Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sundance Creek Post Acute during CMS and state inspections, most recent first.
A resident with cognitive impairment and lower extremity wounds experienced documented deterioration of diabetic heel wounds and new discoloration on the dorsum of the foot over several occasions. Although COC notes showed that physicians were notified and the resident was informed, the resident’s designated representative was not notified, despite facility policy and staff acknowledgment that changes in condition should be communicated to the resident representative and documented accordingly.
Two residents were involved in a physical altercation when a cognitively impaired resident with delusional and impulse disorders, known to wander and enter others’ rooms, went into another resident’s room, attempted to take personal items, and punched the resident in the face, causing minor injuries. The aggressive resident’s care plan identified risk for elopement and wandering but contained only general interventions without specifying the level of supervision or monitoring required, despite a physician order to monitor for impulse control disorder with wandering and danger to self and others. Staff, including an RN, LVN, and CNAs, reported awareness of the resident’s wandering and occasional aggression but were unaware of specific written interventions, there was no documented CNA monitoring of wandering behavior, and the resident was not listed on the facility’s internal communication board as at risk for wandering at the time of the incident.
Failure to assess two residents before allowing bedside medication self-administration. One resident with a BIMS of 14 had an opened bottle of hydrogen peroxide at the bedside and said she used it to rinse her mouth, while another cognitively intact resident with a BIMS of 15 kept multiple open OTC products at his bedside and had used one for a skin issue. Staff stated residents needed a self-administration assessment before keeping meds at the bedside, but neither resident had documentation of such an assessment.
Verbal Abuse Toward a Resident: A resident with hemiplegia and hemiparesis after a stroke was verbally abused when an LVN used inappropriate and derogatory language while preparing to give medications. The resident said he was shocked and considered the language unprofessional and abusive, and another LVN and the DON confirmed the report involved inappropriate language that was inconsistent with staff expectations for respectful communication.
Failure to provide written bed hold notice at hospital transfer. A resident with muscle wasting and atrophy was sent to the hospital for hernia and abdominal pain, but the transfer/discharge paperwork did not document that the resident or representative received the State bed hold notice. Interviews with the SSD, LVN, DON, and FA confirmed the written notice was not provided or documented, despite the facility policy requiring notice in writing at admission and again within 24 hours of transfer.
Failure to provide timely incontinence care for a dependent resident. The resident, who was frequently incontinent and required brief changes q2h and PRN, reported using the call light overnight for help with a brief change, but staff did not return after turning off the light and she remained soaked in urine until her RP called the nurse's station. The CNA stated the brief was changed once during the night and not checked again for several hours, and an LVN said she did not tell the CNA about the q2h brief-check requirement.
Failure to implement ordered nutritional interventions affected two residents. One resident with a stage 4 pressure ulcer did not receive an ordered extra egg at breakfast because nursing did not communicate the diet order to dietary staff, and another resident with protein calorie malnutrition did not receive ordered Boost GC during med pass. An LVN acknowledged the supplement should have been given as ordered, and the facility policy stated licensed nursing personnel must ensure physician orders are implemented.
Failure to document and monitor a PIV was identified for a resident with DM and a UTI who had a 1L NS IV bolus ordered for elevated blood sugar. An RN inserted a 22g IV catheter and started the bolus without verifying a physician order for the PIV, and there was no documented site assessment or monitoring for over 10 days. The dressing remained dated and over 7 days old, and no care plan was initiated for ongoing IV care and monitoring.
Dialysis Pressure Dressing Not Removed as Ordered: A resident with ESRD and a left upper arm dialysis access site was observed with a pressure dressing still in place after returning from dialysis, despite an order to remove the bandage two hours after arrival. The resident said it was supposed to have been removed the prior day but was forgotten. An LVN and the DON both stated the dressing should have been removed as ordered.
An unlabeled bottle of Phenol 1.4% oral relief sore throat spray was found in a med cart at the East Station, half-full with a broken cap and no resident name, identifier, or pharmacy label. An LVN could not identify which resident it belonged to or when it was last used, and stated the item had been opened and should not have remained in the cart without a label.
Failure to Honor Food Preference: A resident with intact cognition and documented dislikes was repeatedly served milk despite an order stating not to serve milk to drink. Meal tickets and dietary records conflicted with the resident’s stated preference, and a CNA was observed bringing milk to the resident’s room even after the resident asked for it to be removed.
Fortified Diets Not Provided as Ordered: Two residents on physician-ordered fortified diets did not receive the required extra 1 oz of gravy with lunch trays. During tray line observation, the DA and DS confirmed the trays were missing the ordered fortified item. One resident had stage 4 pressure ulcer and protein calorie malnutrition, and the other had generalized weakness with a care plan for fortified diet.
A resident with ESBL infection was on contact precautions, but the PPE cart was observed without disposable gowns. The HS said she was responsible for stocking the PPE carts and that the cart should contain the proper PPE, while the IP and DON stated the isolation cart should have disposable equipment and required PPE, including gowns, gloves, and masks, available for staff to use to prevent infection transmission.
Two residents with significant mobility impairments were unable to have their transfer needs and preferences met due to an insufficient number of Hoyer lifts. This resulted in delays, missed activities, and disruption of daily routines, as confirmed by staff and resident interviews and record reviews.
A resident with a history of diabetes, end stage renal disease, and hemodialysis was not assessed or monitored for circulatory insufficiency after a DVT diagnosis, despite care plan interventions and facility protocols requiring monitoring for pain, swelling, discoloration, and pedal pulses. Nursing staff and the DON confirmed that no documentation of such monitoring existed, and the deficiency was identified after the resident developed necrosis and was hospitalized for gangrene.
A resident with diabetes and fluctuating capacity experienced significant changes in skin condition, including a reclassified sacral pressure wound and new deep tissue injuries, as identified by wound care specialists. Despite these findings and new treatment orders, nursing staff did not complete required skin and wound evaluations or update the weekly summaries to reflect these changes, resulting in incomplete and inaccurate medical records. Both the LVN and DON confirmed that documentation should have included updated wound descriptions and measurements, in accordance with facility policy.
A resident with severe cognitive impairment and communication challenges was allegedly struck by another resident with a mental health disorder. The incident was witnessed by a third resident and reported to nursing staff, but the required report to CDPH and the Ombudsman was not made within the mandated two-hour timeframe. Staff interviews revealed miscommunication and lack of follow-through, resulting in delayed notification to the DON and failure to comply with facility policy.
A resident with fluctuating capacity to make medical decisions experienced a right shoulder prosthesis dislocation, an injury of unknown source, which was not reported to CDPH, police, or the Ombudsman within the required two-hour timeframe. Despite facility policy mandating immediate reporting to rule out abuse, the incident was not communicated as required, potentially affecting the resident's well-being.
A resident experienced a dislocation of their right shoulder prosthesis, which was not investigated by the facility despite being an injury of unknown origin. The resident was admitted without initial shoulder issues, but later complained of pain and swelling, leading to an X-ray that confirmed the dislocation. The facility's policy requires investigations for such injuries, but no investigation was conducted, as confirmed by the DON.
A resident with fluctuating decision-making capacity was transferred to a hospital without receiving a written transfer notice, and the LTC Ombudsman was not informed. The facility's policy requires such notices to be provided to both the resident and the Ombudsman, but this was not documented or executed.
A resident with significant mobility impairments and a history of stroke did not receive scheduled showers or bed baths as per their care plan. Despite being dependent on assistance for all ADLs, documentation showed missed showers and bed baths on several occasions, with no record of refusal. Interviews with staff and the DON confirmed lapses in following the care plan and documentation protocols.
A resident with hemiplegia and high risk for pressure ulcers was not repositioned every two hours as required, leading to the development of a pressure ulcer. Facility staff failed to document repositioning, and there was no schedule in place to ensure compliance with the facility's policy.
A resident reported missing finances, including a bank card and $600, to a Social Service Assistant (SSA) in an LTC facility. The SSA failed to report the financial abuse allegation to the California Department of Public Health (CDPH) within the required two-hour timeframe, instead reporting it 25 hours later. The facility's policy mandates immediate reporting of such incidents to ensure resident safety and prevent further abuse.
A resident was not monitored for emotional and psychosocial wellbeing after reporting financial abuse by a family member. Despite the facility's standard practice of 72-hour monitoring following abuse allegations, this was not conducted, and there was no specific policy to ensure such monitoring.
A Physical Therapy Assistant in an LTC facility failed to perform hand hygiene when entering and exiting the rooms of two residents under Droplet Precaution. Despite facility policies and signage requiring hand hygiene to prevent infection spread, the PTA did not comply, as confirmed by the Infection Preventionist.
