Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Ocean Point during CMS and state inspections, most recent first.
Failure to Monitor Intake and Weight Loss: A resident with dysphagia and MDD experienced progressive, significant weight loss while meal intake was inconsistently documented and weekly weights were not started when weight loss thresholds were met. The RD noted inadequate intake, decreased dining room attendance, and the need for meal assistance, but the care plan did not include intake monitoring or meal assistance interventions, and the resident was observed eating in bed without staff assistance.
Insufficient staffing and delayed resident care were identified when PBJ staffing data showed a one-star staffing rating and excessively low weekend staffing. Residents reported long waits for help, especially at nights and on weekends, and a CNA and LPN stated the facility was often short-staffed, which delayed care. The DON acknowledged the staffing issues and frequent use of registry staff.
Failure to Address Staffing in QAPI Program: The facility's QAA Committee did not identify staffing as an area for improvement or include staffing needs in the QAPI plan, even though staffing concerns were identified during the recertification survey and in the PBJ Staffing Data Report. The PBJ showed excessively low weekend staffing, and during a QAPI meeting the DON stated staffing had not been addressed by the QAA committee while other concerns such as call light response, falls, skin/wounds, infection control, weight loss/nutrition, hygiene care, change in condition, and care conference scheduling were discussed.
Improper G-tube Medication Administration: An LPN administered a resident’s medications through a G-tube using a syringe plunger instead of gravity during observation. The resident had gastrostomy status, and the LPN stated the tube had issues with gravity administration and that there was no MD order for syringe flushing. The DON stated nurses are expected to follow professional nursing standards and MD orders, and facility policy required medications to be given by syringe via gravity.
Failure to assess and care plan severe hair matting and hygiene refusals: A resident with anxiety and MDD was observed with tightly matted hair, scalp irritation, and facial skin changes. Staff reported the resident often refused showers and would not allow hair brushing, but refusals and hair care attempts were not documented, and the resident had no specific care plan or interventions for the ongoing hair matting until later. The DON and ADON acknowledged the issue had been long-standing and known to the facility.
Insulin injection sites were not rotated for two residents with diabetes, despite orders and MAR entries showing repeated use of the same arm and abdominal sites. An LN and the DON stated sites should be rotated to prevent bruising, tissue damage, and hardening of the skin, and the consultant pharmacist did not check site rotation during MAR review. The facility also failed to reassess a resident’s critically low temperature readings; staff stated out-of-range vitals should be retaken and reported, and the DON said the early abnormal reading should have been re-evaluated.
Failure to assess, document, and implement interventions for a resident’s left index and left little finger contractures. The resident had Parkinson’s disease and a history of hand contractures, but staff records and interviews showed only right upper extremity ROM and splinting orders, with no active orders or care plan interventions for the left hand. OT was not aware of the left-hand finger contractures, and the DOR later found the fingers could not be fully extended and stated they should have been documented as contractures with stretching and ROM exercises.
A resident with ESRD and dependence on renal dialysis did not receive care consistent with the physician's ordered 1200 ml/day fluid restriction. Staff told surveyors the resident went out for dialysis and was not on fluid restriction, while record review showed repeated fluid amounts above the ordered limits and a water pitcher left at the bedside. The DON stated dialysis residents were on fluid restriction to prevent fluid overload, and the facility policy required ordered diet and fluid restrictions to be followed.
Failure to Identify PTSD Triggers: Two residents with PTSD were not identified and addressed by staff in accordance with professional standards. One resident reported severe childhood trauma and anxiety triggered by yelling, while another described PTSD related to years as a firefighter and ongoing anxiety. Staff stated they were unsure of the residents' PTSD diagnoses, and the facility's TIC screening for one resident documented no traumatic event despite records and psychology notes showing PTSD.
A resident with COPD did not receive an ordered Tiotropium Bromide inhaler when an LPN forgot to administer the medication during the scheduled morning window. During a med cart inspection, an unopened package of the inhaler was found, and the LPN stated it should have been given earlier that day. The DON stated that nurses were expected to administer all medications as ordered by the physician.
Food items in the walk-in refrigerator, freezer, and dry storage were found without required labels, received dates, or use-by/expiration dates. Surveyors observed unlabeled meat, lettuce, ham, bread, cornstarch, and base products, and also found a staff member’s personal coffee mug stored next to resident food items. The DM and RDs acknowledged the unlabeled items, and the DON stated resident food items should be labeled per policy to prevent foodborne illness.
A resident with a history of dysphasia after a stroke was inaccurately coded for malnutrition on the MDS by the MDS nurse without the required physician documentation. Although a query was provided for physician signature, it was not signed before the MDS was completed and submitted to CMS, resulting in inaccurate information being reported.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with severe cognitive impairment and high fall risk was left unattended in a wheelchair, resulting in a fall and injury. The care plan did not include individualized interventions appropriate for the resident's inability to use a call light or communicate needs, and staff resources did not provide specific fall prevention strategies.
A resident with severe cognitive impairment and high fall risk was left unsupervised in their room, despite being unable to use the call light or communicate needs. Usual fall prevention strategies included keeping the resident at the nurses station for monitoring, but on this occasion, the resident was alone and fell from a wheelchair, sustaining a head injury that required hospital assessment. Staff interviews confirmed that the interventions in place were not effective for this resident's specific needs.
A resident was subjected to undignified care when a CNA held a soiled wipe with bowel movement close to the resident's face during perineal care, after the resident questioned the cleaning process. The CNA admitted to this action, and facility leadership confirmed it was inappropriate and demeaning, violating policies that require staff to promote resident dignity and respect.
A resident in a shared room was unable to locate a TV remote control and did not receive assistance from staff, resulting in a physical altercation with another resident. The room had insufficient TV remote controls for the number of beds, and no work order was submitted to address the issue. Facility policy requires staff to accommodate residents' needs and preferences, but this was not followed, leading to the incident.
A resident was transferred from the SNF to a hospital and, after being medically cleared, was denied readmission to the SNF without receiving a timely written discharge notice or information about appeal rights. Facility administration confirmed there was no documentation of discharge notification or communication with responsible parties.
The facility failed to follow infection control practices by not consistently checking water temperatures or testing for pathogens, leaving a personal belonging on a clean bed intended for a new resident, and not performing hand hygiene between medication administrations. These actions were contrary to the facility's policies and placed residents at risk for infections.
A facility failed to obtain informed consent for psychotropic medications prescribed to a resident with schizoaffective disorder and major depressive disorder. The resident, under conservatorship and unable to make medical decisions, was prescribed clonazepam, valproic acid, and olanzapine without documented consent. Interviews and record reviews confirmed the absence of consents, contrary to the facility's policy requiring verification of informed consent by the licensed nurse.
A facility failed to ensure a POLST was signed by the Responsible Party for a resident with cognitive communication deficit, who lacked decision-making capacity. The POLST was signed by the physician but not by the resident's decision maker, as required by facility policy. Interviews with staff confirmed the oversight, highlighting a potential risk of not honoring the resident's end-of-life wishes.
A resident expressed concern about an unstable sink in her bathroom, which had a large hole in the wall beneath it. Despite being reported earlier, the issue was marked as resolved by maintenance staff, although the sink remained unsafe. The resident, who was cognitively intact and had mobility issues, felt uncomfortable with the condition, which was not addressed adequately by the facility.
A resident with cirrhosis of the liver was transferred to an acute care hospital without receiving a written notice of discharge. Two LNs involved in the discharge process admitted to not providing the notice, with one unfamiliar with the form. The DON acknowledged the oversight, which was against the facility's policy requiring a Notice of Proposed Transfer and Discharge document prior to discharge.
