessment was also coded inaccurately for weight loss. The resident’s weights showed 138 pounds on 6/1/26 and 127 pounds on 6/30/26, an 11-pound loss or 7.97% in one month. The MDS assessment coded the resident for 5% or more weight loss in one month and indicated the resident was on a weight-loss regimen, but the medical record did not show documentation of a physician’s order for a weight-loss regimen. The MDS Assistant reviewed the record and verified the weight loss and the absence of an order, and confirmed the assessment was coded inaccurately.
Failure to Complete PASRR Resident Review After Schizophrenia Diagnosis
Penalty
Summary
The facility failed to comply with DHCS requirements for the PASRR process for one sampled resident with a diagnosis of schizophrenia. Resident 10 was admitted with undifferentiated schizophrenia listed in the admission record, and the H&P noted the resident had the capacity to understand and make decisions. The resident’s MDS assessment also showed a diagnosis of schizophrenia. Medical record review did not show documentation that the facility completed a Resident Review or status change screening to PASRR after the schizophrenia diagnosis was identified. During interview and concurrent record review, the MDS Coordinator stated the resident did not have the schizophrenia diagnosis from admission until the physician updated the diagnosis information in June 2026, and acknowledged that a resident review or status change should have been submitted to PASRR for the change in diagnosis related to serious mental illness. The Administrator was informed and acknowledged the findings.
Care Plan Not Updated for Weight Management Interventions
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident 224 was revised to reflect current care needs and interventions. The resident’s care plan for significant weight loss, dated 5/14/26, did not include documented evidence of the weight management interventions ordered by the physician. Resident 224 was admitted to the facility on [DATE]. The physician’s orders included, on 5/14/26, offering Glucerna if the resident refused meals three times a day for weight management, and on 6/8/26, providing a carbohydrate controlled diet with regular texture and thin liquids, along with diabetic snacks at snack times three times a day. Review of the care plan showed it failed to document these interventions. On 7/29/26, RN 4 reviewed the record and verified the resident had a physician’s order for a therapeutic diet and that the significant weight loss care plan did not show any interventions documented. On 7/30/26, the DON-STP was informed and verified the findings.
Failure to Notify Physician of Lab Refusal, Complete Admission Skin Assessment, and Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a physician was informed when a resident refused ordered CBC laboratory testing. The resident had a physician order for monthly CBC and BMP blood tests, and the medical record did not show that the CBC was completed in June 2026. The record also showed the resident refused the CBC and BMP laboratory collections on 6/4 and 6/5/26, but there was no documentation that the physician was notified of the refusal for the ordered CBC test. The facility also failed to complete a skin assessment for a resident upon admission. The resident was admitted with a history of herpes simplex virus blisters and lesions on the right buttocks, and the physician later ordered oral and topical Acyclovir for HSV. The admission assessment documented that the resident refused the skin assessment of the back and buttocks, and facility staff confirmed there was no documented skin assessment when the resident was admitted. Staff also stated the resident sometimes refused a body check and that they were not able to complete the skin assessment. In addition, the facility failed to rotate insulin injection sites as ordered for another resident. The resident had orders for insulin glargine twice daily and Humulin R before meals and at bedtime. The location of administration record showed repeated Humulin R injections given consecutively in the same abdominal quadrants on multiple dates, including repeated use of the RUQ and LLQ. During interview, RN 4 verified the injection sites were documented and acknowledged that the insulin injection sites were not rotated.
Failure to Document and Follow Ordered Hand Splint Use
Penalty
Summary
The facility failed to provide RNA services as ordered for Resident 178, who was admitted on 2/2/23 and had fluctuating capacity to understand and make decisions, moderate cognitive impairment, and impairment on one side of the upper and lower extremity. A physician order dated 3/13/26 directed RNA to apply a resting hand splint to the resident’s right hand for up to three hours every day, five times a week, as tolerated, with skin checks and premedication if indicated. During observation on 7/27/26 and 7/30/26, the splint was not on the resident’s hand and was seen on the bedside drawer during one observation. The resident’s July 2026 RNA documentation showed the splint was applied five days a week and noted an average wear time of four hours with skin checks completed, but it did not show when the splint was applied, when it was removed, or how long the resident tolerated it each day. During interview, RNA 1 stated he applied the splint for approximately four hours each day but acknowledged he did not document the application and removal times or the duration of tolerance. The DON was informed of the findings and acknowledged them.