A resident's family member filed a grievance about the resident being left unattended in a shower. The facility investigated the complaint but failed to document the investigation or inform the family member of the findings, contrary to their grievance policy. The resident had severe cognitive impairment, making family communication essential.
A resident was issued an incomplete discharge notice, lacking the discharge date and location, due to the Social Service Director leaving these fields blank as the resident had not decided on his next living arrangement. The resident, unable to read the notice due to poor eyesight, was unaware of his discharge location, leading to a deficiency in the facility's compliance with notification requirements.
A resident with Type II Diabetes Mellitus and Essential Hypertension did not receive a follow-up ophthalmology consult, as required by their care plan. Despite the resident's capacity to make decisions and their expressed need for an ophthalmologist, the Social Service Director failed to arrange the necessary appointment, as confirmed by interviews with the Director of Nursing and the SSD.
The facility failed to document the administration of narcotic pain medications for 20 residents, leading to potential discrepancies and possible diversion of controlled substances. Licensed nurses signed out medications but did not consistently document their administration in the eMAR, affecting residents with conditions like muscle wasting and chronic pain. Interviews with LVNs confirmed the lack of documentation, highlighting a failure to follow the facility's process for administering PRN narcotic pain medications.
A facility with 132 beds failed to employ a qualified full-time social worker. The Social Service Director lacked the necessary bachelor's degree and was not a licensed medical social worker, nor supervised by one. This deficiency was confirmed by the Administrator, contradicting the facility's job description and policy requirements.
The facility failed to ensure effective narcotic medication accountability and pain assessment. Narcotic medications were signed out by LNs but not documented in the e-MAR, and pain assessments were not conducted after medication administration. Despite identifying these issues, the facility did not monitor or re-evaluate the effectiveness of interventions, risking medication diversion and unmanaged pain.
The facility failed to promptly respond to call lights for several residents, with wait times ranging from 10 to 30 minutes, despite previous discussions in Resident Council meetings. Additionally, a resident consistently received her meal after another resident, impacting her dignity and meal intake. Staff interviews confirmed the expectation for prompt response and simultaneous meal service, but these were not met.
The facility failed to conduct self-administration assessments for three residents, leading to medications and supplements being left at their bedsides without proper authorization or physician orders. LVNs acknowledged the oversight, and the DON emphasized the importance of following facility policies to ensure safe medication administration.
The facility failed to provide education and resources for Advance Directives (AD) to 15 residents and their representatives, as required by policy. Despite some residents having the capacity to make decisions, there was no documentation of AD education in their records. The Social Service Director admitted to not providing the necessary education or follow-up, resulting in a deficiency.
The facility failed to conduct pain assessments and evaluate the effectiveness of PRN narcotic pain medications for 20 residents, including those with osteomyelitis, diverticulosis, and chronic pain syndrome. Licensed nurses did not document pain levels before or after administering medications like Tramadol and oxycodone-acetaminophen, compromising effective pain management.
The facility failed to ensure Food and Nutrition Service employees followed proper procedures, leading to deficiencies. Employees did not clean kitchen equipment correctly, using only sanitizer instead of detergent and sanitizer. Staff also misunderstood the correct chlorine concentration for dish machines, risking cross-contamination. Additionally, a cook did not follow a recipe for pureed Bread Stuffing, resulting in overly salty servings for residents on a pureed diet.
The facility failed to provide appetizing food at appropriate temperatures, affecting nine residents. Observations and interviews revealed issues such as cold meals, bland and tough meat, and improperly seasoned pureed meals. A test meal evaluation confirmed that food temperatures did not meet policy standards, with cold items served warmer and hot items cooler than required. The meal service process was inefficient, contributing to these discrepancies.
The facility failed to maintain sanitary conditions in the kitchen, with mold, dust, and hair found in the walk-in refrigerator, calcium buildup on the hot water spout, and wet containers improperly stored. Dust and rust were observed on equipment, and chipped paint was noted on a mixer and utensil hanger. An unsanitary microwave was also found, posing a risk of contamination.
A resident with hypotension experienced disturbances during sleeping hours due to noise from another resident gardening early in the morning. Despite multiple complaints, the facility failed to maintain a quiet environment, as confirmed by an LVN and acknowledged by the DON. The facility's policy emphasized the need for comfortable noise levels to ensure a homelike setting.
A resident with pulmonary hypertension was not accurately assessed for smoking habits, despite admitting to occasional smoking and being observed by staff. The facility's smoking policy was not followed, as the resident's use of electronic cigarettes was not documented or assessed for safety, posing potential injury risks.
A resident with respiratory issues was receiving oxygen at 4 LPM instead of the prescribed 2 LPM, as observed during an interview with an LVN. The incorrect flow rate was confirmed by an RN, who noted the potential for oxygen toxicity. The facility's policy requires verification of physician orders for safe oxygen administration, which was not followed.
The facility failed to provide proper post-dialysis assessment for a resident with ESRD and did not follow a physician's order to discontinue fluid restriction for another resident. The lack of post-dialysis assessment and incomplete I&O monitoring documentation were confirmed by staff, indicating a failure to adhere to facility policies and physician recommendations.
A resident with schizophrenia was prescribed Olanzapine for auditory hallucinations, but the LTC facility failed to monitor the resident's behavior as required. The Director of Nursing confirmed the absence of a care plan for the resident's hallucinations, despite facility policies mandating such monitoring and care planning.
The facility failed to properly store discontinued medications, as two vials of Lorazepam and an Insulin Lispro Injection pen marked as discontinued were found in the medication room refrigerator. The RN stated that these medications should have been discarded by the night shift nurses, while the DON confirmed that discontinued medications should be placed in a discontinue bin and destroyed monthly with the pharmacist consultant.
A resident with End-Stage Renal Disease did not receive meals according to the physician's NAS diet order, which included specific food preferences and restrictions. The dietary department failed to adhere to these instructions, serving meals with items the resident disliked. Additionally, the RD's recommendation to fortify the resident's diet due to weight loss was not communicated to the physician or implemented, contrary to facility policy.
A CNA failed to disinfect a Hoyer lift between resident uses, and an RN did not wear PPE while caring for a resident with an ESBL infection. Both actions were against the facility's infection control policy, risking the spread of infection.
The facility failed to maintain an effective pest control program, leading to house flies being observed in the kitchen and East activity room. A fly was seen on a cleaned container in the kitchen, attributed to a delivery man propping the door open. Another fly was observed on a resident's food in the East activity room, entering when residents opened the door to smoke. The Registered Dietitian confirmed that flies carry bacteria, and the facility's policies emphasize the need for pest control to maintain sanitation standards.
A Treatment Nurse failed to perform hand hygiene between glove changes during wound care for a resident with a sacral wound, contrary to facility policy. The resident had a complex medical history, including a stage 4 pressure ulcer. The Infection Preventionist confirmed the protocol breach.
The facility failed to employ a dedicated Dietary Manager, leading to lapses in food safety practices such as missing use-by dates on food items. Duties were shared among a Dietary Corporate Consultant, a Registered Dietitian, and a DM from a sister facility, resulting in negative impacts on staff work and oversight issues.
The facility failed to store food items according to professional standards, as observed when Italian dressing and egg salad in the refrigerator were missing use-by or expiration dates. The DCC confirmed that all food items should be labeled with these dates, but the dietary staff member responsible for the egg salad forgot to do so. The task of checking expiration dates was not completed due to the absence of a DM, and the DCC had not yet checked the dates upon starting her shift.
Failure to Notify Resident Representative of Wound Deterioration
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of multiple documented changes in condition related to deteriorating lower extremity wounds. A resident admitted with acute osteomyelitis of the left ankle and foot had a history and physical dated October 7, 2025, indicating a change in cognitive function that affected her ability to make informed medical decisions, and her grandson was designated as the responsible party for medical decision-making. Review of the resident’s change of condition (COC) documentation from November through December 2025 showed that on November 21, 2025, staff noted deterioration of right and left heel diabetic wounds during wound rounds, with the primary care provider notified and the resident updated. On December 5, 2025, the right heel diabetic wound was again documented as deteriorating by a wound specialist, with updated treatment orders and a notation that the family or resident was notified, marked as “self.” On December 8, 2025, during wound care, dark brown/purple discoloration was observed on the right dorsum of the foot, the MD was notified, and documentation again indicated the family or resident was notified, marked as “self.” There was no documented evidence that the resident’s representative was notified of these changes in condition on November 21, December 5, and December 8, 2025. During an interview and concurrent record review, the LVN who completed the COC entries stated she recalled providing wound care and completing the COCs, and explained that the process for communicating a change in condition was to notify the resident, family or resident representative, and the primary care and wound care physicians. She acknowledged that on the three dates in question she notified only the resident and did not notify the resident’s representative, and stated she should have communicated the changes to the representative. In a separate interview and record review, the DON confirmed that the resident experienced changes in condition on those dates and that the resident’s representative should have been notified, consistent with the facility’s policy titled “Change in a Resident’s Condition or Status,” which requires the nurse to notify the resident’s representative and document information related to significant changes in the resident’s condition or status.