A resident with liver cirrhosis was transferred to a hospital without receiving a written notice of the bed-hold policy, as required by the facility's policy. Two LNs involved in the discharge confirmed the omission, and the DON acknowledged the oversight.
A facility failed to accurately document medication in the MDS for a resident, leading to potential errors in medical decisions. The MDS indicated insulin administration, but no orders were found in the resident's medical record. The MDS coordinator admitted to marking the MDS in error, contrary to the facility's policy on accurate resident assessments.
A resident with mental health diagnoses did not have a timely PASARR II completed due to a letter indicating inability to participate in the evaluation. Despite this, no follow-up was conducted, contrary to facility policy requiring the MDS Coordinator to ensure PASARR updates.
The facility failed to create care plans for psychotropic medications for two residents, potentially affecting communication among healthcare providers. One resident with Vascular Dementia and Major Depressive Disorder was on Seroquel without a care plan, while another with Major Depressive Disorder was on lorazepam and citalopram without care plans. Both a Licensed Nurse and the DON highlighted the importance of care plans for individualized care and communication.
A resident with cerebral infarction and reduced mobility was found with long, yellowish fingernails, indicating a failure in routine nail care. Despite being capable of understanding, the resident required assistance with personal care. Staff, including CNAs and LNs, acknowledged the oversight and the need for nail care to maintain hygiene, as per the facility's grooming policy.
A resident did not receive their prescribed medication, ropinirole, for three days due to the facility's failure to ensure timely delivery from the pharmacy. The medication was marked as unavailable, and there was no documentation of reordering. The DON indicated that the nurse should have contacted the pharmacy, but the facility's policy lacked guidance on reordering medications.
The facility failed to implement specific behavior monitoring for two residents prescribed psychotropic medications, increasing the risk of unnecessary medication use. One resident with Vascular Dementia and Major Depressive Disorder was on Seroquel without specific monitoring, while another with Major Depressive Disorder was on Lorazepam and Citalopram without behavior monitoring. The DON acknowledged the need for specific behavior indications to assess medication effectiveness, as required by the facility's policy.
A LTC facility failed to maintain a medication error rate below 5%, with errors involving two residents. A nurse administered famotidine without a physician's order and omitted cholecalciferol for one resident. Another resident received levothyroxine at the wrong time, affecting its effectiveness. These errors were identified through observations and interviews.
Expired needles and eyewash solutions were found in a medication storage room and cart, posing a risk of infection if used. A nurse confirmed the items were expired and should have been discarded. The facility's policy lacked guidance on discarding expired supplies.
A kitchen staff member failed to properly test disinfectants by not following the test strip instructions, which required a 10-second immersion. The Registered Dietician confirmed the correct procedure, but the facility lacked a policy on testing disinfectants.
The facility failed to properly thaw frozen meat, as observed during a survey. A plastic bag of frozen chicken was found floating in water on a kitchen counter, contrary to the facility's policy of thawing in the refrigerator or under running water. The Dietary Manager confirmed the improper method and stated that the cook knew the correct procedure.
The facility failed to ensure arbitration agreements were signed by responsible parties for two residents who lacked decision-making capacity. Despite assessments indicating incapacity, both residents signed agreements themselves. The DON confirmed that agreements should be signed by responsible parties when residents lack capacity.
The facility failed to ensure a pest-free kitchen environment, with multiple insects observed during food preparation. A staff member continued chopping pork despite an insect landing on it. Interviews revealed a lack of awareness and communication about pest control measures, and the facility's policy lacked specific guidelines for kitchen pest management.
Two CNAs failed to wear PPE while caring for a resident on Enhanced Barrier Precaution (EBP) with a urinary catheter, despite clear signage indicating the need for PPE. This was observed by the Director of Staff Development, who confirmed the requirement to prevent infection spread. The Infection Preventionist and DON acknowledged the protocol breach, which contradicted both facility policy and CDC guidelines.
The facility failed to maintain a comfortable temperature environment during an AC malfunction, affecting several residents. The maintenance department did not routinely check or document room temperatures, and staff areas had cooling units that were not offered to residents. The assistant director of nursing was unaware of the residents' complaints and the lack of temperature monitoring, leading to several rooms exceeding the federal temperature limit.
During an unannounced visit, unsecured containers of liquids and an overflowing sharps container were found in resident shower rooms, posing risks of ingestion and injury. Additionally, a water leak in the hallway near the east nursing station created a slip hazard. Staff interviews revealed confusion over responsibilities for managing these hazards, and the issues remained unresolved, posing risks to residents.
The facility failed to secure medication, treatment, and IV carts, allowing unauthorized access to medications and needles. During an unannounced visit, surveyors found an unlocked medication cart with insulin pens, an unattended treatment cart with medicated creams, and an unlocked IV cart with needles and labeled medication bags. Nursing staff acknowledged the carts should be locked to prevent unauthorized access, but the ADON could not provide a specific policy for safe medication storage.
A resident with functional quadriplegia and joint contractures did not have a person-centered care plan addressing repeated refusals of showers and skin treatments. Despite being dependent on staff for ADLs, the facility failed to document refusals or hold IDT meetings to investigate the reasons. Staff interviews confirmed the lack of documentation and care planning, violating facility policies on care planning and treatment refusal.
A resident with functional quadriplegia and joint contractures did not receive routine showers or bed baths as required, leading to a risk of skin infections and injuries. The resident was dependent on staff for personal care, but there was no care plan addressing these needs. Facility staff acknowledged issues with adherence to shower schedules and documentation, and an in-service was conducted for evening shift staff but not for the day shift.
A resident with functional quadriplegia and joint contractures did not receive ordered wound treatments on two consecutive days, leading to potential delayed healing and worsening of wounds. The resident was later found with maggots in her ear and sent to the hospital. Interviews revealed no documentation of treatment refusal or reasons for missed treatments, and the ADON confirmed the lack of documentation.
A resident with COPD, capable of making his own decisions, had his PHI disclosed without authorization when the social services director contacted his family to assist with discharge planning. The director of nursing acknowledged that permission should have been obtained, violating the facility's policy on third-party disclosure of PHI.
The facility failed to administer medications as ordered for two residents. A resident with anxiety received Ativan more frequently than prescribed, while another with osteomyelitis missed several doses of Cefazolin. The DON acknowledged these errors, which did not meet the facility's expectations.
A facility failed to develop a baseline nutrition care plan within 48 hours for a resident with COPD and moderate cognitive deficits. The dietary service supervisor initiated the care plan late and was unaware of the required timeframe. The registered dietitian expected timely gathering of food preferences, which were not included in the care plan, risking weight loss and health decline.
The facility failed to complete a comprehensive discharge care plan for a resident with diabetes mellitus type 2 and moderate cognitive impairment. Despite physician's orders for wound care and a discharge order with home health, the discharge care plan was not located or completed, as confirmed by the SSD and DON.
The facility failed to administer medications as ordered for two residents. One resident did not receive Lidocaine gel 4% every morning as prescribed, and another resident missed multiple doses of Lidocaine patches 4% due to refusal, being held, and unavailability. There was no documentation of physician notification or progress notes for the missed medications.