GT Feeding Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide necessary GT care and services for Resident 9, who was admitted with diagnoses including encounter for attention to gastrotomy and oral phase dysphagia and whose history included failure to thrive and Parkinson's disease. The resident's physician orders directed that the head of bed be elevated at least 30 degrees during feeding and for one hour after feeding, and the care plan also directed head-of-bed elevation during enteral feeding. During observation on 7/27/26, Resident 9 was seen lying flat in bed with the head resting on one pillow while receiving enteral feeding and water through a feeding pump. The observation also showed that the water bag connected to the feeding pump was not labeled with the date and time it was connected to Resident 9. CNA 2 stated the resident had been lying flat in bed since the start of the shift, and LVN 4 confirmed the resident was lying flat while receiving the feeding and water. LVN 4 also verified that the water bag was not labeled with the resident's name, date, and time when it was changed, and stated the head of bed should be elevated at least 40 degrees during feeding.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure Resident 4 received appropriate respiratory care when the resident's nasal cannula tubing was not changed weekly as ordered. Resident 4 was observed in bed receiving continuous oxygen at 2 liters per minute via nasal cannula, and the tubing was labeled with a date of 7/2/26. The physician's orders dated 6/30/26 directed staff to administer continuous oxygen at 2 liters per minute via nasal cannula for hypoxia and to change the oxygen tubing weekly. During interview and observation, LVN 1 stated the oxygen tubing should be changed at least once a week and verified that the tubing at the bedside was dated 7/2/26, stating it should have been discarded and changed. A later review of the medical record with LVN 4 confirmed the findings. The DON stated the oxygen tubing should be changed every seven days and as needed, and that it should be labeled with the date for infection control purposes.
Medication Administration and Controlled Drug Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for two residents. For one resident with diabetes mellitus, the physician ordered insulin glargine 27 units subcutaneously at bedtime and regular human insulin before meals and at bedtime per sliding scale. The order summary did not include any hold parameters for insulin glargine, yet the MAR showed the insulin glargine dose was held on multiple dates in July 2026. On those same dates, the regular human insulin was held appropriately based on the documented blood sugar values. During interview and record review, the DON acknowledged the insulin glargine doses were shown as held on the MAR but stated the medication had been administered as ordered. For another resident, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for severe pain, not to exceed 3 g in 24 hours. The facility's controlled medication record showed one tablet was dispensed and signed out, but the MAR did not show documentation that the dose was administered. The resident's H&P indicated the resident had the capacity to understand and make decisions. An LVN and later the DON reviewed the record and verified that the medication had been pulled and that there was no documented evidence on the MAR. Facility policy required medications to be administered according to physician orders and required controlled medications to be documented on both the accountability record and the MAR at the time of administration. The survey findings showed that insulin glargine was documented as held on the MAR despite the DON stating it had been given, and that a controlled pain medication was signed out but not documented as administered on the MAR.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to provide proper pharmacy services for two medication carts, including Medication Carts C and E. On Medication Cart C, orally administered medications were stored in the same compartment as externally used medications. During inspection, two boxes of Alendronate Sodium tablets were found stored with five bottles of Artificial Tears eye drops in one compartment, and another compartment contained Pradaxa, Alkums Antacid tablets, Enoxaparin Sodium injection, Lidocaine Patch 5%, and Diclofenac Sodium topical gel together. The LVN who inspected the cart confirmed that internal and external medications should not be stored together because they are administered by different routes and could cause medication errors and contamination. On Medication Cart E, three eye drop medications, including dorzolamide hydrochloride/timolol maleate and latanoprost ophthalmic solution, were found inside an unlabeled Ziplock bag along with one unlabeled eye drop bottle. The LVN confirmed these medications belonged to a recently admitted resident and stated they should have been labeled with the resident's name and stored in the designated medication storage area while awaiting family pickup. The same cart also contained two opened multidose insulin vials stored in a plastic bottle labeled to discard after 31 days once opened, but the vials had no open dates, and the LVN stated he could not determine how long they had been opened or whether they were safe to administer.
Missing COVID-19 Vaccine Education and Tracking Documentation
Penalty
Summary
The facility failed to maintain staffing documentation of education regarding the risks and benefits of the COVID-19 vaccine and the offering of the vaccine. Review of the facility policy showed staff were to be provided education on the benefits, risks, and potential side effects before the vaccine was offered, and the infection preventionist was to maintain a tracking worksheet documenting staff vaccination status, including whether the vaccine was received or declined. The policy also required documentation that staff were offered the vaccine or information on obtaining it, were provided education, and had verification of vaccination or exemption/delay. During interviews and document review, the infection preventionist stated she tracked staff COVID-19 vaccination status on a log and that the log included staff who received or declined the vaccine. However, the facility’s untitled vaccination document showed CNA 1 had received a third COVID-19 dose on 10/27/21, while the same document also listed CNA 1 as refused with the vaccination date left blank. The infection preventionist verified the facility did not keep documentation showing the vaccine was offered to staff who declined it or that education on the risks and benefits was provided to those staff members, and specifically confirmed there was no documentation that CNA 1 was offered the vaccine or educated on its risks and benefits.