Failure to Implement Effective Wandering Interventions Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent resident-to-resident physical altercations, specifically related to a resident with known wandering and impulse control issues. One resident with intact decision-making capacity reported that another resident entered his room, attempted to take his cup and blanket, and then punched him twice in the face when he tried to stop the behavior. As a result, he sustained swelling of the right upper lip and a scratch on the nose. He stated that he pressed his call light but did not receive an immediate staff response and had to yell for help before staff intervened. The resident who initiated the altercation had documented diagnoses of delusional disorder and impulse disorder and was noted in the medical record to be unable to make decisions. The care plan for this resident, dated several months prior, identified risk for elopement and wandering related to altered cognitive status and forgetfulness, with a goal that the resident’s safety would not be endangered by these behaviors. However, the care plan only contained a general intervention for elopement/wandering and did not specify the type or level of supervision or monitoring needed to address the resident’s wandering behavior. A physician’s order in the eMAR directed staff to monitor this resident for episodes of impulse control disorder manifested by wandering and danger to self and others, but there was no documentation that such behaviors were monitored or addressed on the date of the incident. Staff interviews further showed gaps in implementation and communication of interventions for the wandering resident. The DON acknowledged that the care plan for elopement and wandering lacked specific prevention interventions and that there was no CNA documentation that monitoring of wandering behavior had been completed. The DON also stated that the internal communication board did not list this resident as at risk for wandering prior to the incident. Nursing staff, including an LVN and the charge RN on duty at the time of the altercation, reported awareness of the resident’s history of wandering into other residents’ rooms and occasional aggression, but were unaware of any written interventions to address this behavior. A CNA assigned to the wandering resident on the evening of the incident stated that the resident frequently wandered and needed to be checked every 15 to 30 minutes, and that while she was on her lunch break, no one was assigned to check on the resident, during which time the altercation occurred.
Failure to Assess Residents Before Allowing Bedside Medication Self-Administration
Penalty
Summary
The facility failed to ensure that a self-administration assessment was completed before two residents kept medications at their bedsides and used them on their own. Resident 146 was observed in bed with an opened bottle of 3% hydrogen peroxide on the bedside table. She stated her daughter bought it from a drug store and brought it to the facility so she could rinse her mouth after eating, and she said she had used it that morning and had kept it at her bedside for several days. She also stated that staff had not asked her about it. An LVN who entered the room stated she was not aware of any medication at the bedside and was unsure whether Resident 146 had been evaluated for self-administration. The record showed the resident was cognitively intact with a BIMS score of 14 and had capacity to make decisions, but there was no documentation of a medication self-administration assessment. Resident 2 was also observed in his room with multiple open OTC medications at the bedside, including hydrogen peroxide topical solution, triple antibiotic ointment, antifungal powder, and medicated body powder. He stated he had ordered the medications three weeks earlier and had last used the antibiotic ointment two weeks earlier for a pimple on his right cheek, and that he had kept the medications on top of his drawer without anyone asking about them. A CNA stated licensed nurses were supposed to check whether residents were safe to keep medications at the bedside. An LVN stated she was not aware the resident had been ordering and storing medications in his room and said residents were not allowed to keep medications at the bedside without a self-administration assessment. The resident’s record showed diagnoses including atrial fibrillation and low back pain, a BIMS score of 15, and no documentation that he had been assessed for medication self-administration. The DON stated that without a self-administration assessment, Residents 2 and 146 should not have had medications at the bedside and that staff were expected to inspect rooms for bedside medications and report them right away. The facility policy stated residents may self-administer medications only if the IDT assesses cognitive and physical abilities, determines self-administration is safe and clinically appropriate, and documents that the resident can safely and securely store the medications in the medical record and care plan.
Verbal Abuse Toward a Resident
Penalty
Summary
The facility failed to protect Resident 127 from verbal abuse when an LVN directed inappropriate and derogatory language toward the resident. Resident 127 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and his history and physical dated July 17, 2025 indicated he had the capacity to understand and make decisions. During an interview, Resident 127 stated that LVN 3 called him a vulgar name while telling him to come get his medications, and he said he was shocked and viewed the interaction as unprofessional. LVN 4 confirmed hearing LVN 3 say something inappropriate to Resident 127 while at the nurse's station. The DON stated the resident reported that a nurse had called him a vulgar name and that staff were expected to speak respectfully to all residents. During interview, LVN 3 acknowledged she had been informed of the allegation and stated she and Resident 127 had good rapport and would joke around using inappropriate language, sexual remarks, and cuss words; she said she could have told him to come on and let her give his meds. Resident 127 later stated he felt the language used was inappropriate and derogatory and considered it verbal abuse.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to Resident 1 or the resident representative at the time of transfer to an acute care hospital. Resident 1 was admitted with diagnoses including muscle wasting and atrophy, and the record showed the resident was sent to the hospital for hernia and abdominal pain because needs could not be met at the facility. The admission agreement stated that if the resident was transferred to an acute hospital for seven days or less, the facility would notify the resident or representative that it was willing to hold the bed and that they had 24 hours to respond. The Notice of Proposed Transfer/Discharge contained sections for resident and representative notification and verification of receipt of the State Bed Hold Notice, but those sections were blank, and there was no documented evidence that a written bed hold notice was provided after the transfer. During interviews, the SSD stated he spoke with the ex-wife and that a discharge notice was provided, while also stating nursing staff were responsible for providing the bed hold notice to the resident. The LVN stated there was no other form used to indicate a resident had a bed hold or that the resident or representative had been notified, and the DON and FA both stated the written notice should have been sent and documented, but it was not.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was provided in a timely manner for one resident who was unable to perform activities of daily living independently. The resident was admitted with a diagnosis of fracture of the right acetabulum, had fluctuating capacity to make decisions, and was assessed as dependent for toilet transfer. The care plan identified the resident as frequently incontinent of bladder and directed staff to change disposable briefs every 2 hours and as needed. During a concurrent observation and interview, the resident stated she used her call light during the night shift to request a brief change, but after a staff member turned off the call light and did not return, she activated it again without response. She reported remaining soaked in urine from her shoulders to her toes, with her pad and blanket saturated, until her responsible party called the nurse's station and staff then provided incontinence care the following morning. Interviews with staff showed the CNA changed the resident's brief around 11:30 p.m. and did not check or change it again until about 4:30 a.m., while the LVN stated she did not inform the CNA that the resident needed brief checks every two hours per the care plan.
Failure to Implement Ordered Nutritional Interventions
Penalty
Summary
The facility failed to ensure physician-ordered nutritional interventions were implemented for two residents reviewed for nutrition. One resident had diagnoses including a stage 4 pressure ulcer and an August physician order to add one extra egg at breakfast for the Nutrition and Decubitus Protocol. The resident’s care plan identified nutritional risk and directed staff to provide diet per physician order, but the September meal ticket did not include the extra egg. During a breakfast tray line observation, the Dietary Service Supervisor stated the tray did not include the ordered egg and that dietary staff had not been notified of the order by nursing. A second resident had diagnoses including unspecified protein calorie malnutrition and a physician order for Boost Glucose Control, one carton twice daily, to be given with med pass. During medication administration observation, an LVN stated she had finished giving medications and acknowledged that she should have prepared and administered the ordered supplement during med pass. The facility policy on accepting, transcribing, and implementing physician orders stated licensed nursing personnel would ensure written telephone and verbal orders were implemented.