Failure to Monitor Intake and Weight Loss
Penalty
Summary
The facility failed to monitor intake, initiate weekly weights, and implement timely interventions for a resident with dysphagia and major depression who experienced significant weight loss. Resident 116 was admitted with a goal weight range of 145 to 165 lbs. and had a documented weight of 153.8 lbs. in July 2025. By October 2025, the resident had lost 7.6 lbs. over about one month, and the RD noted the loss was just below the 5 percent threshold for significant weight loss and might be related to inadequate energy intake. The RD recommended increasing meal portions, but weekly weights were not initiated. The resident continued to lose weight after the facility documented a change of condition for significant weight loss in December 2025. The facility did not complete a nutritional risk assessment in November or December 2025. December meal intake documentation showed 16 meals without intake recorded and 38 meals with less than 50 percent intake. The resident’s weight dropped to 127.2 lbs. in January 2026, and the RD documented continued weight decline, decreased attendance in the dining room, and a noticeable decrease in intake. The RD recommended assistance and encouragement with meals, a magic cup daily, and a fortified diet, but weekly weights still were not started. In February 2026, the resident weighed 119.4 lbs., and the RD then recommended weekly weights. The next documented weight, 112.6 lbs., was obtained about two weeks later. The care plan addressed nutritional status and monthly weights, but it did not include interventions to monitor or document oral intake or provide assistance or supervision during meals. During observation, the resident was seen in bed with a lunch tray and no staff assisting with the meal. Staff interviews confirmed that CNAs were expected to document every meal, notify nurses when intake was low, and that significant weight loss should trigger weekly weights and IDT review. The DON and ADON stated the resident’s significant weight loss should have triggered weekly weight monitoring, IDT review, and updated care plan interventions, but those actions were not implemented in a timely manner.
Insufficient Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure that sufficient staff were available to provide care and services to residents in a timely manner and did not have a licensed nurse in charge on each shift as required. The deficiency was identified from review of the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 4 2025, which showed the facility had a one-star staffing rating and excessively low weekend staffing. During interviews, Resident 13 stated there were times when help took a long time to arrive, although the resident could do most things independently, and expressed frustration about waiting. Resident 11 stated he had to wait for help and believed nights and weekends were when he waited the longest. CNA 31 stated the facility needed more care staff and was often short of CNAs, which impacted resident care and caused residents to wait a long time. LN 31 stated the facility needed more staff on all shifts and all days, not just weekends, and that resident care was impacted mainly by delays in care. Housekeepers 1 and 2 also stated the weekends were bad and that the facility could definitely use more staff, especially on weekends. The DON acknowledged awareness of the staffing issues and stated the facility had been using registry a lot and was working on improving the PBJ data.
Failure to Address Staffing in QAPI Program
Penalty
Summary
The facility's QAA Committee failed to identify areas of improvement and include the facility's staffing needs in the QAPI plan, despite staffing concerns identified during the recertification survey and in the PBJ Staffing Data Report. Review of the PBJ Staffing Data Report for Quarter four 2025 showed excessively low weekend staffing. During a QAPI meeting on 3/2/26, the DON, ADON, a charge nurse, and the Administrator discussed facility concerns including call light response, falls, skin/wounds, infection control, weight loss/nutrition, hygiene care, change in condition, and care conference scheduling, and the DON stated staffing had not been addressed by the QAA committee. The Administrator stated it was important to address areas of concern in the QAPI meeting because those areas affect resident safety and well-being. Review of the facility's QAPI policy showed the program was intended to monitor and evaluate the quality of resident care, pursue methods to improve quality of care, and resolve identified issues.
Improper G-tube Medication Administration
Penalty
Summary
Licensed nurse 23 did not administer Resident 10’s medications via the gastrostomy tube by gravity during a medication administration observation. Resident 10 was admitted with diagnoses that included gastrostomy status. On 2/26/26 at 8:30 A.M., LN 23 administered aspirin 162 mg and bupropion HCL 50 mg through the G-tube and was observed flushing the medications with a syringe plunger instead of using gravity. On 2/27/26 at 9:00 A.M., LN 23 stated he used gravity when administering medications to Resident 10 because the G-tube has issues when administering via gravity, and stated there was not a doctor’s order but there should have been for flushing medications with a syringe. On 3/2/26 at 9:00 A.M., the DON stated it was her expectation that nurses follow professional nursing standards and doctor’s orders when administering medications. Facility policy titled Feeding Tube - Administration of Medication, dated 6/12/24, stated nursing staff are to administer medications by syringe via gravity into the feeding tube, and the Medication - Administration policy, dated 8/19/25, stated all medications shall be administered by licensed nursing staff according to physician orders, current best practices and federal and state regulations.
Failure to assess and care plan severe hair matting and hygiene refusals
Penalty
Summary
The facility failed to assess, care plan, and implement interventions to address severe hair matting and hygiene refusals for one resident who was unable to perform activities of daily living independently. The resident was admitted with diagnoses of anxiety and major depression, and during observation was found sitting up in bed with gray hair tightly matted across the top and back of the scalp. Yellow crusted material and flaking were present on the right forehead at the hairline, and skin discoloration with red splotching was present on both cheeks. During interview, the resident appeared unaware of the condition of her hair and adjusted the matted hair herself. Record review showed the admission nursing assessment, history and physical, and initial psychiatric evaluation did not document matted hair, scalp irritation, or other hair hygiene concerns. CNA interviews indicated the resident did not allow staff to brush her hair, frequently refused showers, and did not like to get her hair wet. Staff stated attempts to brush her hair were not documented, and refusals of hair care were not specifically documented beyond shower sheets. Shower and bathing records from December and January showed multiple shower refusals, but neither the shower sheets nor the electronic flowsheets documented refusals of hair care or attempts to address the matted hair. The resident’s progress notes contained only one reference to the hair and scalp condition, a skin check note that described the hair as extremely matted with dry flaked areas to the top of the head. The resident did not have a care plan for the hair matting until it was initiated later, and the existing ADL self-care performance deficit care plan did not include interventions related to hair care or management of hygiene refusals. The DON and ADON acknowledged the matted hair had been a long-standing issue known to the facility and that no care plan had been in place prior to that date.
Failure to Rotate Insulin Sites and Reassess Abnormal Vital Signs
Penalty
Summary
Insulin injection sites were not rotated for two residents with diabetes. Resident 16 was admitted with type 2 diabetes mellitus with hyperglycemia and was receiving insulin glargine. Review of the February 2026 MAR showed repeated administrations at the same sites, including the right arm, left arm, and left abdominal quadrants. During record review, an LN stated the injection sites were not rotated. Resident 7 was admitted with type 2 diabetes mellitus and muscle weakness and had physician orders for insulin lispro sliding scale and insulin glargine at bedtime with instructions to rotate sites. Review of the February 2026 MAR showed insulin glargine and insulin lispro were repeatedly given in the right arm, left arm, rear upper arm, and abdomen-right upper quadrant. The LN stated insulin injection sites should be rotated to prevent bruising or hardening of the skin. The consultant pharmacist stated he reviewed residents’ MARs monthly to check whether medications were administered but did not check rotation of insulin injection sites. The DON stated insulin injection sites should be rotated to prevent side effects, tissue damage, and allow sites a chance to heal. The facility policy for Medication Administration required medications to be administered according to physician orders, current best practices, and federal and state regulations, and the Diabetic Care policy stated the facility would provide necessary care and services to diabetic residents, but it did not address rotation guidance for insulin administration sites. The facility also failed to reassess abnormal vital signs for Resident 126, who was admitted with metabolic encephalopathy and later died at the facility. The record showed a temperature of 72 degrees Fahrenheit taken orally at 5:22 p.m. and another temperature of 72 degrees Fahrenheit taken tympanically at 12:13 a.m. CNA31 stated that if a vital sign was out of range, staff would tell the nurses, and LN31 stated out-of-range vitals should be retaken and reported if still abnormal. The DON stated that if a vital sign is out of normal range, it should be repeated and, if it remains out of range, reported and a change of condition initiated; for this case, the early reading should have been re-evaluated. The facility’s vital signs policy stated vital signs are clinical measurements of basic body functions and are taken when there is a change in the resident’s condition.