Glucometer Calibration and Quality Control Not Documented
Penalty
Summary
The facility failed to ensure one of three glucometers, Glucometer A, was calibrated and that quality control was performed as scheduled on 7/27/26. Review of the EvenCare G2 User's Guide showed that control solution testing is used to make sure the EvenCare G2 Meter and EvenCare G2 Test Strips are working properly. Review of the Quality Control Record for Medication Cart D dated 7/2026 showed no documented evidence that the glucometer with serial number 48072751 was calibrated or had a quality control check, and the log was blank for 7/27/26. During a concurrent inspection of Medication Cart D on 7/28/26, LVN 7 verified the findings and stated that licensed nurses on the 11-7 shift calibrated the glucometer and performed quality control, and that the glucometers and quality controls were checked nightly to ensure accurate blood sugar level checks for residents. On 7/30/26, the DON also verified the findings and stated that glucometer quality control performance testing should be done daily on the 11-7 shift to ensure accurate blood sugar readings.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents. Review of the facility policy titled Abuse Prohibition, dated 2/23/21, showed the facility prohibits abuse for all residents and defines physical abuse as hitting, slapping, pinching, or kicking, with willful infliction of injury resulting in physical harm, injury, or mental anguish. Resident 1 was in the hallway speaking with staff when Resident 2 approached, stated, "I don't want to fight you," and began swinging at Resident 1, grazing Resident 1's left cheek and causing a small cut. Resident 1 was assessed after the incident, had a small cut to the left cheek, denied pain or distress, and stated, "I'm okay, I did not fight back." Resident 2 was documented as cognitively intact and had a care plan focus for aggressive behavior/assaultive behavior related to schizoaffective disorder. During interview, Resident 2 stated he punched Resident 1 because he heard Resident 1 was talking bad about him. Resident 3, who also had schizoaffective disorder and was cognitively intact, struck Resident 4 on the left side of the head. Staff documentation and interviews showed Resident 3 heard voices telling him to hit Resident 4, and Resident 4 stated Resident 3 randomly hit her on the left side of her head. MHW 1 witnessed the altercation and separated the residents. The Administrator and DON were informed of the findings and acknowledged them.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for two residents during observed care. For Resident 5, CNA 1 was observed holding clean linens and entering the room, then picking up the resident’s tube syringe from the bedside table after it fell to the floor. CNA 1 picked up the syringe from the floor with bare hands, held it against the clean linen, and placed it back on the bedside table. CNA 1 did not dispose of the syringe and did not perform proper handwashing or disinfect the bedside table. CNA 1 confirmed the observation and stated that anything on the floor is considered dirty and must be thrown away. Resident 5 had been admitted and later readmitted to the facility, and the record showed a physician’s order for EBP related to GT. For Resident 6, LVN 1 was observed picking up the resident’s call light from the floor and placing it on the resident’s lap without disinfecting it or performing hand hygiene. LVN 1 confirmed the call light was dirty because it had been on the floor and acknowledged that she did not disinfect it before placing it on the resident’s lap. The MDS Assistant stated that nurses must disinfect the call light before giving it to the resident and then perform proper hand hygiene or handwashing. The IP later stated that anything on the floor is considered dirty or contaminated and must be disposed of unless it can be disinfected, and that staff must perform proper handwashing or hand hygiene before and after providing care and handling contaminated items.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse when one resident pushed and kicked another resident in the abdomen, causing the resident to fall to the floor and experience pain. The incident was documented in the facility’s SOC 341 and nursing progress notes, which described the resident being pushed with open hands and feet and landing on the buttocks. The abused resident was cognitively intact with a BIMS score of 15 and later stated that the abdomen hurt for a short while and that the resident sometimes feared the other resident would do it again. The resident who initiated the assault also had a BIMS score of 15 and a documented history of labile mood, horseplaying, poor boundaries, child-like behavior, and difficulty with redirection. The record showed prior behavior notes describing the resident as easily upset, disruptive, difficult to redirect, and still horseplaying with peers. Although the care plan included labile mood and a prior incident of pushing a peer, the record did not show a care plan developed for the resident’s child-like behavior, horseplaying, and poor boundaries. The record also showed the resident was on a physician’s order for every 15-minute checks due to unpredictable behavior and aggressive/assaultive behavior. The monitoring documentation did not include entries for several required time points, and the DON verified that the checks should have been completed and documented every 15 minutes by MHW staff. Staff interviews described that one MHW was assisting other residents in the TV room, another was at the nursing station, and others responded only after hearing the commotion, by which time the resident who was assaulted was already on the floor. The DON acknowledged the findings.