Failure to Document and Monitor a Peripheral IV
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids for a resident when needed was not maintained for a resident admitted with diabetes and a UTI. The resident’s record showed a physician order for a 1L NS IV bolus for elevated blood sugar, and a nurse documented inserting a 22g IV catheter in the right wrist and starting the bolus. However, there was no documented evidence that a physician’s order was in place prior to PIV insertion, and there was no documentation of assessment or monitoring of the IV site from September 13 through September 23, 2025. The resident was observed with a PIV dressing on the right hand dated September 13, 2025, with an illegible time and initials, and stated he was unsure how long he had the PIV in place and did not want to accidentally pull it out. An LVN stated the dressing was over 7 days old and should have been changed per facility policy, and that there was no way to confirm PIV site assessments were completed. An RN stated he inserted the PIV and forgot to verify whether a physician order was in place for the PIV insertion, and that he should have initiated a care plan and monitoring for the PIV. The DON stated the facility had a standard order set for IV monitoring that was not followed because the physician order was not entered completely, and that documentation should have been present in the MAR and/or progress note to confirm assessments were completed.
Dialysis Pressure Dressing Not Removed as Ordered
Penalty
Summary
The facility failed to ensure that Resident 148’s dialysis pressure dressing was removed two hours after arrival from dialysis as ordered. On September 25, 2025, the resident was observed lying in bed with the dialysis access site on the left upper arm still covered with a pressure dressing. The resident stated the dressing was supposed to have been removed the previous day when he returned from dialysis, but it was forgotten. Resident 148 was admitted with end stage renal disease and had a history and physical dated September 12, 2025, indicating he had the capacity to understand and make decisions. The order summary for September 2025 directed dialysis on Monday, Wednesday, and Friday and to remove the bandage two hours after arrival from dialysis every shift. During interview, an LVN stated the pressure dressing should have been removed within two hours of the resident’s return from the dialysis clinic to prevent infection, and the DON stated nursing staff should have removed it as ordered to prevent further complications such as clotting and infection.
Unlabeled Sore Throat Spray Found in Medication Cart
Penalty
Summary
A bottle of Phenol 1.4% oral relief sore throat spray was found in the East Station medication cart unlabeled and available for use. The bottle was half-full, the cap was broken, and there was no resident name, identifier, or pharmacy label on it. LVN 9 stated she could not identify which resident the spray belonged to or when it was last used, and she was unsure how long it had been in the cart. She also stated that the bottle had been opened and used because half of the fluid remained visible. During interview, LVN 9 stated it was the medication nurse’s responsibility to check the carts so there were no unlabeled or expired medications available for use. She stated she normally checks her carts at the beginning of each shift but did not notice the bottle, and that unidentified items should be discarded and not kept in the carts without a label. A review of the facility policy titled Storage of Medications stated that drugs and biologicals must be stored in a safe, secure, and orderly manner, nursing staff are responsible for maintaining medication storage and preparation areas, and resident medications must be assigned to an individual cubicle, drawer, or other holding area to prevent mixing medications of several residents.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to honor a resident’s food preference by serving milk despite a documented dislike and order not to serve milk to drink. Resident 120 stated she was prescribed a regular diet with large portions and repeatedly told staff she did not like milk, and a large note on her table read, “NO MILK PLEASE.” The meal ticket listed milk for cereal only, 4 fl oz milk, and an order for 8 fl oz milk 2%, while also noting “Dislikes. Milk to drink.” Resident 120 was admitted with diagnoses including a right femur fracture and diverticulosis of the large intestine. Her MDS showed a BIMS score of 14, and the dietary interview documented a dislike of cold cereal. The order summary report stated she was on an NAS diet with regular texture and thin consistency, with “Dislikes milk. Do not serve milk to drink.” Despite this, a CNA was observed serving milk to the resident in her room, and the resident stated she asked staff to remove it from her tray. The RD and DS both stated the resident should not have been served milk, and the DS noted the meal ticket still listed 8 fl oz of milk 2% even though the resident should not have received milk with meals.
Fortified Diets Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that physician-ordered fortified diets were provided as prescribed for two residents reviewed for nutrition, Resident 98 and Resident 125. The report states that the facility’s undated Fortified Menu Plan called for an additional 300-400 calories and 3-4 grams of protein per day, including an extra 1 oz of gravy or sauce with lunch and dinner meat items. During a lunch tray line observation on September 24, 2025, the meal trays for Resident 98 and Resident 125 were not provided with the required extra one ounce of gravy. During a concurrent observation and interview, the Dietary Aid stated the cart containing meals for Residents 98 and 125 had been checked and was ready for delivery, and the Dietary Supervisor compared the trays with the printed meal tickets and confirmed that both trays did not contain the required extra ounce of gravy. The Dietary Supervisor stated that residents on a fortified diet must receive the added gravy per physician order and that additional protein assists with weight gain and wound healing. Resident 98’s record showed diagnoses including a stage 4 pressure ulcer and protein calorie malnutrition, with a care plan intervention for a fortified diet and a physician order for a fortified diet dated August 23, 2025. Resident 125’s record showed a diagnosis of generalized weakness and a care plan intervention for a fortified diet.
PPE Cart Not Fully Stocked for Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that Resident 8’s PPE cart did not contain disposable gowns. Resident 8 had been re-admitted to the facility with diagnoses including ESBL infection and was on contact precautions. During a concurrent observation and interview with the Housekeeping Supervisor, the PPE cart for Resident 8 was found missing disposable gowns, and the HS stated she was responsible for stocking the PPE carts and that the cart should contain the proper PPE required for staff to prevent infection transmission. During later interviews, the Infection Preventionist stated that Resident 8 was on contact precautions and that the isolation cart should have disposable equipment available for staff to properly perform their duties. The DON stated that for contact precautions, required PPE including gowns, gloves, and masks must be stocked and available for staff to use to prevent infection transmission, and that any staff member who observed the isolation cart was not fully stocked should restock it. The facility policy titled Infection Prevention and Control Program stated that important facets of infection prevention include implementing appropriate enhanced barrier and transmission-based precautions when necessary.
Failure to Provide Adequate Hoyer Lifts for Resident Transfers
Penalty
Summary
The facility failed to make reasonable accommodations to meet the needs and preferences of two residents who required a Hoyer lift for transfers. Both residents had medical conditions necessitating total assistance with transfers: one with morbid obesity and chronic pain syndrome, and the other with hemiplegia and hemiparesis following a stroke. Observations, interviews, and record reviews revealed that there were only three functioning Hoyer lifts available for over 100 residents, with at least ten residents in one station alone requiring the device. Staff and residents reported frequent delays in transfers due to the limited number of lifts, resulting in residents having to wait for extended periods or missing scheduled activities. Resident A reported disruptions to his established daily routine, including delays in being transferred to and from bed, which sometimes resulted in not being up at his preferred time. Resident B experienced missed activities, specifically being unable to attend scheduled smoking times on multiple occasions due to the unavailability of a Hoyer lift. Staff interviews confirmed that these delays were common and directly related to the insufficient number of mechanical lifts. Facility policies required accommodation of resident needs and preferences to the extent possible, but the lack of adequate equipment led to unmet care plans and resident dissatisfaction.
Failure to Monitor Resident Following DVT Diagnosis
Penalty
Summary
The facility failed to assess and monitor a resident for signs and symptoms of circulatory insufficiency in the right lower leg after the resident tested positive for deep vein thrombosis (DVT). The resident, who had a history of diabetes, end stage renal disease, and was on hemodialysis, was admitted with a diagnosis of DVT in the right popliteal vein. The care plan included interventions to monitor for swelling, pain, discoloration, and changes in the ability to move the lower extremity. However, there was no documentation that these assessments or monitoring were performed following the DVT diagnosis. Interviews with nursing staff and the DON confirmed that standard care and facility protocol required monitoring for pain, swelling, temperature changes, skin discoloration, and checking pedal pulses after a DVT diagnosis. Despite this, there was no evidence in the resident's records that such monitoring occurred. The lack of assessment and documentation was identified after the resident developed necrosis of the right foot, leading to hospital admission with a diagnosis of gangrene affecting multiple toes. The DON acknowledged the absence of a specific DVT management policy but stated that monitoring was an expected standard of practice.
Failure to Accurately Document Skin Changes and Wound Care
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurate and complete in accordance with accepted professional standards and practices. Specifically, for one resident with a history of diabetes and fluctuating decision-making capacity, the nursing weekly summary and skin evaluations did not reflect significant skin changes that occurred over a ten-day period. Documentation showed that the resident was seen by wound care specialists who identified and reclassified a sacral pressure wound and noted new deep tissue injuries (DTIs) on the right heel and right lateral malleolus, with new treatment orders issued. However, there were no corresponding skin and wound evaluations or updated measurements recorded on the dates when these changes were identified, as required by facility protocol. Additionally, the nursing weekly summaries during this period consistently indicated that there were no new skin changes or breakdowns, despite the documented findings and new treatment orders from the wound care team. Interviews with the LVN and DON confirmed that skin evaluations and documentation should have been completed to reflect the changes in the resident's condition, including wound descriptions and measurements. The facility's own policy required that all changes in a resident's medical condition be documented in the clinical record, but this was not done, resulting in incomplete and inaccurate medical records for the resident.
Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH) as required by policy and regulation. On the evening of March 28, 2025, a resident (who is deaf and nonspeaking, with severe cognitive impairment) was allegedly struck on the back of the head by another resident with schizoaffective disorder and moderate cognitive impairment. The incident was witnessed by a third resident, who reported it to the nurse's station, where both an LVN and an RN were present. Documentation in the medical record confirmed the incident and subsequent monitoring of the resident, but there was no evidence that the required report to CDPH or the Ombudsman was made at that time. Interviews with staff revealed that the LVN informed the RN of the incident and relied on the RN for direction, but no further action was taken to report the abuse within the mandated timeframe. The RN assumed the LVN would handle the reporting, but did not follow up to ensure it was completed. The Director of Nursing was not informed of the incident until the following morning, well beyond the two-hour reporting window. Facility policy clearly states that all allegations of abuse must be reported to the appropriate authorities immediately, and within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the alleged abuse in a timely manner was confirmed through record review, staff interviews, and review of facility policy. The delay in reporting had the potential to place the affected resident at continued risk of abuse and negatively impact her emotional and psychosocial well-being, as noted in the findings.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report a significant injury of unknown source for a resident, which involved a total right shoulder prosthesis dislocation. This incident was not reported to the California Department of Public Health (CDPH), police, or the Ombudsman within the required two-hour timeframe after the facility became aware of the injury. The resident, who had fluctuating capacity to make medical decisions, was admitted to the facility and later experienced pain and swelling in the right shoulder, leading to an X-ray that revealed the dislocation. Despite the facility's policy requiring immediate reporting of such injuries to rule out abuse, the incident was not reported as mandated. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the injury was of unknown source and should have been reported promptly to ensure resident safety and prevent further harm. The facility's policy on reporting injuries of unknown origin was not followed, as the injury was not communicated to the necessary authorities. This oversight had the potential to impact the resident's physical, emotional, and psychosocial well-being, as the injury could have been related to abuse.
Failure to Investigate Prosthesis Dislocation
Penalty
Summary
The facility failed to investigate the dislocation of a right shoulder prosthesis for a resident, which was identified as an injury of unknown source. The resident was admitted to the facility with no initial signs of limited range of motion, edema, or skin concerns. However, six days after admission, the resident complained of pain and swelling in the right shoulder, leading to an X-ray that revealed a dislodgement of the glenoid fossa portion of the prosthesis and a total shoulder dislocation. The resident was subsequently sent to the emergency room for further evaluation. Interviews with the Registered Nurse and the Director of Nursing revealed that the facility did not conduct an investigation into the cause of the prosthesis dislocation, despite the facility's policy requiring investigations for injuries of unknown origin to rule out possible abuse. The Director of Nursing acknowledged that the incident should have been investigated, as the facility was unaware of how the dislocation occurred, and there were no documented falls or injuries prior to the event. The facility's policy mandates that all reports of resident abuse, including injuries of unknown origin, be thoroughly investigated and reported to the appropriate agencies within five working days.
Failure to Provide Transfer Notice to Resident and Ombudsman
Penalty
Summary
The facility failed to provide a written copy of the transfer or discharge notice to a resident and their representative, as well as to the LTC Ombudsman, for a resident who was transferred to a hospital. The resident, who had fluctuating capacity to make medical decisions, was transferred due to a dislodgement and dislocation of a right shoulder prosthesis. Despite the facility's policy requiring that such notices be provided as soon as practicable, there was no documentation indicating that the resident received a written notice of the transfer or discharge. Additionally, the facility did not send a copy of the transfer or discharge notice to the LTC Ombudsman, which is required to ensure advocacy and oversight of the resident's discharge plan. The Director of Nursing and the Social Service Director acknowledged that the notice was not sent to the Ombudsman, as required by the facility's policy. The Social Service Director mistakenly believed that the hospital would send the notice, but admitted that it was his responsibility to ensure the Ombudsman was informed.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to provide scheduled showers and bed baths for a resident, identified as Resident A, who was admitted with bilateral lower extremities contractures and a history of cerebrovascular accident with left-sided deficits. Resident A's care plan indicated a risk for decline in activities of daily living (ADLs) and required assistance due to hemiplegia, hemiparesis, muscle weakness, and atrophy. Despite this, documentation revealed that on several scheduled shower days in July and August 2024, Resident A received bed baths instead of showers, and on one occasion, neither a shower nor a bed bath was provided. There was no documentation indicating that Resident A refused showers on these days. Interviews with facility staff, including CNAs and an LVN, confirmed that Resident A was dependent on assistance for all ADLs and preferred bed baths. The Director of Nursing (DON) acknowledged that Resident A had a scheduled shower routine and that refusals should be documented and included in the care plan. However, the DON admitted that there were instances when Resident A was not provided with either a shower or a bed bath, contrary to the facility's protocol. This lack of adherence to the care plan and documentation requirements led to the deficiency identified in the report.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident A, was repositioned and turned every two hours, which resulted in the development of a pressure ulcer. Resident A was admitted with diagnoses including hemiplegia and hemiparesis on the left side of the body, and was assessed as being at high risk for pressure ulcers according to the Braden Scale. The resident was completely immobile and required moderate to maximum assistance for movement. Despite these needs, the facility did not maintain a log or documentation to confirm that Resident A was repositioned as required. Interviews with facility staff, including a CNA and the Treatment Nurse, revealed that there was no documentation or schedule in place to track when Resident A was last turned. The Director of Nursing acknowledged gaps in the documentation and stated that if repositioning was not documented, it was assumed not to have been done. The facility's policy required repositioning every two hours for residents at risk of pressure ulcers, but this was not adhered to, leading to the progression of Resident A's pressure ulcer from Stage I to Stage II.
Failure to Timely Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property, a form of financial abuse, to the California Department of Public Health (CDPH) within the required two-hour timeframe. This incident involved a resident who reported missing finances, including a bank card and approximately $600, to a Social Service Assistant (SSA) on October 9, 2024, at around 2 p.m. The SSA did not report the incident to CDPH until October 10, 2024, at 3:16 p.m., which was 25 hours after the facility was made aware of the allegation. Both the SSA and the Director of Nursing (DON) acknowledged that the incident should have been reported within two hours to ensure the resident's safety and prevent further abuse. The facility's policy, titled 'Abuse Prevention,' mandates that all employees are required to report any allegations of abuse, including misappropriation of resident property, within two hours, even if there is no reasonable suspicion. The DON confirmed that all staff are mandated reporters and that any type of abuse, including financial abuse, should be reported promptly to CDPH, the ombudsman, and the police. The failure to adhere to this policy resulted in a delay in reporting the financial abuse allegation, potentially affecting the resident's emotional and psychosocial well-being.
Failure to Monitor Resident After Financial Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident after an allegation of financial abuse, which had the potential to affect the resident's emotional and psychosocial wellbeing. The incident was reported on October 9, 2024, when the resident informed the social services that a family member had taken their wallet, resulting in missing cash and cards. A police report was filed, but the resident was not assessed or monitored for any negative psychosocial effects following the allegation. Interviews with the Social Service Director and the Director of Nursing revealed that the facility's standard practice was to monitor residents for 72 hours after any abuse allegations to assess for emotional distress and changes in behavior. However, this practice was not followed for the resident in question, and there was no specific policy in place to ensure such monitoring. The facility's existing policy on abuse prevention did not explicitly address the need for a 72-hour monitoring period, leading to a lapse in care for the resident involved in the financial abuse allegation.
Infection Control Deficiency Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, as observed during a survey. A Physical Therapy Assistant (PTA) was seen not performing hand hygiene upon exiting and entering the rooms of two residents who were under Droplet Precaution, a type of transmission-based precaution (TBP). The PTA acknowledged the requirement to wash hands before entering and upon exiting these rooms to prevent the spread of pathogens and infections but admitted to not doing so. The facility's signage and policy on Droplet Precaution and Handwashing/Hand Hygiene clearly indicated the necessity of hand hygiene as a primary method to prevent the spread of infections. The Infection Preventionist (IP) confirmed that staff should perform hand hygiene when entering and exiting a resident's room, emphasizing its importance in preventing the spread of infection and disease. The failure of the PTA to adhere to these protocols was identified as a deficiency in the facility's infection control practices.
