Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Shores Post-acute during CMS and state inspections, most recent first.
The facility failed to report an unusual occurrence to the Department when a resident with altered mental status and critically low oxygen saturation was transferred to the hospital, later died, and was subsequently confirmed to have Legionnaires' disease. The IPN acknowledged that the positive Legionnaires' test result, communicated by the County Nurse, was not reported to the Department. The DON confirmed that this incident should have been reported within 24 hours in accordance with the facility’s "Unusual Occurrences" policy, which requires reporting of epidemic outbreaks and other events that threaten the health or safety of residents, staff, or visitors.
A resident with hemiplegia who tested positive for Influenza A was placed on contact/droplet precautions with posted signage indicating the need for a surgical mask, gown, and gloves. Despite this, a CNA entered the resident’s room, interacted with the resident, and handled the lunch tray without wearing a gown or gloves, then exited without doffing PPE or performing the full required protocol. The CNA later stated she had not realized the room was under contact/droplet precautions but understood the expectation to use full PPE and hand hygiene. The IP and DON confirmed that staff were required to follow posted transmission-based precaution signage and the facility’s PPE policy, which specifies PPE use based on the type of isolation and potential exposure.
A resident deposited $1000 in cash with facility staff for placement in the facility safe, and the deposit was correctly recorded in the safe log. When the resident later requested to withdraw the funds, the money was missing and there was no documentation of any authorized access, withdrawal, or release of the funds. Social services staff could not account for the missing money or provide records explaining its disposition, despite a facility policy requiring that all resident funds be handled to ensure the safety and integrity of each transaction.
A resident with a history of psychiatric disorders and high risk for wandering was admitted without a baseline care plan addressing their elopement risk. Despite assessments indicating the need, no interventions or instructions were documented, resulting in the resident eloping while under staff escort for an outpatient appointment.
A resident with a history of psychiatric disorders and high risk for wandering was not provided with a care plan addressing her elopement risk and was left unsupervised during an outpatient appointment. The CNA escort briefly fell asleep and later left the resident unattended, resulting in the resident leaving the clinic unnoticed. The resident was missing for over 24 hours, traveled a significant distance, consumed alcohol and medications, and was eventually found at a hospital with pneumonia and altered mental status.
A resident with Parkinsonism and End Stage Renal Disease was discharged to an assisted living facility, requiring ongoing dialysis. The case manager communicated the resident's care needs to the receiving facility via email and text, but failed to document this coordination in the resident's EHR at the time of discharge. The required documentation was only entered weeks later, contrary to facility policy and expectations.
A resident with a history of stroke and significant care needs was discharged from an LTC facility without adequate caregiver support, leading to re-hospitalization. The Social Service Director failed to ensure a safe discharge plan, relying on a care management company that did not provide 24-hour care. The resident's son requested a caregiver, but the facility did not arrange for proper support or training, resulting in the resident's return to the hospital.
The facility failed to develop and implement comprehensive care plans for residents, leading to potential risks and inconsistent care. A resident on fluid restrictions lacked a care plan for fluid overload, resulting in fluid intake exceeding limits. Another resident, identified as a smoker, did not have a safe smoking care plan. A third resident had two medication patches applied simultaneously and an incorrectly set pressure-relieving mattress. Lastly, a resident's care plan lacked personalized activities, contributing to social isolation.
The facility failed to follow safe food handling practices, including unlabeled and undated food in refrigerators, incomplete temperature logs, and inadequate hand hygiene by dishwashers after trash disposal. These actions were against the facility's policies, risking food safety and cross-contamination.
The facility failed to maintain infection control practices, including improper handling of urinary catheter tubing, unsanitary wrist splint maintenance, undated oxygen tubing, and lack of gown use for residents on Enhanced Barrier Precautions. These actions increased the risk of infection and cross-contamination among residents and staff.
A resident with a urinary catheter bag was observed without a dignity bag covering it, contrary to the facility's policy and care plan. Staff interviews confirmed the oversight, noting the resident had returned from the hospital the previous night and the dignity bag should have been applied to protect the resident's privacy.
A facility failed to provide a written notice of transfer to a resident's responsible party and the LTC Ombudsman. The deficiency was identified when Resident 296 was transferred to the hospital after being found unconscious, but no documentation of the required notice was found. The DON confirmed the oversight, which was against the facility's policy requiring written notice in cases of immediate transfer due to urgent medical needs.