Failure to Assess and Treat Left-Hand Finger Contractures
Penalty
Summary
The facility failed to assess, document, and implement interventions for contractures affecting a resident’s left index finger and left little finger. The resident was admitted with Parkinson’s disease and had a history of bilateral hand contractures documented in prior H&P, NP, and physician notes, including a right hand contracture and a small contracture of the left fingers. During observation, the resident was seen seated in a wheelchair and propelling himself with his feet, with the right hand severely contracted at the wrist and the left index and little fingers positioned in flexion. The resident was unable to provide additional information about the condition of his hands. Staff interviews and record review showed the resident had active orders for passive ROM to the right upper extremity with splinting and sit-to-stand exercises, but no active orders for ROM to the left hand or fingers. CNA staff and RNA staff stated there were no RNA interventions ordered for the left hand. OT staff were not aware of contractures affecting the left-hand fingers, and an OT evaluation identified limitations related to the right upper extremity contracture but did not identify left-hand finger contractures. When the DOR attempted to extend the left index and little fingers, the resident was unable to fully extend them, and the DOR stated these fingers should be documented and assessed as contractures with stretching and ROM exercises. The care plan addressed sit-to-stand exercises and right wrist flexion contracture ROM with splinting, but did not include goals or interventions for the left index or left little finger contractures.
Dialysis Resident Received Fluids Beyond Ordered Restriction
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not maintained for Resident 15, who was re-admitted with diagnoses including end stage renal disease and dependence on renal dialysis. During observation and interview, Resident 15 was in bed, stated he went for dialysis treatments, and did not know the schedule. Staff interviews showed CNA 14 and CNA 16 both stated Resident 15 went out for dialysis and was not on fluid restriction, and CNA 16 reported giving snacks to calm the resident during episodes of agitation and screaming. Record review and further observation showed a physician's order for a 1200 ml fluid restriction per day, with specific amounts assigned by shift. LN 11 reviewed the MAR and stated Resident 15 received more than the ordered fluid restriction on multiple dates, including 480 ml during morning shift on several days, 300 ml during an afternoon shift, and 240 ml during several night shifts. A pitcher that was 3/4 full of fluid was also observed on the resident's overbed table during two separate observations. LN 12 stated residents on dialysis and on fluid restriction should not have a water pitcher because drinking too much fluid can cause water retention and fluid overload. The DON stated residents on dialysis were on fluid restriction to prevent fluid overload and staff had to monitor how much fluid was being provided to the resident. The facility policy stated that diet and fluid restrictions would be followed as ordered.
Failure to Identify and Address PTSD Triggers
Penalty
Summary
The facility failed to ensure that two residents with diagnoses of PTSD received care and services in accordance with professional standards because their PTSD was not identified and addressed by healthcare providers. Resident 16 was admitted with diagnoses including PTSD and acute pain due to trauma, and during an observation he stated he had PTSD after being raped at age five and beaten until age 17. He also stated that hearing residents screaming made him anxious and that he did not want to close his room door. However, the facility's Trauma Informed Care Screening for this resident dated 9/16/24 indicated no traumatic event, and staff interviewed later stated they were unsure whether he had PTSD. The MDS nurse confirmed the quarterly MDS dated 12/21/25 indicated PTSD, and a psychology note dated 2/18/26 documented mild distress and difficulty concentrating due to PTSD symptoms. Resident 1 was re-admitted with diagnoses including post traumatic disorder, major depressive disorder, and anxiety. During an observation, he stated he had PTSD related to 20 years as a firefighter and described exposure to traumatic events such as people burning and suicides, stating he was often anxious. Staff interviewed later stated they did not know he had PTSD, although one CNA noted that certain things could be triggered from his past experience. The LN reviewed his care plan and noted it included a mood problem related to PTSD, while the SSD and DON stated staff should be aware of residents' PTSD and triggers to avoid recreating the experience or causing re-traumatization. A psychology note dated 1/21/26 documented PTSD, persistent nightmares related to past military and firefighting trauma, and constant anxiety throughout the day.
Failure to Administer Ordered COPD Medication
Penalty
Summary
The facility failed to follow a physician’s order when a licensed nurse did not administer Tiotropium Bromide inhaler to a resident with COPD as ordered. The resident’s admission record showed diagnoses that included chronic obstructive pulmonary disorder, and the physician’s order directed that the inhaler be given as 1 puff daily for COPD. During a concurrent observation and interview at the medication storage cart, an unopened single package of Tiotropium Bromide for the resident was found, and the nurse stated he forgot to administer the medication and that it should have been given between 8:00 A.M. and 10:00 A.M. as ordered. The nurse also stated that the unopened inhaler was intended to be administered that day and that there was not another opened Tiotropium Bromide inhaler available in the medication cart. During an interview, the DON stated it was her expectation that nurses administer all medications as ordered by the physician. The facility policy titled Medication - Administration stated that all medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.
Food Items Stored Without Required Labels and Dates
Penalty
Summary
Food items were found stored in the walk-in refrigerator, freezer, and dry storage areas without proper labeling or dating. During the kitchen observation, surveyors found a small metal container of browned ground meat and another container of a gelatinous tan substance that were both unlabeled and undated, along with three boxes of whole leaf lettuce, a plastic container of lettuce with six bags of chopped lettuce, and a large whole ham that had use-by dates of 2/20/26 or 2/22/26. Two extra-large casings of raw meat were also present with no label identifying the contents and no use-by or expiration date. A metal tumbler mug containing a brown liquid was stored on the food shelving next to resident food items, and the cook identified it as his personal coffee mug and stated it should not be stored with resident food because it creates an infection control risk and could cause cross contamination. In the freezer, four boxes of ready-to-bake 10-inch apple pies were observed without a received-on date or expiration date. In dry storage, five racks of bread, one opened box of cornstarch, ten 16-ounce containers of beef base, and seven 16-ounce containers of chicken base were found without required labels or dates. The dietary manager and registered dietitians acknowledged the unlabeled items, and one RD stated that items without an expiration date should not be used because they could create a foodborne illness risk. The DON later stated that all resident food items should be labeled according to policy to prevent foodborne illnesses. The facility policy titled Food Storage and Handling required raw meat, frozen fruit, fresh vegetables, and dry storage products to be labeled and dated.
Inaccurate MDS Coding Due to Lack of Physician Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was admitted with diagnoses including dysphasia following a stroke. During the assessment process, the MDS nurse marked malnutrition on the MDS form without having the required physician documentation to support this diagnosis. Although the nurse had provided a query form for the physician to sign as supporting documentation, it had not been signed at the time the MDS was coded and submitted. Interviews with the MDS nurse and the Director of Nursing confirmed that physician documentation was necessary to accurately code malnutrition in the MDS, as this information is submitted to CMS for billing purposes. Review of facility policy and the CMS RAI MDS 3.0 Manual further supported the requirement for accurate and documented assessments. The deficiency resulted in the submission of inaccurate information to the federal database.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Implement Individualized Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive and individualized care plan to address fall prevention for a resident with severe cognitive impairment and high fall risk. The resident, diagnosed with dementia and muscle weakness, was unable to use the call light or effectively communicate needs, yet the care plan interventions focused on ensuring the call light was within reach and anticipating needs. Staff interviews revealed that the resident was often left unattended in his room, and the care plan did not include specific interventions such as not leaving the resident in a wheelchair unattended, despite his inability to call for help. On the date of the incident, the resident was left alone in his room in a wheelchair, resulting in a fall that caused a head injury and required hospital assessment. Staff were aware of the resident's fall risk status, but the resources available to them, such as the binder at the nurses station, did not provide individualized interventions. The care plan lacked specificity and did not address the resident's unique needs, contributing to the failure to prevent the fall.