Failure to Notify Family of Grievance Investigation Results
Penalty
Summary
The facility failed to notify a resident's family member of the findings and results of a grievance investigation. The family member had filed a complaint regarding the resident being left unattended in a shower with cold running water. Despite the complaint being received and acknowledged by the facility, there was no documented evidence that the family member was informed of the investigation's outcome. The resident, who had severe cognitive impairment, was unable to advocate for themselves, making the family member's involvement crucial. Interviews with facility staff, including the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), revealed that the investigation was conducted but not documented on a grievance form, nor were the findings communicated to the family member. The facility's grievance policy requires that grievances be investigated and the findings communicated to the complainant within five working days, which was not adhered to in this case. This oversight could lead to ongoing dissatisfaction from the family member, as they were left unaware of whether the complaint was addressed.
Incomplete Discharge Notice for Resident
Penalty
Summary
The facility failed to provide a complete written notice of transfer or discharge for a resident, which is a requirement for ensuring residents are informed about their future living arrangements. The deficiency was identified when a resident, who had been issued a discharge notice, stated that he could not read the notice due to poor eyesight and was unaware of his discharge location. The resident's record indicated that he was advised by the Ombudsman and CDP not to sign the notice but to appeal it instead. The Notice of Proposed Transfer/Discharge was found to be incomplete, lacking both the effective date of transfer/discharge and the discharge location. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) revealed that the SSD had provided the incomplete notice to the resident. The SSD admitted to leaving the discharge date and location blank because the resident had not yet decided on his next living arrangement, whether it would be a board and care or assisted living. The facility's policy requires that the discharge location be documented, but this was not adhered to in this case, leading to the deficiency.
Failure to Follow-Up on Ophthalmology Consult
Penalty
Summary
The facility failed to ensure a follow-up ophthalmology consult was provided for a resident, which increased the risk of the resident not receiving necessary care for their medical condition. The resident, who was admitted with diagnoses including Type II Diabetes Mellitus and Essential Hypertension, expressed the need to see an ophthalmologist, but reported that the facility had not taken any action. The resident's records indicated a need for an eye health and vision consult with follow-up treatment, as documented in the Order Summary Report and Care Plan. However, there was no documentation of a follow-up by the Social Service Director (SSD) for a consult with an optometrist or ophthalmologist from February to August 2024. Interviews with the Director of Nursing (DON) and the SSD revealed that the SSD did not make a follow-up on the resident's consult with the optometrist or ophthalmologist. The DON stated that the SSD should have ensured the follow-up and scheduled the appointment if the resident needed to be seen by an ophthalmologist. The facility's job description for the SSD emphasized the responsibility to assist residents in achieving the highest practicable level of self-care and well-being, which includes providing medically related social services.
Narcotic Medication Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper accountability for narcotic pain medications for 20 residents, leading to potential medication discrepancies and possible diversion of controlled substances. The report highlights multiple instances where licensed nurses signed out narcotic medications from the medication count sheet but failed to document their administration in the electronic Medication Administration Record (eMAR). This lack of documentation was observed across various residents, including those with conditions such as muscle wasting, chronic pain, and severe pain management needs. For example, Resident 58, who was admitted with diagnoses including muscle wasting and polyneuropathy, had several doses of Oxycodone-Acetaminophen signed out by nurses without corresponding documentation in the eMAR. Similarly, Resident 65, with necrotizing fasciitis and polyneuropathy, had multiple instances where Oxycodone-Acetaminophen was signed out but not documented as administered. These discrepancies were confirmed through interviews with the involved Licensed Vocational Nurses (LVNs), who acknowledged the failure to document the administration of these medications. The report further details similar issues with other residents, such as Resident 19, whose hydrocodone/acetaminophen doses were inconsistently documented, and Resident 83, who had numerous doses of hydrocodone-acetaminophen signed out without eMAR documentation. The facility's process for administering PRN narcotic pain medications requires nurses to sign out the medication, administer it, and document the administration in the eMAR. However, this process was not consistently followed, leading to significant gaps in medication administration records and raising concerns about potential medication errors and resident safety.
Facility Lacks Qualified Social Worker for 132-Bed Capacity
Penalty
Summary
The facility, which has a licensed capacity of 132 beds, failed to employ a full-time qualified social worker, as required for facilities with more than 120 beds. During an interview and record review, it was revealed that the Social Service Director (SSD) had been employed for over a year but did not possess a bachelor's degree in social work or a related human services field, nor was she a licensed medical social worker. Furthermore, the SSD was not supervised by a qualified social worker, which is a requirement for her role. The SSD admitted to not being qualified to perform psychosocial assessments, which could potentially lead to physical and psychosocial distress among residents. The facility's job description for social service staff, dated March 2017, clearly stated the requirement for a bachelor's degree in social work or human services. Additionally, the facility's policy and procedure document from October 2010 specified that the Director of Social Services should be a qualified social worker to provide medically related social services, ensuring residents attain or maintain their highest practicable physical, mental, or psychosocial well-being. The Administrator confirmed that the SSD was not qualified to fulfill the responsibilities of a social worker for the facility, highlighting a significant deficiency in meeting the required standards for resident care.
Failure in Narcotic Accountability and Pain Assessment
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed issues related to narcotic medication accountability and pain assessment. During QAPI meetings held in February and April 2024, concerns were raised about narcotic medications being signed out by Licensed Nurses (LNs) on the narcotic count sheet but not documented as administered in the Electronic Medication Administration Record (e-MAR). Additionally, it was noted that pain assessments, monitoring, and evaluations were not being conducted by LNs after administering pain medication. Despite these issues being identified, the facility did not monitor or re-evaluate the effectiveness of the interventions implemented to address them. The Director of Nursing (DON) acknowledged that the facility should have re-evaluated and monitored these interventions to ensure the safety and accountability of narcotic medications and to manage residents' pain effectively. This oversight had the potential to lead to the diversion of controlled medications and unrelieved pain among residents, which could compromise their overall health and wellbeing.