A resident experienced an unwitnessed fall resulting in a wrist sprain, which was not reported to CMS as required. The MDS assessment failed to capture the fall, leading to an incomplete report of the resident's condition. Interviews with staff confirmed the oversight, highlighting a lapse in following reporting protocols.
A resident with dementia and a history of falls did not have their care plan updated to include a positioning aide, such as a pillow under the sheet, to prevent falls. Staff interviews revealed inconsistent use of this intervention, and the Director of Nursing confirmed the care plan should have been updated according to facility policy.
A resident admitted with multiple pressure injuries did not receive a low air loss (LAL) mattress as ordered by the physician. The resident was observed on a regular mattress, and staff acknowledged the oversight. The facility's policy and care plan indicated the need for a LAL mattress to prevent further skin breakdown, but it was not provided, posing a risk to the resident's condition.
The facility failed to conduct a quarterly smoking assessment for a resident with chronic kidney disease, potentially compromising safety. Additionally, another resident with balance issues was observed eating in an unsafe manner due to improper meal tray setup. The facility lacked a policy for meal tray arrangements, contributing to the oversight.
A resident with hypertensive chronic kidney disease did not receive prazosin as ordered due to a nurse holding the medication without physician approval. The nurse failed to notify the physician, contrary to facility policy, which requires immediate notification if medications are held without parameters.
A resident's medication was left unattended at the bedside, posing a risk of misuse or unauthorized access. A nurse found an unlabeled pill on the resident's table, which was against the facility's policy. Interviews with staff confirmed that medications should not be left unattended, as it could lead to safety concerns or medication divergence.
A resident with a history of CHF was served coffee despite it being listed as a food intolerance. Interviews with CNAs and a Licensed Nurse revealed that the responsibility for checking meal tickets was not properly executed, leading to the resident's dissatisfaction. The DON confirmed the expectation to honor food preferences.
The facility failed to accurately document the care of two residents, leading to deficiencies. A resident with a central line for dialysis was incorrectly documented as having a shunt, while another resident prescribed a low air loss mattress was observed on a regular mattress, with inaccurate records indicating otherwise. Interviews revealed a lack of training and understanding among staff, and the DON stressed the need for accurate documentation.
A survey found that 113 rooms in the facility did not meet the minimum space requirement of 80 square feet per resident. Despite this deficiency, no adverse effects on residents' health, safety, or quality of life were observed. A room size waiver is recommended to continue, as the current room sizes are deemed acceptable under the circumstances.
The facility failed to implement its elopement policy when a resident with paranoid schizophrenia and moderate cognitive impairment eloped. Staff did not initiate the required emergency procedures immediately upon noticing the resident was missing, delaying the search and notification process.
A resident admitted with sepsis and pyomyositis had an IV antibiotic order incorrectly transcribed as an intramuscular injection. The error was identified during a review with the ADON and RN, who could not explain the discrepancy. The facility's policy on reconciling medication lists was not followed, potentially leading to a medication error.
Failure to Report Resident’s Legionnaires' Disease as an Unusual Occurrence
Penalty
Summary
The facility failed to report an unusual occurrence to the Department when a resident was known to have Legionnaires' disease. During an abbreviated survey, the Infection Preventionist Nurse (IPN) reported that the resident had been transferred to the hospital for altered mental status and a very low oxygen saturation of 38%, and subsequently died in the hospital. The IPN stated they did not become aware that the resident had Legionnaires' disease until notified by the County Nurse of a positive test result, and acknowledged that the case was not reported to the Department as required. The Director of Nursing confirmed that the incident should have been reported to the Department to comply with facility policy and regulations. Per the facility’s undated policy and procedure titled "Unusual Occurrences," the facility is required to report occurrences such as epidemic outbreaks, poisoning, fires, major accidents, death from unnatural causes, or other catastrophes and unusual occurrences that threaten the welfare, safety, or health of residents, personnel, or visitors within 24 hours. Despite this policy, the resident’s confirmed Legionnaires' disease case was not reported to the Department, resulting in a delay by the Department in beginning their investigation.