Care Plan Did Not Address Behavioral Concerns
Penalty
Summary
The facility failed to ensure the comprehensive care plan was developed and implemented to reflect the individual care needs of Resident 4. Review of the resident’s record showed a BIMS score of 15, indicating functional cognition, along with repeated documentation of behavioral concerns including childlike behavior, horseplaying, poor boundaries, poor insight into mental illness, poor judgment, and difficulty being redirected. Progress notes documented that the resident became upset and agitated when unable to go to the store, was disruptive at times, tested limits, and had close contact with a female peer. The record also showed multiple behavior-related entries, including horseplaying with peers and concern about getting into a fight. On 5/18/26, nursing documentation stated Resident 4 was observed pushing Resident 3 with open hands and one foot, causing Resident 3 to land on her buttocks. Review of the care plans showed no care plan problem addressing Resident 4’s childlike behavior, horseplaying, or poor boundaries. During interview and record review, the DON acknowledged that Resident 4 had a history of no boundaries, child-like behavior, and horseplaying, and stated that a care plan should have been created.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to thoroughly investigate abuse allegations involving two residents. In the first incident, a resident alleged being struck on the face by another resident. Although both residents were separated and the alleged victim received first aid, the facility did not interview the alleged victim's roommate, who was present in the room and could have been a witness. There was no documentation explaining why this potential witness was not interviewed, and the Director of Nursing (DON) confirmed that the interview should have occurred. In the second incident, another resident was struck on the back of the neck by a peer while waiting in the patio. Although staff intervened and separated the residents, the facility did not interview other residents who were present and may have witnessed the event. The DON acknowledged that these potential witnesses were not interviewed, stating that staff relied on their own observations. In both cases, the facility's investigation documentation did not include interviews with all possible witnesses as required by policy.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Incomplete Documentation on Resident Out on Pass Logs
Penalty
Summary
The facility failed to ensure that the Resident Out on Pass Log was accurately and completely filled out for two of four sampled residents. For both residents, multiple entries on the Out on Pass Log were missing critical information, including the time the resident went out, the time they returned to the facility, and the nurse's initials. These omissions were identified through a review of the medical records and facility documents, which showed repeated instances where required documentation was left blank on several dates for both residents. Facility policy requires that nursing documentation be concise, clear, pertinent, and accurate, and that all resident information be entered in the appropriate section of the clinical record following established guidelines. The Out on Pass policy further specifies that residents or their responsible persons must sign out and back in on the log, and that nurses are to sign the entries. During interviews, the DON confirmed that the logs for the two residents had blank entries and acknowledged that nurses were supposed to sign the log. The Administrator and DON both acknowledged these findings during the survey.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them in their shared room. Both residents alleged that the other initiated the altercation and admitted to hitting each other in the face in self-defense. Staff assessments found one resident with a small abrasion on the lip and the other with a swollen lip. The facility's policy on abuse prevention required staff to identify, correct, and intervene in situations where abuse is more likely to occur, including understanding behavioral symptoms that may increase the risk of abuse. Medical record reviews revealed that one resident had a documented history of physically aggressive and assaultive behaviors, including multiple incidents of verbal threats, striking staff, punching walls, and previously striking another resident. The other resident also had a care plan for aggressive behavior, with documented episodes of agitation, responding to internal stimuli, threatening staff, and physical aggression such as punching walls and plexiglass. Interviews with facility leadership and the residents confirmed ongoing behavioral issues, including command hallucinations and medication changes that may have contributed to escalating behaviors prior to the altercation.
Failure to Maintain Accurate and Complete Medical Record
Penalty
Summary
The facility failed to ensure the accuracy and completeness of a resident's medical record by not maintaining a signed copy of the admission physician's orders in the electronic health record (EHR). Upon review, it was found that after the resident was readmitted and subsequently discharged to an acute care hospital, the signed Order Summary Report was missing from the EHR. The Health Information Manager (HIM) confirmed that paper records are shredded after scanning, and the signed order should have been present in the EHR but was not. Later, a signed Order Summary Report was produced by the Medical Records Clerk, but the physician confirmed he had signed it only that morning, despite the document being pre-dated. This sequence of events resulted in the resident's medical record containing inaccurate and incomplete information at the time of review.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in one resident sustaining multiple injuries after being pushed by another resident. The incident occurred when one resident, who had a documented history of aggressive and assaultive behaviors, reacted to being bumped in the hallway by forcefully pushing the other resident into a wall, causing an abrasion to the forehead and a laceration to the left eyelid. The injured resident required assessment and was sent to an acute care hospital for further evaluation, where imaging revealed a cervical spine injury. Prior to the incident, the aggressive resident had a known history of similar behaviors, including previous assaults on peers at both the current and prior facilities. Documentation indicated that this resident had been placed on 1:1 supervision in the past due to high risk for violence and had requested a unit change, expressing ongoing frustration with the other resident's behavior. Despite these known risks and repeated requests for separation, the two residents were not adequately separated, and the aggressive resident was not moved to another unit. Staff interviews and medical record reviews confirmed that the aggressive resident had previously assaulted the same peer and had communicated intentions to harm if the situation persisted. The facility's policies required identification and intervention in situations where abuse was likely, as well as immediate reporting and investigation of such incidents. However, the facility did not implement sufficient measures to prevent further altercations, resulting in the resident's injuries.