Delayed Call Light Response and Meal Service Issues
Penalty
Summary
The facility failed to ensure the residents' rights were promoted and respected, as evidenced by the delayed response to call lights for several residents. Residents 23, 29, 59, 106, and 126 reported that their call lights were not answered promptly, leading to potential risks of not receiving timely care. During interviews, these residents expressed concerns about waiting times ranging from 10 to 30 minutes for assistance after activating their call lights. The issue was previously discussed in Resident Council meetings but remained unresolved. Staff interviews confirmed the expectation for prompt response to call lights, yet the facility's policy was not adhered to, as evidenced by the residents' experiences. Additionally, the facility failed to serve meals simultaneously to residents dining together, impacting Resident 112's dignity and meal intake. Resident 112 observed that Resident 41 consistently received her meal first, causing Resident 112 to feel upset and left out. The Registered Dietitian acknowledged that both residents should have received their meals at the same time, and the facility's policy emphasized treating residents with dignity and respect. This oversight in meal service had the potential to affect Resident 112's enjoyment and intake of her meals.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for the safe self-administration of medication for three residents. One resident had a pink medication pill left on their overbed table by a nurse, which the resident did not take because they were sleepy. This resident had no documented self-administration assessment in their medical record. Another resident had an opened bottle of eyedrops on their overbed table, which they used to relieve irritation and itchiness, but there was no physician's order or self-administration assessment documented. A third resident had an opened bottle of dietary supplements on their overbed table, which they took daily with the staff's awareness, yet there was no physician's order or self-administration assessment documented. The Licensed Vocational Nurses (LVNs) involved acknowledged the lack of assessments and physician orders for the medications and supplements found at the residents' bedsides. The Director of Nursing (DON) stated that the facility's policy and procedure require medications to be administered according to physician orders and that self-administration assessments should be conducted to ensure safety. The facility's policy also specifies that medications should not be left with residents unless they have been approved for self-administration, and any unauthorized medications found at the bedside should be turned over to the nurse in charge.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to provide education and resources for Advance Directives (AD) to 15 out of 25 residents, as well as their Resident Representatives (RP). This deficiency was identified through interviews and record reviews, revealing that residents and their representatives were not informed about ADs, which are crucial for understanding and documenting a resident's wishes regarding medical treatment. The lack of documentation and education was evident in the medical records of the affected residents. Several residents, including those with dementia and Alzheimer's disease, were found to have no documented evidence of receiving information or education about ADs. For instance, Resident 15, who was diagnosed with dementia, did not have the capacity to make decisions, yet there was no record of AD education provided to the resident or their RP. Similarly, Resident 60, who had the capacity to make decisions, also lacked documentation of AD education, despite the resident's ability to understand and make informed choices. The Social Service Director (SSD) acknowledged during interviews that she did not provide the necessary AD education or follow-up to the residents and their representatives. This oversight was consistent across multiple cases, where residents either had the capacity to make decisions or were unable to do so due to cognitive impairments. The facility's policy required that residents be provided with written information about their right to formulate an AD upon admission, but this was not adhered to, leading to the deficiency.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to ensure proper pain management for 20 residents who required such services. The deficiency was identified through observations, interviews, and record reviews, revealing that licensed nurses did not conduct pain assessments prior to administering PRN narcotic pain medications, nor did they evaluate the effectiveness of the medications after administration. This lack of documentation and assessment was consistent across multiple residents, including those with conditions such as osteomyelitis, diverticulosis, muscle wasting, atrophy, polyneuropathy, necrotizing fasciitis, and chronic pain syndrome. For instance, Resident 18, who was admitted with osteomyelitis and diverticulosis, had multiple doses of Tramadol administered without prior pain assessment or post-administration evaluation. Similarly, Resident 58, diagnosed with muscle wasting and polyneuropathy, received oxycodone-acetaminophen without documented pain assessments or evaluations of the medication's effectiveness. Interviews with licensed vocational nurses confirmed the absence of necessary documentation and assessments, acknowledging the failure to follow the facility's pain management protocols. The deficiency extended to other residents, such as Resident 65 with necrotizing fasciitis, Resident 19 with knee pain, and Resident 278 with idiopathic neuropathy, all of whom received narcotic pain medications without proper assessments. The lack of documentation and evaluation potentially compromised the residents' pain management, as the facility's process for administering PRN narcotic pain medications was not adhered to, placing residents at risk of experiencing unrelieved and unmanaged pain.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that Food and Nutrition Service employees were able to carry out their functions safely and effectively, leading to several deficiencies. Firstly, multiple employees were observed not following the proper cleaning procedures for kitchen equipment. Specifically, Diet Aide 1 and Cook 1, among others, were using only sanitizer instead of first cleaning with detergent and then sanitizing, as per the facility's policy. This improper cleaning method was acknowledged by the Registered Dietitian and Dietary Service Supervisor, who confirmed that the correct procedure involves removing debris, washing with detergent, rinsing with water, and then sanitizing. Secondly, there was a lack of knowledge regarding the correct concentration of chlorine for the dish machine among the staff. Diet Aides 3 and 4 were observed checking the chlorine levels incorrectly, believing it should be 200 ppm, while the Dietary Service Supervisor clarified that the correct range is 50-100 ppm. This misunderstanding could lead to a strong chloride odor being transferred to clean kitchenware, as the concentration was too high. Lastly, Cook 1 did not follow the recipe for making pureed Bread Stuffing, resulting in overly salty servings for eight residents on a pureed diet. Instead of using milk as specified in the recipe, chicken broth was used, which combined with the bread stuffing, led to a high salt content. The Registered Dietitian confirmed that the failure to follow the recipe and sample the food before serving contributed to the issue.
Deficiency in Meal Service Temperature and Palatability
Penalty
Summary
The facility failed to adhere to its MEAL SERVICE policy, resulting in the provision of unappetizing food at inappropriate temperatures for nine residents. Observations and interviews revealed that residents consistently received cold meals, bland and tough meat, and vegetables that appeared old and reheated. Additionally, milk was served warm, and pureed meals were excessively salty due to improper recipe adjustments. These issues were confirmed through resident interviews and a test meal evaluation conducted with the Registered Dietitian (RD) and Dietary Services Supervisor (DSS). The test meal evaluation showed that food temperatures did not meet the facility's policy standards, with cold items being served warmer than recommended and hot items cooler than required. The RD acknowledged that the meal service process was inefficient, with meal carts left open during delivery, contributing to temperature discrepancies. The facility's policy specified that cold desserts should be served at 50 degrees Fahrenheit or less, milk and cold beverages at 45 degrees Fahrenheit or less, and vegetables at 120 degrees Fahrenheit or more, but these standards were not met during the survey.
Unsanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as evidenced by multiple observations of unsanitary conditions. Mold, dust, and hair were found in the walk-in refrigerator, with the Dietary Service Supervisor (DSS) confirming the presence of these contaminants. The Registered Dietitian (RD) verified the mold and dust, acknowledging that no staff member was assigned to clean the storage shelves in the refrigerator. Additionally, calcium buildup was observed on the hot water spout, which the RD stated could contaminate the hot water. Further observations revealed that wet plastic containers were improperly stacked with dry ones, which the DSS and RD agreed could promote microbial growth. Dust was also found on various kitchen equipment, including fans and shelves, which the DSS confirmed could contaminate food and clean dishes. Rust was observed on several pieces of equipment, such as storage shelves and a can opener base, with the RD stating that rust should not be present as it could cause cross-contamination. Chipped paint was noted on kitchen equipment, including a mixer and utensil hanger, which the RD indicated needed repair or replacement to prevent contamination. An unsanitary microwave was found in a pantry room, with black and brown particles inside, which the RN confirmed was an infection control issue. The facility's policies and procedures emphasized the importance of keeping equipment clean and free from corrosion, yet these standards were not met, posing a risk of foodborne illness to the residents.
Failure to Maintain Homelike Environment Due to Noise Disturbance
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 107, who complained about uncomfortable noise levels during sleeping hours. Resident 107, who was admitted with a diagnosis of hypotension, reported being disturbed by noise from another resident gardening early in the morning. This issue was documented in the resident's care plan and health status notes, indicating repeated complaints about the noise disrupting sleep. During an interview, the resident expressed being woken up early due to banging noises outside. A Licensed Vocational Nurse (LVN) confirmed that Resident 107 had made multiple complaints about the noise, emphasizing the need for a quiet and comfortable environment to promote rest. The Director of Nursing (DON) acknowledged the expectation for staff to maintain acceptable noise levels during sleeping hours, in line with the facility's policy on providing a homelike environment. The facility's policy, dated May 2017, highlighted the importance of person-centered care and maintaining comfortable noise levels.
Failure to Conduct Accurate Smoking Assessment for Resident
Penalty
Summary
The facility failed to conduct an accurate smoking assessment for a resident who uses electronic cigarettes. The resident, who was admitted with a diagnosis of pulmonary hypertension and was assessed as cognitively intact, was not properly evaluated for smoking habits. Despite the resident's admission record indicating no use of tobacco products, the resident admitted to smoking occasionally when stressed and was observed smoking in a non-designated area. Staff, including an LVN, were aware of the resident's smoking habits, as evidenced by the smell of smoke on the resident after gardening. The Activity Director, responsible for conducting smoking assessments, did not update the resident's smoking status despite being informed of the resident's smoking behavior. The facility's smoking policy, which includes guidelines for the use of electronic cigarettes, was not adhered to, as the resident was not assessed for safe handling of the device, nor was the use documented in the resident's care plan. This oversight had the potential to result in injury to the resident due to the risks associated with electronic cigarette use.
Failure to Adhere to Oxygen Therapy Order
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 52, by not adhering to the physician's order for oxygen therapy. Resident 52 was admitted with diagnoses involving the circulatory and respiratory systems and had a care plan indicating a potential for shortness of breath, with an intervention of oxygen at 2 liters per minute (LPM) via nasal cannula. However, during an observation and interview, it was found that Resident 52 was receiving oxygen at a flow rate of 4 LPM, which was not in accordance with the physician's order. Licensed Vocational Nurse (LVN) 1 confirmed that the oxygen flow rate was set incorrectly at 4 LPM instead of the prescribed 2 LPM. Registered Nurse (RN) 1 also acknowledged that the resident should have been receiving oxygen at the correct flow rate of 2 LPM, and that the increased flow rate had the potential to cause oxygen toxicity. The facility's policy on oxygen administration, dated October 2010, requires verification of the physician's order to ensure safe oxygen administration, which was not followed in this instance.