Failure to Prevent Fall in High-Risk Resident with Cognitive Impairment
Penalty
Summary
A resident with muscle weakness and severe cognitive impairment, as indicated by a BIMS score of six, was identified as being at high risk for falls, with a Fall Risk Assessment score of 17. The resident's care plan included interventions such as anticipating needs, ensuring the call light was within reach, and providing assistance as needed. However, staff interviews revealed that the resident was unable to use the call light or effectively communicate needs, making some interventions ineffective. The resident was typically supervised at the nurses station or in the Director of Staff Development's office, where staff could monitor for safety, but on the day of the incident, the resident was left alone in his room without staff presence. During this unsupervised period, the resident fell from his wheelchair, sustained a head injury, and required hospital assessment. Staff acknowledged that the resident should have been left in an area where supervision was possible, given his high fall risk and inability to call for help. The facility's fall management policy required individualized care planning and ongoing evaluation of interventions, but the implemented strategies did not adequately address the resident's specific needs, resulting in a preventable fall with injury.
Resident Dignity Compromised During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) provided care to a resident and, during perineal care, held a soiled wipe with bowel movement approximately one to two inches from the resident's face. The resident had requested a brief change due to urination and questioned the CNA about the prolonged cleaning process. In response, the CNA showed the soiled wipe close to the resident's face and stated that the resident had a bowel movement. The resident reported feeling disrespected, humiliated, and uncomfortable, and subsequently requested a different CNA for care. Interviews with facility staff, including a licensed nurse, the assistant director of nursing (ADON), and the director of staff development (DSD), confirmed that the CNA admitted to showing the soiled wipe to the resident because the resident did not believe her. Both the ADON and DSD stated that this action was inappropriate and could be seen as a demeaning practice. Facility policy prohibits demeaning practices and requires staff to promote dignity and respect for residents.
Failure to Provide TV Remote Control Leads to Resident Altercation
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring that each resident in a shared room had access to their own TV remote control. On the date of the incident, there were only two TV remote controls available for three beds, and at the time, only one remote was present. One resident became upset after being unable to locate the TV remote control and asked his roommate about its whereabouts. This interaction led to a physical altercation, with the resident being struck in the chest by his roommate. The incident was subsequently reported as a physical abuse case to the California Department of Public Health (CDPH). Interviews with staff revealed that the resident had asked for assistance in locating the missing TV remote control, but no staff member assisted him. The Maintenance Director was unaware that the room was lacking sufficient TV remote controls and stated that no work order had been submitted for a replacement. Facility policy requires staff to assist residents in maintaining independence, dignity, and well-being, including accommodating individual needs and preferences. However, staff failed to provide the necessary support, resulting in the altercation between residents.
Failure to Provide Timely Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to implement an appropriate discharge plan for one resident who was transferred from the skilled nursing facility (SNF) to a general acute care hospital (GACH) and subsequently denied readmission to the SNF after being medically cleared for return. During a joint interview and record review with facility administration, it was revealed that there was no documented evidence of a discussion with the resident or responsible parties regarding a discharge notification or process. Additionally, when the GACH attempted to transfer the resident back to the SNF, the facility declined the transfer without providing a timely written discharge notice or informing the resident of their right to appeal the decision. This lack of notification and documentation was acknowledged by the facility administration during the interview.
Infection Control Deficiencies in Water Management, Bed Preparation, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection control practices in several areas, as observed during a survey. Firstly, the facility did not consistently check water temperatures or test the water for pathogens, as required by their Water Management policy. Interviews with the Maintenance Director and Infection Preventionist revealed that biological testing of the water supply was not conducted unless there was a cluster of infections, such as pneumonia or diarrhea, present in the facility. Additionally, the facility was unable to provide any logs for water temperature checks prior to October 24, 2024. Secondly, a personal belonging, specifically a comb, was found on a clean bed intended for a new resident admission. This was observed by a Licensed Nurse, who acknowledged that the bed should have been free of any items to ensure it was properly cleaned and disinfected. Lastly, a Licensed Nurse failed to perform hand hygiene after administering medications to one resident and before administering medications to another. This was contrary to the facility's Hand Hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections. The Infection Preventionist and Director of Nursing both confirmed the expectation for staff to perform hand hygiene between resident care and when entering and exiting resident rooms.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications prescribed to Resident 18, who was admitted with diagnoses including schizoaffective disorder and major depressive disorder. The medications prescribed were clonazepam, valproic acid, and olanzapine, intended to manage anxiety and schizophrenia. During interviews and record reviews, it was revealed that there were no consents for these medications in Resident 18's medical records. Licensed Nurse 1 and the Medical Records staff confirmed the absence of these consents, indicating a lapse in the facility's procedure for obtaining informed consent. Resident 18 was under conservatorship and unable to make medical decisions, necessitating informed consent from a responsible party. The Director of Nursing acknowledged the importance of informed consent to ensure the resident's family or decision-maker was aware of the medications being administered. The facility's policy on Behavior/Psychoactive Drug Management required verification of informed consent by the licensed nurse, which was not documented in this case, leading to the deficiency.
Failure to Complete POLST for Resident
Penalty
Summary
The facility failed to ensure that a POLST (Physician Orders for Life-Sustaining Treatment) was signed by the Responsible Party for one of the two sampled residents, identified as Resident 221. Resident 221 was admitted with a cognitive communication deficit and was determined by a physician to lack the capacity to understand and make decisions. The POLST, dated 10/5/24, was signed by the physician but lacked the required signature from the resident's legally recognized decision maker. Interviews with Licensed Nurse 31 and the Director of Nursing revealed that the POLST should have been completed and signed within 24 hours of admission to ensure the resident's end-of-life wishes were honored. The facility's policy mandates that a completed and signed POLST is a legal physician order that must include the signature of the resident or their representative. The failure to obtain the necessary signature resulted in a potential risk of not honoring Resident 221's end-of-life preferences.
Failure to Maintain Homelike Environment Due to Unstable Sink
Penalty
Summary
The facility failed to provide a homelike environment for a resident when a large opening was observed in the wall under the sink in the resident's bathroom. The resident, who was cognitively intact and admitted with diagnoses including muscle weakness and abnormalities of gait and mobility, expressed concern about the sink potentially falling. During an observation, the sink was found to be unstable, with a piece of plaster falling off when it was wiggled by a licensed nurse. The maintenance log indicated that the issue of the sink falling off the wall was reported months earlier, but the maintenance assistant had marked it as resolved after placing a seal around the sink. However, the maintenance director acknowledged that the hole in the wall was not aesthetically pleasing and needed fixing. The resident stated that such a condition would not be acceptable in her own home, indicating discomfort with the current state of her environment.