Failure to Timely Report Suspected Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, as well as the results of investigations, to the appropriate authorities for four out of ten sampled residents. According to the facility's Abuse Prohibition Policy, allegations of abuse must be reported within two hours of the allegation being made. However, in multiple instances, this policy was not followed, resulting in delayed notifications to the California Department of Public Health (CDPH) Licensing & Certification (L&C) Program and local law enforcement. One incident involved a resident who alleged physical abuse by a mental health worker (MHW), stating that the staff member choked and slammed the resident's face into the ground. The resident was observed with visible injuries, including bruising and scratches. The DON acknowledged the incident and confirmed that the reporting was not completed within the required timeframe. In another case, a resident reported verbal abuse by a staff member who mocked his stutter and made derogatory comments. The DON was informed of the allegation but did not report it within the mandated period. Additionally, the facility failed to report a resident-to-resident altercation in which one resident admitted to physically assaulting another on two separate occasions. Both residents were cognitively intact and had psychiatric diagnoses. The second incident resulted in visible injuries to the assaulted resident, and interviews revealed that the first incident had not been reported as required. Facility leadership acknowledged these reporting failures during interviews.
Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
The facility failed to implement its abuse investigation policies and procedures for four of ten sampled residents. In one case, a resident alleged that a mental health worker (MHW) choked and assaulted him, resulting in visible injuries such as bruising and scratches on the face and neck. Despite the allegation and physical evidence, the MHW was not immediately removed from duty, and no investigation was conducted. Other residents who witnessed the incident were not interviewed, and the DON dismissed the allegation as false without following the required investigative process. Another resident reported that a staff member mocked his stutter and that other staff called him derogatory names. The DON acknowledged the allegation but did not initiate an investigation or report the incident within the required two-hour timeframe. The facility later submitted a report, but it was acknowledged as late by the Administrator and DON. Additionally, two residents were involved in two separate physical altercations, with one resident sustaining visible injuries. The facility failed to conduct a thorough investigation after the first incident, did not report the initial allegation, and did not separate the residents until after the second incident. Interviews revealed that staff and residents were aware of the altercations, but appropriate actions to ensure safety and compliance with policy were not taken. The DON and Administrator acknowledged these failures during interviews.
Failure to Develop and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and revised as required for three residents. For one resident with a history of falls and a physician's order for bilateral floor mats, the care plan did not include this intervention, despite documented falls and the presence of the mats during observation. The Director of Nursing (DON) confirmed that the care plan lacked this intervention. Another resident experienced a significant, unplanned weight loss of 24 lbs (17.91%) over a period of less than three months. Although the resident's care plan noted a nutritional problem, it did not address the severe weight loss, and both the Registered Dietician and DON acknowledged the omission. A third resident, who was cognitively intact, sustained facial abrasions following a physical altercation. While the care plan identified the resident as a victim of assault, it did not include interventions for the facial injuries. The DON confirmed that there was no care plan or interventions for the injuries, and agreed that the injuries represented a change in condition. The Administrator and DON acknowledged these findings during the survey.
Resident Injured During Manual Restraint in De-escalation Incident
Penalty
Summary
The facility failed to ensure a resident was free from injury during a de-escalation process, resulting in the resident sustaining multiple bruises and scratches to the face and neck. According to the facility's policy, the least restrictive method should be used to resolve situations, with manual restraint reserved for acute episodes of dangerous behavior. On the date of the incident, the resident became verbally aggressive and attempted to pour out a community water jug. Staff attempted therapeutic communication, which was unsuccessful, and the situation escalated to physical contact. During the struggle, the resident and staff fell to the ground, and staff manually restrained the resident by holding his limbs until he calmed down. Medical examination documented small bruises on the resident's left eyebrow and neck, as well as bruising and swelling around the nose bridge and a scratch on the forehead. Observations confirmed these injuries, and the resident reported being taken to the ground, choked, and having his head smashed into the ground by staff. Staff interviews corroborated that a physical altercation occurred, resulting in the resident being restrained on the ground. The DON confirmed that the injuries were not present upon admission and occurred during the incident on the patio.