Failure in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for Resident 100, who was diagnosed with end-stage renal disease and required hemodialysis. On August 17, 2024, Resident 100 returned from a dialysis appointment, but there was no documented post-dialysis assessment conducted by a licensed nurse, as required by the facility's policy. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the assessment was not performed, which was necessary to monitor for potential dialysis complications. For Resident 23, the facility did not adhere to the physician's recommendation to discontinue fluid restriction, nor did it consistently monitor the resident's intake and output (I&O). Despite a physician's order dated June 21, 2024, to discontinue the fluid restriction, staff continued to restrict fluids, as indicated by the green dot sticker on the resident's door and the absence of a water pitcher at the bedside. The facility's records showed incomplete documentation of I&O monitoring, which was crucial for managing the resident's condition, given the diagnosis of end-stage renal disease and dependence on dialysis. Interviews with various staff members, including LVNs and CNAs, revealed a lack of communication and understanding regarding Resident 23's fluid management plan. The staff was unaware of the updated physician's orders and failed to document fluid intake accurately, as required by the facility's policy. This oversight in monitoring and documentation could lead to complications related to fluid imbalance, such as fluid overload or dehydration, for Resident 23.
Failure to Monitor Behavior for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to conduct behavior monitoring for a resident receiving Olanzapine, a medication used to treat schizophrenia. The resident, who was admitted with a diagnosis of schizophrenia, had a physician order for Olanzapine to manage auditory hallucinations. However, there was no documentation of behavior monitoring for these hallucinations in the resident's medical record. This lack of monitoring was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan addressing the resident's auditory hallucination behavior. The facility's policies on psychotropic medication use and care planning emphasize the importance of monitoring the effectiveness of medications and assessing for adverse consequences. Despite these policies, the resident's behavior was not monitored, and a care plan was not developed upon admission. The MDS coordinator also confirmed that licensed nurses should have been monitoring the resident's behavior to provide a basis for gradual dose reduction and potential medication adjustment by the doctor.
Improper Storage of Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued medications were stored properly and not readily available for use. During an observation in the Westside medication room, two vials of Lorazepam and an Insulin Lispro Injection pen, both marked as discontinued, were found in the medication room refrigerator. The Registered Nurse (RN) present stated that the facility's process for discontinued medication is to either give it to the resident at discharge or destroy it, and acknowledged that the medications should not have been left in the refrigerator. The RN was unsure why the medications were still there and mentioned that the night shift nurses should have discarded them. The Director of Nursing (DON) confirmed that discontinued medications should not be kept in the refrigerator and should be placed in a designated discontinue bin. The DON also stated that narcotic medications require destruction with two nurse signatures and that she, along with the pharmacist consultant, destroys medications once a month. The facility's policies indicate that discontinued or outdated drugs should be stored in a secured area until picked up by the pharmaceutical disposal service or pharmacy personnel, and that the facility shall not use discontinued, expired, or deteriorated drugs.
Failure to Implement Therapeutic Diet and Fortification for a Resident
Penalty
Summary
The facility failed to implement the therapeutic diet order prescribed by the attending physician for Resident 23, who was diagnosed with End-Stage Renal Disease and was on hemodialysis. Despite the physician's order specifying a No Added Salt (NAS) diet with certain food preferences and restrictions, the dietary department did not adhere to these instructions. Observations revealed that Resident 23 was served meals that included items he disliked, such as rice, which was explicitly mentioned in his dietary preferences as something to avoid. This inconsistency between the physician's diet order and the meals provided to Resident 23 was confirmed by the Registered Dietician (RD), who noted that the dietary department was not following the prescribed diet order. Additionally, the RD had recommended fortifying Resident 23's diet due to his poor appetite and weight loss, which was documented in the progress notes. However, there was no evidence that this recommendation was communicated to the physician or implemented. The RD stated that after making such a recommendation, the nursing staff should have followed up with the physician and the Director of Nursing (DON) to ensure the diet was fortified. The lack of follow-up on the RD's recommendation meant that Resident 23's diet was not adjusted to provide the extra nutrients he needed. The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department and be determined in accordance with the resident's preferences and treatment goals, was not adhered to in this case. The failure to implement the physician's diet order and the RD's recommendation for fortification had the potential to impact Resident 23's nutritional status and overall health.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a Certified Nursing Assistant (CNA) did not clean and disinfect a Hoyer lift before and after using it to transfer a resident. The CNA acknowledged the oversight and admitted that the lift should have been cleaned to prevent the spread of infection. The resident involved was on enhanced barrier precautions due to an Extended Spectrum Beta Lactamase (ESBL) infection, which requires specific measures to prevent transmission. In the second instance, a Registered Nurse (RN) did not wear personal protective equipment (PPE) while administering intravenous medication and changing the dressing of a resident with an ESBL infection. The RN admitted to not wearing PPE and acknowledged the necessity of doing so to prevent the spread of pathogens. The Infection Preventionist Nurse and the Director of Nursing confirmed that the staff should have followed the facility's infection control policy, which mandates the use of PPE and disinfection of equipment to prevent infection transmission.
Pest Control Deficiency Due to House Flies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of house flies in the kitchen and East activity room. On August 19, 2024, a house fly was observed landing on a cleaned plastic container in the kitchen's prep juice area during an observation and interview with the Dietary Service Supervisor (DSS). The DSS indicated that the delivery man had propped the door open, allowing the fly to enter. On August 20, 2024, another house fly was seen landing on a resident's served food in the East activity room during an observation and interview with Certified Nurse Assistant (CNA) 3. CNA 3 noted that the fly entered when residents opened the door to go outside to smoke. An interview with the Registered Dietitian (RD) on August 21, 2024, confirmed that house flies carry bacteria that could contaminate food, emphasizing that the facility should be free of pests. A review of the facility's Policy and Procedure (P&P) on pest control, revised in May 2008, stated that the facility should maintain an ongoing pest control program to keep the building free of insects. Additionally, the P&P on miscellaneous areas, dated 2023, highlighted that flies are carriers of disease and pose a threat to sanitation standards in the Food & Nutrition Services Department.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during wound care for a resident, leading to a potential risk of contamination. During an unannounced visit, a Treatment Nurse (TN) was observed providing wound care to a resident with a sacral wound. After removing her gloves, the TN did not perform hand hygiene before donning a new pair of gloves, which is against the facility's policy. This lapse occurred while the TN was handling wound care materials, including gauze and wound cleanser, for the resident's sacral wound. The resident involved had a complex medical history, including sepsis, osteomyelitis, hemiplegia, and a stage 4 pressure ulcer in the sacral region. The facility's policy requires hand hygiene to be performed after removing gloves and before putting on a new pair, which the TN acknowledged she failed to do. The Infection Preventionist confirmed that the staff should follow this protocol during wound care. The resident's medical records indicated ongoing treatment for the sacral pressure injury, which required careful handling to prevent infection.
Lack of Dedicated Dietary Manager Leads to Food Safety Oversight Issues
Penalty
Summary
The facility failed to employ a dedicated Dietary Manager (DM) to oversee the food and nutrition services, which led to a lack of oversight in food safety practices. During an unannounced visit, it was observed that the facility did not have a dedicated DM, and the duties were being shared among a Dietary Corporate Consultant (DCC), a Registered Dietitian (RD), and a DM from a sister facility. This arrangement resulted in lapses in food safety practices, such as missing use-by dates on food items in the refrigerator, including Italian dressing and egg salad. Interviews with staff revealed that the absence of a dedicated DM negatively impacted their work, as they experienced issues like running out of supplies. The DCC admitted that checking expiration dates was the DM's responsibility, but due to the lack of a dedicated DM, this task was not consistently performed. The Administrator confirmed the absence of a dedicated DM, highlighting the facility's failure to ensure proper staffing for food and nutrition services.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were stored in accordance with professional standards for food service safety. During an observation and interview on July 18, 2024, it was noted that certain food items in the refrigerator, such as Italian dressing and egg salad, were missing use-by or expiration dates. The Dietary Care Coordinator (DCC) acknowledged that all food items should have received, open, and use-by dates, and confirmed that the egg salad prepared that morning was missing an expiration date. The dietary staff member responsible for preparing the egg salad admitted to forgetting to label the container with an expiration date. Further interviews revealed that it was the responsibility of the Dietary Manager (DM) to check expiration dates on all foods in the kitchen, including those in the refrigerator. However, this task was not completed because there was no DM present at the time. The DCC, who had just started her shift, had not yet had the opportunity to check the expiration dates. The facility's policy and procedure on labeling and dating foods, dated 2023, clearly indicated that all food items in storage areas need to be labeled and dated, but this was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 405 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Banning
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Real Post Acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Sunrise Post Acute | 1.7 mi | ★★★★★ | 30 | 0 |
| Highland Springs Care Center | 2 mi | ★★★★★ | 23 | 0 |
| Oak Glen Post Acute | 3.9 mi | ★★★★★ | 0 | 0 |
| Yucaipa Hills Post Acute | 7.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sundance Creek Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.