Failure to Provide Written Notice of Discharge
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident who was transferred to an acute care hospital. The resident, who had been admitted with a diagnosis of cirrhosis of the liver, was transferred on the order of a physician. However, the progress notes from the day of transfer did not document that the staff provided the required written notice of discharge. During interviews, two licensed nurses involved in the discharge process admitted that they did not provide the written notice, with one nurse unfamiliar with the discharge form. The Director of Nursing acknowledged that the notice should have been given according to the facility's policy, which mandates providing a Notice of Proposed Transfer and Discharge document prior to discharge.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident at the time of discharge to an acute care hospital, resulting in the resident not being fully informed of their bed-hold rights. The resident, who was admitted with cirrhosis of the liver, was transferred to a hospital following a physician's order. A review of the resident's medical record revealed no documentation of the staff providing the required written notice of bed-hold. Interviews with two licensed nurses involved in the discharge confirmed that they did not provide the notice. The Director of Nursing acknowledged that the notice should have been given, as per the facility's policy revised in July 2017, which mandates written notification of bed-hold options during transfers to acute care hospitals.
Inaccurate Medication Documentation in MDS
Penalty
Summary
The facility failed to ensure accurate documentation of medication in the Minimum Data Set (MDS) for a resident, leading to an increased risk of error in medical decisions based on the MDS. The deficiency involved Resident 88, who was admitted to the facility and whose MDS indicated that they received one insulin injection over the previous seven days. However, a review of Resident 88's medical record revealed no orders for insulin. During an interview, the MDS coordinator acknowledged the error, stating that the MDS was marked incorrectly, as there were no orders for insulin for Resident 88. This discrepancy was contrary to the facility's policy on utilizing the Resident Assessment Instrument process for accurate resident assessments.
Failure to Complete PASARR II for Resident with Mental Health Needs
Penalty
Summary
The facility failed to complete the PASARR II in a timely manner for a resident with mental health diagnoses, including schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. The resident was admitted with a suspected mental illness, as indicated by the PASARR I. However, the PASARR II was not completed due to a letter from the Department of Health Care Services stating the individual was unable to participate in the evaluation. The Director of Nursing acknowledged that the PASARR II should have been followed up by the MDS Coordinator. Interviews with the MDS consultant and MDS Coordinator revealed that the PASARR II was crucial for the resident's placement and referral for mental health services. Despite the letter indicating the inability to complete the Level II evaluation, no further PASARR reviews were conducted after the initial letter. The facility's policy required the MDS Coordinator to ensure updates to the PASARR, which was not adhered to in this case.
Failure to Develop Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement care plans for psychotropic medications for two residents, which could potentially hinder communication among healthcare providers regarding the residents' medication monitoring. Resident 47 was admitted with diagnoses of Vascular Dementia and Major Depressive Disorder and was prescribed Seroquel. However, there was no care plan in place for the Seroquel medication, as confirmed by a Licensed Nurse during an interview. Similarly, Resident 105, who was admitted with Major Depressive Disorder, was prescribed lorazepam and citalopram, but no care plan was developed for these medications. The Licensed Nurse acknowledged the importance of a care plan for effective communication among staff. The Director of Nursing also emphasized the necessity of care plans to individualize resident care and communicate specific interventions required. The facility's policy mandates the development of a baseline care plan within 48 hours of admission, which was not adhered to in these cases.
Failure to Provide Routine Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide routine nail care to a resident who was dependent on staff for personal care, leading to a deficiency in the provision of activities of daily living (ADL). The resident, who was admitted with diagnoses including cerebral infarction, ataxia, and reduced mobility, was observed with long, yellowish fingernails. Despite being capable of understanding and making decisions, the resident required assistance with personal care due to muscle weakness and slow response from a brain injury. During interviews, staff members acknowledged the resident's dependency and the need for assistance with personal care, including nail care. Observations and interviews with various staff members, including a Restorative Nursing Assistant, a Certified Nursing Assistant, a Licensed Nurse, and the Director of Nursing, revealed that the resident's long fingernails were not addressed, despite the facility's policy on grooming. The staff confirmed that CNAs and LNs were responsible for cutting residents' fingernails to maintain hygiene and prevent germ buildup. The Director of Nursing acknowledged that the resident's long fingernails should have been cut for upkeep and hygiene, indicating a lapse in following the facility's grooming policy.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of medication from the pharmacy for a resident, resulting in the resident not receiving their prescribed medication, ropinirole, for three consecutive days. The resident, who was admitted with a diagnosis that included chronic pain, had an order to take ropinirole twice daily for restless leg syndrome. However, the medication was not administered on October 1st, 2nd, and 3rd, as indicated in the Medication Administration Record. Progress notes from the facility revealed that the medication was marked as unavailable on these dates, with no documentation indicating that the medication was reordered from the pharmacy. The Licensed Nurse responsible for the resident's care was not available for an interview. During an interview, the Director of Nursing stated that the nurse should have contacted the pharmacy to request the medication and documented the call. The facility's policy on medication ordering and receiving did not provide guidance on reordering medications or ensuring medications are reordered before they run out.
Lack of Specific Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure specific behavior monitoring for the use of psychotropic medications for two residents, leading to an increased risk of unnecessary medication administration. Resident 47, diagnosed with Vascular Dementia and Major Depressive Disorder, was prescribed Seroquel without specific behavior monitoring documented in the physician's orders, medication administration record (MAR), or care plan. Licensed Nurse 1 acknowledged that the behaviors being monitored, such as mood changes, falls, and medication side effects, were not specific or appropriate for psychotropic medication monitoring. Similarly, Resident 105, diagnosed with Major Depressive Disorder, was prescribed Lorazepam and Citalopram without specific behavior monitoring in place. Licensed Nurse 1 confirmed the absence of specific behavior monitoring for these medications in the physician's orders, MAR, or care plan. The Director of Nursing recognized the importance of specific behavior indications to assess medication effectiveness and communicate the care plan to healthcare staff. The facility's policy on Behavior/Psychoactive Drug Management requires specific behavior manifestations to be included in psychoactive medication orders, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by three medication errors involving two residents. During a medication administration observation, a Licensed Nurse (LN) administered famotidine to a resident without a physician's order, as the medication was intended for another resident. This error was acknowledged by the LN, who realized the potential negative impact if the resident had been allergic to the medication. Additionally, the same LN failed to administer cholecalciferol (Vitamin D) to the same resident, despite an active physician's order for daily administration. Another medication error involved the administration of levothyroxine to a different resident at an incorrect time. The medication was given in the morning instead of the scheduled 1 P.M. time, which was necessary to ensure its effectiveness. The Director of Nursing confirmed that the medication should have been administered on an empty stomach, aligning with the scheduled tube feeding times. These errors were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to physician orders and proper medication administration protocols.
Expired Medical Supplies Found in Medication Storage
Penalty
Summary
The facility failed to ensure that medication storage rooms and carts were free from expired medical supplies, which could potentially lead to infections if used on residents. During an observation of a medication storage room, expired needles with various expiration dates were found mixed with non-expired needles. Additionally, expired eyewash solution bottles were discovered. A licensed nurse confirmed that these items were expired and should have been discarded. The facility's policy on medication storage did not provide guidance on discarding expired medical supplies. In a separate observation, expired needles were found in one of the medication carts. A licensed nurse acknowledged that using these expired needles could have caused infections in residents. The Director of Nursing confirmed that expired medical supplies would not be sterile and could contain bacteria, emphasizing that expired items should not be present in medication storage areas or carts. The facility's failure to remove expired supplies from these areas was a significant oversight.
Improper Testing of Kitchen Disinfectants
Penalty
Summary
The facility failed to ensure that a kitchen staff member, referred to as Cook 12, properly tested the kitchen disinfectants. During an observation, Cook 12 was seen testing the disinfectant in a red bucket used for sanitizing surfaces by dipping a test strip into the disinfectant and immediately pulling it out to check the color. Cook 12 stated that he believed the strip only needed to be dipped for one second. However, the directions on the test strip container specified that the strip should be immersed for 10 seconds before comparing the color while wet. When questioned, Cook 12 retested the disinfectant by immersing the strip for seven seconds, still not adhering to the instructions. An interview with the Registered Dietician confirmed that the kitchen staff should have held the test strip in the liquid for the full 10 seconds as per the instructions. The facility did not have a policy on testing the red bucket disinfectant.