IV Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safe administration and maintenance of intravenous (IV) therapy for four residents, leading to potential complications. Resident 932's IV tubing contained multiple air bubbles, which were not removed before the administration of the antibiotic Zosyn. Despite attempts by RN 1 and the QA RN to remove the air bubbles, they were unsuccessful, and it was recommended to change the IV tubing. This oversight posed a risk of air embolism to the resident. Resident 184's midline dressing was not dated or labeled, and there was no documentation of the midline site being monitored for patency or complications such as infection or displacement. The resident was receiving IV medication for a foot infection, but the lack of proper labeling and monitoring could lead to catheter-related infections. Additionally, there was no evidence of a physician's order for flushing the midline to maintain its patency. Resident 983 had a peripheral IV (PIV) line that was not discontinued after the completion of antibiotic therapy, and there was no physician's order for maintenance flushes. The PIV line remained in place without a clear indication, increasing the risk of infection. Similarly, Resident 733's PIV site was not dated or labeled, which is necessary for infection control and to ensure timely site changes. These deficiencies highlight the facility's failure to adhere to IV therapy protocols, potentially compromising resident safety.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations of unsanitary conditions in the kitchen and food preparation areas. White plastic trash was found on the floor, in the sink area, and in the main food preparation hallway. Additionally, gloves and dietary menu forms were improperly placed in clean serving areas. The top surface of the soup machine was cluttered with unwashed cabbages, cooking mittens, basins, and a cutting board, which should have been cleared. Vegetables that fell on the floor were picked up and placed on a food cart without being cleaned, posing a risk of contamination. Further observations revealed that equipment and utensils were not properly cleaned. Fryer baskets and a serving utensil had food residues, and a can opener had brownish-orange residues. Microwaves used by residents in various stations had dried food residues, and the Station 4 refrigerator had food residue and a dried brown liquid spill. The lack of an air gap in the kitchen sink also violated sanitation guidelines, as it could lead to backflow contamination. Personal food items stored in residents' rooms were found unlabeled and undated, which is against the facility's policy. Residents 205, 222, and 133 had food items in their rooms that were not labeled with the resident's name, date brought, or use-by date, increasing the risk of food contamination. These deficiencies in food safety and sanitation practices posed a risk for foodborne illnesses among the residents who consumed food prepared in the facility's kitchen.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the administration of psychotropic medications to a resident, identified as Resident 147, who was readmitted to the facility. The medications in question were olanzapine, quetiapine, and valproic acid, which were prescribed for managing psychosis and mood lability. The facility's policy and procedure required that informed consent be obtained by the prescriber prior to the initiation of psychotropic medication and verified by the facility before administration. However, upon review, it was found that no informed consents were obtained for these medications upon the resident's readmission. Interviews with facility staff, including an LVN, the Health Information Manager, and the Director of Nursing (DON), confirmed the absence of informed consents in the resident's medical record. The Health Information Manager noted that new orders and informed consents are required if a resident is readmitted after a week from an acute care hospital. The DON acknowledged the findings and stated that informed consent must be obtained for each psychotropic medication prior to its initiation. This oversight had the potential to leave the resident unaware of the risks associated with the medications, which could have adverse side effects detrimental to the resident's well-being.
Failure to Maintain Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one of the residents reviewed for advance directives. This deficiency was identified during a review of the facility's policies and procedures, which stated that a copy of the advance directive should be maintained as part of the resident's medical record. The review of Resident 184's medical record revealed that although the resident had an advance directive, there was no copy of it in the medical record, nor was there any documentation indicating that the facility had requested a copy from the resident or their representative. Interviews and concurrent medical record reviews with the Social Services Assistant (SSA) confirmed the absence of the advance directive in the resident's medical record and the lack of documentation regarding any follow-up actions to obtain it. The SSA acknowledged that the facility's procedure was to request a copy of the advance directive and to document any follow-up actions if the resident or their representative could not provide it. However, no such documentation was available for Resident 184. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Inaccurate PASRR Level 1 Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the PASRR Level 1 assessments for two residents, which is a federal requirement to prevent inappropriate placement in nursing homes. Resident 132's PASRR Level 1 Screening Form indicated no serious mental illness and no prescribed psychotropic medications, despite the resident having diagnoses of major depressive disorder and schizoaffective disorder. The resident's medical records showed prescriptions for quetiapine and lorazepam, which are used to manage symptoms of these conditions. Similarly, Resident 147's PASRR Level 1 Screening Form also inaccurately indicated no serious mental illness and no prescribed psychotropic medications. However, the resident had diagnoses of mood disorder and psychosis, with medical records showing prescriptions for quetiapine and olanzapine to manage symptoms such as hallucinations and agitation. The MDS Coordinator confirmed these discrepancies and acknowledged the errors in the PASRR Level 1 assessments, which posed a risk of the residents not receiving appropriate specialized care and services.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident, identified as Resident 147, which potentially affected the resident's psychosocial well-being. Observations on multiple occasions revealed Resident 147 lying awake in bed, staring at the wall, with the television turned off, indicating a lack of engagement in preferred activities. The resident's medical records indicated severe cognitive impairment and dependency on staff for activities of daily living. The Recreation Comprehensive Assessment highlighted the importance of engaging the resident in activities such as watching TV, exercising, and listening to music, yet these preferences were not consistently met. The facility's policy stated that residents should be encouraged to choose activities based on their preferences and medical conditions, but the Activity Director admitted that due to insufficient staff, the resident was only scheduled for room visits three times a week. The Participation Record for February showed gaps in activity provision, with no activities recorded on several days. Interviews with the Activity Director and a CNA confirmed the lack of daily activities for the resident, with the CNA noting that the resident was unable to attend the activity room and had not received in-room activities. The Director of Nursing and the Administrator acknowledged these findings.