Improper Thawing of Frozen Meat
Penalty
Summary
The facility failed to ensure that frozen meat was thawed appropriately, as observed during a survey. During an observation and interview with the Dietary Manager, it was noted that a plastic bag containing cubes of meat was floating in a container of water on a kitchen counter. The Dietary Manager identified the meat as frozen chicken and acknowledged that it was being thawed improperly in sitting water. The correct procedure, as per the facility's policy on Food Storage and Handling, is to thaw foods in the refrigerator or under running water. The Dietary Manager also stated that the cook responsible for placing the frozen chicken in standing water was aware that this was not the proper method for thawing frozen meats.
Failure to Ensure Proper Signing of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were signed by the responsible party for two residents who lacked the capacity to understand and make decisions. Resident 67, diagnosed with schizoaffective disorder, was admitted to the facility and signed an arbitration agreement despite a physician's assessment indicating the resident did not have the capacity to understand and make decisions. The staff member responsible for completing arbitration agreements was unavailable for an interview. Similarly, Resident 171, diagnosed with schizophrenia, signed an arbitration agreement even though a physician's assessment noted the resident could not make medical decisions. The Director of Nursing confirmed that if a resident lacks decision-making capacity, the arbitration agreement should be signed by the resident's responsible party. The facility's policy states that only residents with capacity at the time of admission may sign the arbitration agreement.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the food preparation area, as evidenced by multiple observations of insects in the kitchen. During an observation, a staff member was seen chopping roast pork while a winged black insect flew around and landed on the food. The staff member did not remove the contaminated piece of pork and continued with food preparation. Further observations revealed additional insects, including a small winged insect on the wall above the ice machine and other insects flying above and around the food being prepared for lunch. Interviews with facility staff highlighted a lack of awareness and communication regarding pest control measures. The Registered Dietician mentioned plans to install an air curtain to prevent flying insects from entering the kitchen, but the Maintenance Director was unaware of any pest concerns or plans for such an installation. A review of the facility's pest control policy, last revised in 2012, showed no specific guidelines for managing pests in the kitchen, indicating a gap in the facility's pest management practices.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to infection control policies when two Certified Nursing Assistants (CNAs) did not wear the required personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precaution (EBP). The resident, who was admitted with chronic kidney disease and urinary retention, had a urinary catheter in place. Despite a sign outside the resident's room indicating the need for PPE, the CNAs entered the room and repositioned the resident without donning gowns and gloves. This oversight was observed during a concurrent observation and interview with the Director of Staff Development (DSD), who confirmed that PPE should have been worn to prevent infection spread. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged the lapse in protocol during a joint interview. They confirmed that the expectation was for staff to follow the EBP sign instructions and use PPE when caring for residents with indwelling medical devices, as outlined in the facility's policy and the CDC guidelines. The facility's policy, dated August 2019, emphasized the use of enhanced standard and transmission-based precautions to reduce pathogen transmission, including multidrug-resistant organisms (MDROs).
Failure to Maintain Comfortable Temperature Environment
Penalty
Summary
The facility failed to maintain a comfortable temperature environment for residents during an air conditioning malfunction, affecting five out of seven residents interviewed. The air conditioning unit in the west/south hallway stopped working, and the temperature exceeded the federal regulation limit of 79 degrees Fahrenheit. The maintenance aide was aware of the issue but was unable to proceed with repairs or use alternative cooling methods without the administrator's permission, who was on vacation. Residents expressed discomfort due to the heat, and some had to rely on fans brought by their families. The maintenance department did not routinely check or document room temperatures, and there was no temperature log maintained as a proactive measure. The assistant director of nursing was unaware of the residents' complaints and the lack of temperature monitoring. Staff areas were equipped with fans and portable air conditioning units, but these were not offered to residents. The facility's policy required room temperatures to be maintained between 71 and 81 degrees Fahrenheit, but this was not adhered to during the AC malfunction. The director of maintenance acknowledged the AC issues and informed the administrator, who instructed the ordering of new AC units. However, the maintenance department did not document temperature checks, contrary to the facility's policy. The facility's failure to maintain a comfortable environment and document temperature checks resulted in several rooms exceeding the temperature limit, with some reaching as high as 90 degrees Fahrenheit.
Hazardous Conditions in Shower Rooms and Hallway
Penalty
Summary
The facility failed to maintain a hazard-free environment in several areas, as observed during an unannounced visit. In two of the three resident shower rooms, unsecured containers of liquids such as shampoo, body wash, and shaving cream were found. These containers were left unattended on metal shelves and handrails, with some open to the environment, posing a risk of ingestion by confused and cognitively impaired residents. The Director of Staff Development acknowledged the potential danger, noting that the shower rooms were unlocked and accessible to residents. Additionally, a red sharps container in one of the shower rooms was found overflowing with used razors, creating a risk of injury. Interviews with staff revealed confusion over responsibility for managing the sharps containers, with the housekeeping supervisor and central supply staff each indicating that nursing staff were responsible. A charge nurse confirmed the hazard, stating that the situation was unacceptable and posed a risk of injury to residents. Furthermore, a water leak was observed in the hallway near the east nursing station, with saturated towels and blankets on the floor and no warning signs present. The maintenance aide reported that the leak had persisted for a week due to a delay in obtaining a replacement part from the water dispenser company. Despite daily calls to the company, the issue remained unresolved, and no alternative solutions had been pursued. The Assistant Director of Nursing acknowledged that the leak should have been addressed immediately to prevent slips and falls.
Failure to Secure Medication and IV Carts
Penalty
Summary
The facility failed to secure medication, treatment, and intravenous (IV) carts, leading to unauthorized access to medications and IV needles. During an unannounced visit, surveyors observed an unlocked medication cart in the north hallway of the east unit, containing multiple medications and insulin pens. A licensed nurse acknowledged leaving the cart unlocked, admitting that it allowed unauthorized access to medications, which could be harmful. Additionally, a treatment cart was found unlocked and unattended, containing medicated creams and ointments. A treatment nurse was unaware of the cart's ownership and confirmed that treatment carts should always be locked to prevent unauthorized access. Further observations revealed an unlocked IV cart in the south hallway of the east unit, containing packaged needles and liquid medication bags labeled with resident names. The charge nurse confirmed that the IV cart should be locked to prevent unauthorized access to its contents. Interviews with nursing staff, including the Assistant Director of Nursing (ADON), highlighted the expectation that all carts should be locked when not in use to maintain safety. The ADON was unable to provide a specific policy for safe medication storage, relying instead on a CMS critical element pathway as their guideline.
Failure to Develop Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with functional quadriplegia and joint contractures, who was dependent on staff for activities of daily living (ADLs) such as turning, transferring, toileting, and showering. Despite the resident's cognitive abilities being intact, the facility did not address the resident's repeated refusals of care, including showers and skin treatments, in their care plan. This lack of a comprehensive care plan led to potential miscommunication and inconsistent care, which could delay wound healing and increase the risk of infections. The resident's clinical records and interviews revealed that the resident was offered showers on multiple occasions but refused them, yet there was no documentation or care plan addressing these refusals. The facility's shower book showed inconsistencies in documenting whether showers were offered or refused, and there was no evidence of interdisciplinary team (IDT) meetings to investigate the reasons behind the refusals. Additionally, the resident refused skin treatments multiple times, but again, no care plan was developed to address these refusals. Interviews with facility staff, including licensed nurses and the assistant director of nursing, confirmed that there was a lack of documentation and care planning for the resident's refusals of showers and skin treatments. The facility's policies on comprehensive person-centered care planning and refusal of treatment were not followed, as there were no updates or assessments made to address the resident's needs and refusals. The absence of a care plan for the resident's ADLs and refusals of care highlighted a significant deficiency in the facility's care planning process.
Failure to Provide Routine Showers and Hygiene Care
Penalty
Summary
The facility failed to provide routine showers and/or bed baths to a resident who was dependent on staff for activities of daily living (ADLs), including bathing. The resident, who was admitted with functional quadriplegia and joint contractures, was at risk for skin infections and injuries due to the lack of proper hygiene care. The resident's clinical record indicated a dependency on staff for personal care, yet there was no care plan addressing these needs. Observations and interviews revealed that the resident had not refused showers or bed baths, but was only offered a shower two out of seven scheduled opportunities in July, and none after returning from a hospital stay in August. Interviews with facility staff, including a Licensed Nurse (LN) and the Director of Staff Development (DSD), highlighted a lack of adherence to the facility's policy of offering showers at least twice a week. The DSD acknowledged complaints from residents about missed or delayed showers and confirmed that an in-service was conducted for evening shift staff, but not for the day shift. The Assistant Director of Nursing (ADON) emphasized the importance of documenting shower provision and addressing repeated refusals in the care plan. The facility's policies on showering and refusal of treatment were not followed, contributing to the deficiency in care.
Failure to Provide Ordered Wound Treatments
Penalty
Summary
The facility failed to provide wound treatments as ordered for a resident, leading to the potential for delayed healing and worsening of wounds. The resident, who was admitted with functional quadriplegia and joint contractures, had a care plan and physician orders for daily wound treatment on the left neck. However, the Treatment Administrative Record (TAR) indicated that wound treatments were not provided on two consecutive days. The resident was later found with maggots in her left ear and was sent to the hospital for evaluation. Interviews and record reviews revealed that the resident preferred to lift her own head during treatments due to pain, and there was no documented evidence of treatment refusal or reasons for missed treatments on the specified dates. The wound treatment nurse acknowledged the difficulty in treating the resident's neck area due to contractures but confirmed that treatments were not performed on the weekend. The registered nurse who provided treatment on a previous date did not notice anything unusual with the wound and emphasized the importance of daily wound care. The Assistant Director of Nursing (ADON) confirmed that wound treatments were not documented as completed on the specified dates and acknowledged the lack of documentation for treatment refusal. The facility's policy on skin and wound management requires licensed nurses to document the effectiveness of treatments, but this was not adhered to in this case. The facility's administrator and director of nursing were unavailable for interviews.
Unauthorized Disclosure of Resident's PHI
Penalty
Summary
The facility failed to safeguard a resident's protected health information (PHI) by disclosing it without proper authorization. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and had intact cognitive abilities as indicated by a BIMS score of 15, was capable of making his own decisions. Despite this, the facility's social services director contacted the resident's family, listed as the emergency contact, without the resident's permission. The resident stated that it was not an emergency and he did not want his family to know about his whereabouts. During an interview, the social services director acknowledged contacting the family without the resident's authorization, stating the intention was to gather information for the resident's discharge plan. The director of nursing confirmed that permission should have been obtained from the resident before contacting the family. The facility's policy on third-party disclosure of PHI, dated 12/1/12, mandates upholding residents' rights under federal and state health privacy laws, which was not followed in this instance.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for two residents. Resident 1, who was admitted with an anxiety disorder, was prescribed Ativan 0.5 mg to be taken once in the afternoon. However, the Controlled Drug Record indicated that Resident 1 received Ativan more than once a day on specific dates in June 2024. The Director of Nursing (DON) acknowledged that the physician's orders were not followed in this case. Resident 2, admitted with osteomyelitis of the left foot, had a physician's order for Cefazolin 2 grams to be administered intravenously every eight hours for a bacterial infection. The Medication Administration Record showed that the Cefazolin was not administered on four separate occasions in July 2024. The DON confirmed that the IV antibiotic was not given as ordered, which was not acceptable according to the facility's expectations.
Failure to Implement Timely Nutrition Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline nutrition care plan within 48 hours of admission for a resident during a complaint investigation. The resident was admitted with a history of chronic obstructive pulmonary disease (COPD) and had moderate cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The dietary service supervisor (DSS) acknowledged that the care plan was initiated late, on May 23, 2024, instead of within the required 48-hour timeframe. The DSS was unaware of the specific timeframe for initiating a baseline care plan, which is crucial for preventing weight loss by understanding the resident's meal preferences. The registered dietitian (RD) expected the DSS to gather information about the resident's food preferences upon admission and complete the care plan within 48 hours. The RD noted that the resident disliked oatmeal and spinach, as observed by the DSS on May 20, 2024, but this information was not included in the care plan. The facility's policy, dated November 2018, requires that a baseline care plan be completed within 48 hours of admission. The failure to timely incorporate the resident's food preferences into the care plan had the potential to lead to weight loss and a decline in health status due to poor meal intake.
Failure to Complete Comprehensive Discharge Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive discharge care plan was completed for Resident 2, who was admitted with a history of diabetes mellitus type 2 with circulatory complications. The Minimum Data Set (MDS) dated 1/24/24 indicated that Resident 2 had a moderate cognitive impairment, and there was no referral to a local contact agency for post-discharge transition. Resident 2's physician's orders included wound care treatments and a discharge order with home health for wound management. However, during an interview and record review on 5/7/24, the social services director (SSD) could not locate Resident 2's discharge care plan and acknowledged that it was not completed. The director of nursing (DON) also confirmed that the discharge care plan was missed and emphasized the importance of having it updated to ensure a safe discharge for Resident 2. The facility's policy and procedures titled
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medication orders for two residents were administered as ordered. Resident 1, who was admitted with diagnoses including muscle weakness and a fracture of the right femur head, was supposed to receive Lidocaine gel 4% topically every morning according to physician's orders dated 2/2/2024. However, during a medication administration observation on 4/18/2024, the Lidocaine gel was not administered by the licensed nurse. Resident 1 also stated that he did not remember receiving the medication every morning. The licensed nurse confirmed that the medication should have been administered and acknowledged that there was no documentation of physician notification or progress notes regarding the unavailability of the medication. Resident 2, admitted with diagnoses including osteoarthritis, was to receive 4 Lidocaine patches 4% to the lower back and 1 Lidocaine patch 4% to the neck and cervical spine every morning as per physician's orders dated 12/1/2023. The medication administration record (MAR) for April 2024 indicated that the Lidocaine patches were not given on 4/16, 4/17, and 4/18, with reasons including refusal by the resident, being held, and unavailability. There was no documentation in the nursing progress notes indicating that the physician was notified of the missed medications. Both the licensed nurse and the Director of Nursing acknowledged that the physician should have been notified and documentation should have been made in the resident's chart when medications were not administered as ordered.
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 540 citations issued within 25 miles in the last 12 months — including the 3 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 San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Heights Healthcare Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Mission Hills Post Acute Care | 3 mi | ★★★★★ | 0 | 0 |
| Balboa Nursing & Rehabilitation Center | 3.6 mi | ★★★★★ | 7 | 0 |
| St. Pauls Health Care Center | 3.7 mi | ★★★★★ | 9 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 4.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.