Failure in GT Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident, identified as Resident 735, who was part of the final sample. The deficiency was observed during a medication administration session where the Licensed Vocational Nurse (LVN) did not check the GT placement before administering medications and water. This was contrary to the facility's policy and procedure, which required checking the tube placement by inserting air and listening for gurgling sounds, as well as aspirating stomach contents. The LVN acknowledged the oversight and stated that the check would be done later, which was not in compliance with the established protocol. Additionally, the LVN administered medications and water flushes by pushing the syringe's plunger instead of allowing them to flow via gravity, as required by the facility's procedures. This improper technique could potentially lead to complications such as tube dislodgement or trauma. The resident involved, Resident 735, had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 1, indicating an inability to understand and make decisions. The Director of Nursing (DON) was informed of these findings and acknowledged the issues.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. For Resident 96, the facility did not ensure that the humidifier was labeled and dated, and there was no documented physician's order for the use of oxygen, as required by the facility's policies and procedures. During an observation, it was noted that Resident 96 was using oxygen without a physician's order, and the humidifier was not properly labeled. The Licensed Vocational Nurse (LVN) confirmed these findings and acknowledged the need for a physician's order for oxygen use. For Resident 161, the facility did not adhere to the physician's order for oxygen administration. The order specified that oxygen should be administered at 2 liters per minute via nasal cannula, with the possibility to titrate up to 3 liters per minute. However, during an observation, Resident 161 was found to be receiving oxygen at 5 liters per minute, which exceeded the physician's order. The Infection Preventionist (IP) verified this discrepancy, and the Administrator acknowledged the findings. These failures had the potential to impact the respiratory health and well-being of the residents.
Pharmaceutical Service Deficiencies in Medication Reconciliation and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in discrepancies in the reconciliation of controlled medications for three residents and one medication cart. For Resident 40, the facility did not ensure that the administration of oxycodone-acetaminophen was accurately documented in the Medication Administration Record (MAR), despite being signed out on the controlled drug record. This discrepancy was verified by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the lack of documentation for the administered doses. Resident 735, who had severe cognitive impairment, was prescribed digoxin with a specific order to hold the medication if the apical pulse was below 60 beats per minute. However, the LVN administering the medication failed to obtain the apical pulse before administration, as required by the physician's order. This oversight was confirmed during an observation and interview with the LVN. Additionally, the facility did not maintain accurate narcotic shift counts for Medication Cart A, with a missing signature for a specific shift. For Resident 27, the facility failed to maintain accurate controlled medication count sheets, leading to discrepancies in the documentation of oxycodone administration and wastage. The DON confirmed that the count sheets were incorrectly maintained, with errors in tablet strength and missing co-signatures for medication wastage.
Failure to Monitor Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for two residents receiving psychotropic medications. Resident 146 was not monitored for orthostatic blood pressure as ordered by the physician, despite being administered quetiapine fumarate for psychosis. The medical records showed that the orthostatic blood pressure readings were identical for lying and sitting positions, which is unlikely and suggests incorrect documentation or monitoring. This lack of proper monitoring could not confirm whether Resident 146 experienced orthostatic hypotension. Resident 147 was administered quetiapine without documented evidence of non-pharmacological interventions being attempted first, as required by the facility's policy. Additionally, there was no behavioral monitoring or AIMS assessment completed after the resident's readmission, which is necessary to evaluate the effects and necessity of the psychotropic medication. Interviews with facility staff confirmed these findings, indicating a failure to adhere to the facility's policies on psychotropic medication use. The facility's policy requires that psychotropic medications be used only after non-drug approaches have been attempted and that residents' behaviors be monitored. The failure to follow these protocols for Residents 146 and 147 had the potential to negatively impact their well-being, as the necessary assessments and interventions were not conducted to ensure the safe and appropriate use of psychotropic medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 25.93%. During a medication administration observation, LVN 3 administered medications to a resident via a gastrostomy tube (GT) and left residue in the medication cups, indicating incorrect dosage administration. Additionally, LVN 3 did not follow the physician's order for the form of Keppra, administering a solution instead of the prescribed tablet. LVN 3 acknowledged these errors and stated that the order should have been updated in the electronic health record (EHR) upon receiving a different medication form from the pharmacy. RN 1 was observed preparing and administering an intravenous (IV) antibiotic, Zosyn, to another resident. During the process, multiple air bubbles were found in the IV tubing, which RN 1 initially attempted to remove by priming the tubing, risking medication waste. The QA RN and DON 1 were consulted, and it was decided to replace the IV tubing to ensure safe administration. RN 1 acknowledged the error and stated that a new Zosyn and tubing should have been prepared to prevent the medication error.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as observed during inspections of various medication and treatment areas. In Medication Room A, expired vancomycin bags were found in the refrigerator, and bisacodyl suppositories were stored without an open date. Additionally, the refrigerator's temperature was significantly below the recommended range. In Medication Room C, several expired medications, including clotrimazole cream and various vitamins, were not discarded. Medication Cart B contained an expired bottle of vitamin C liquid. Further deficiencies were noted in Treatment Carts A and B. Treatment Cart A contained an opened bottle of sterile saline, expired antifungal powder, and culture swabs, along with unclean conditions in the last drawer. Treatment Cart B also had expired antifungal powder and shampoo, with similar cleanliness issues. These findings were verified by the respective LVNs present during the inspections, and the Director of Nursing acknowledged the issues upon being informed.
Improper Waste Disposal and Handling
Penalty
Summary
The facility failed to ensure the proper disposal and handling of waste, leading to potential safety and pest contamination risks. Observations revealed scattered food residues on the ground next to the food waste dumpster and trash, including disposable cups with orange liquid and tortilla plastic containers, in the open space storage area. These areas were not maintained in accordance with the USDA Food Code 2022, which requires refuse to be stored in a manner that is inaccessible to insects and rodents. The Maintenance Director confirmed these findings and acknowledged that the surrounding areas of the dumpster should be clear of trash to prevent pest attraction. Additionally, two of the six soiled linen barrels were found with trash inside, uncovered, and without lids. One barrel was overfilled with trash bags, and the other contained two bags of trash with a milky substance spilled at the bottom. The Maintenance Director stated that these barrels were intended for trash and were not covered because the trash was placed in plastic bags. The facility's policy requires all garbage and refuse containers to have tight-fitting lids or covers, which were not adhered to in this instance. The Administrator and DON acknowledged these findings, indicating a lapse in compliance with established waste management protocols.
Infection Control Deficiencies in Medication Administration and Sanitation
Penalty
Summary
The facility failed to implement appropriate infection control practices for several residents, leading to potential risks of infection transmission. For Resident 184, who had a midline catheter, the facility did not ensure that the Licensed Vocational Nurse (LVN) wore the necessary personal protective equipment (PPE) such as gloves and gowns during medication administration. This was despite the resident's need for Enhanced Barrier Precautions (EBP) due to the presence of an indwelling medical device. Additionally, there was no EBP sign outside the resident's room to indicate the need for such precautions. In other instances, the facility failed to ensure proper hand hygiene during medication administration. LVN 5 did not perform hand hygiene before and after donning and doffing gloves while administering eye medication to Resident 151. Similarly, LVN 3 did not perform hand hygiene after removing gloves and before preparing medication cups for Resident 735. Furthermore, RN 1 did not disinfect the septum of a Zosyn antibiotic vial before connecting it to a normal saline bag for Resident 932, which is a critical step in preventing contamination and infection. The facility also neglected to maintain a sanitary environment in shared restrooms. Residents 64 and 118's shared restroom had a strong foul odor, and the toilet rim was visibly soiled with dried yellow urine. This lack of cleanliness poses a risk for the transmission of disease-causing microorganisms. These observations were verified by staff members, including the Director of Nursing (DON) and the Maintenance Director, who acknowledged the deficiencies in infection control practices.
Incomplete Documentation of Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure complete documentation of medication administration for two residents, leading to potential gaps in their care. For Resident 184, the administration of piperacillin-tazobactam was not documented on several occasions, including specific times on 2/16/25, 2/17/25, 2/18/25, and 2/26/25. RN 1 admitted to administering the medication on 2/26/25 but failed to document it, and there was no explanation for the missing documentation on the other dates. The pharmacist confirmed that there should have been eight doses left if the medication had been administered as ordered, which was verified by RN 1 during an observation of the IV cart. For Resident 132, the facility failed to document monitoring for antipsychotic side effects and episodes of schizoaffective disorder as ordered by the physician on 1/13/25 during the evening shift. The orders included monitoring for side effects of quetiapine and documenting non-pharmacological interventions for schizoaffective disorder. RN Supervisor 1 confirmed the missing documentation and stated that the monitoring was performed but not recorded in the MAR. These documentation failures were acknowledged by the Director of Nursing (DON) and the Administrator, indicating a lapse in adherence to the facility's policies and procedures for medication administration and documentation. The lack of complete medical records for these residents could potentially impact the quality of care provided, as the clinical information was not fully captured.
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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 | 0.4 mi | ★★★★★ | 7 | 0 |
| South Coast Global Medical Center D/p Snf | 0.7 mi | ★★★★★ | 25 | 0 |
| Fountain Valley Post Acute | 2.9 mi | ★★★★★ | 34 | 0 |
| French Park Care Center | 3 mi | ★★★★★ | 57 | 0 |
| Foothill Regional Medical Center D/p Snf | 3.1 mi | ★★★★★ | 12 | 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 October 2026) and official state health department websites.