Failure to Use Required PPE for Resident on Contact/Droplet Precautions for Influenza A
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently used required personal protective equipment (PPE) for a resident on contact/droplet precautions for Influenza A. Resident 10, admitted with hemiplegia, tested positive for Influenza A following persistent cough and flu-like symptoms and was placed on contact/droplet precautions with isolation in their room. Facility signage at the room indicated droplet/contact precautions and displayed required PPE, including a surgical mask, gown, and gloves. The Infection Preventionist (IP) reported that multiple Influenza A cases had occurred among residents and a staff member, that positive residents were isolated in their rooms, and that mandatory masking and specific PPE requirements for contact/droplet isolation rooms were in place. During an observation of Resident 10’s room, a CNA was seen entering and interacting with the resident without wearing a gown or gloves, despite the posted droplet/contact precaution signage and PPE requirements. The CNA handled the resident’s lunch tray and spoke with the resident, then exited the room without donning or doffing the required gown and gloves. In an interview, the CNA stated she did not realize the room was under contact/droplet precautions but acknowledged that the expectation was to sanitize hands, don full PPE (mask, gown, gloves) before entering, and remove PPE and perform hand hygiene upon exit, and that failure to wear PPE could result in catching or spreading the virus. The IP and DON both confirmed that staff were expected to follow the signage and wear the required PPE for the assigned isolation type, consistent with the facility’s PPE policy, which states that PPE is based on the type of transmission-based precaution and that employees who fail to use PPE when indicated may be disciplined.
Failure to Safeguard and Account for Resident Trust Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage personal financial affairs when cash entrusted to the facility for safekeeping went missing. According to interviews with the Administrator (ADM) and Director of Nursing (DON), the resident deposited $1000 in cash into the facility safe through the social services office on 9/25/25, and the funds were correctly logged as received in the safe log. When the resident later attempted to withdraw the money on 2/17/26, the funds were not in the safe, and there was no documentation of any authorized access, withdrawal, or release of the money. Social services staff were unable to account for the missing funds or provide any documentation showing an authorized transaction. Review of the facility’s resident trust policy indicated that all resident funds received in the facility were to be handled in a manner that ensured the safety and integrity of the transaction. This deficiency centers on the lack of documentation and accountability for the resident’s deposited funds, as evidenced by the safe log showing only the initial receipt entry with no corresponding record of withdrawal or release, and the inability of staff to explain or substantiate what happened to the money.
Failure to Develop Baseline Care Plan for High-Risk Wandering Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was identified as high risk for wandering and elopement. Despite the resident's documented history of psychiatric conditions, including bipolar disorder, psychosis, major depressive disorder, and a history of increased agitation and auditory hallucinations, no care plan was created to address the resident's high risk of wandering. The resident's clinical record and assessments indicated a high risk for wandering, but this was not reflected in a care plan with specific interventions. On the day of the incident, the resident was escorted by a CNA to an outpatient appointment but was lost during the outing. Staff interviews revealed that while the resident was considered alert and ambulatory, there was an expectation that staff would closely monitor residents, especially those at high risk. However, the lack of a care plan meant there were no documented interventions or instructions for staff to follow, which contributed to the resident's successful elopement from the facility. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident in question.
Failure to Supervise High-Risk Resident During Outing Leads to Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and accident hazard prevention for a resident under conservatorship with a known high risk for wandering. The resident, who had diagnoses including convulsions, bipolar disorder, psychosis, and major depressive disorder, was placed in a locked unit due to her risk of elopement. Despite this, there was no care plan developed to address her high risk for wandering, as confirmed by record review and staff interviews. On the day of the incident, a CNA was assigned to escort the resident to an outpatient appointment. While waiting at the clinic, the CNA briefly fell asleep and later left the resident unattended to use the bathroom without arranging for another staff member to supervise. Upon returning, the CNA assumed the resident had been called in for her appointment, but later realized she was missing. The resident was not found for over 24 hours, during which time she traveled more than 11 miles from the facility, consumed alcohol, took her prescribed antipsychotic and antidepressant medications, and was eventually found at a hospital emergency department with pneumonia and altered mental status. Interviews with staff revealed that the expectation was for residents to never be left unattended during outings, and that staff should notify others if they needed to step away. The facility's policies required identification of residents at risk for wandering and the development of care plans with specific interventions, but these were not followed in this case. The lack of a resident-centered care plan and failure to maintain supervision directly led to the resident's elopement and subsequent hospitalization.
Failure to Timely Document Discharge Coordination in Medical Record
Penalty
Summary
The facility failed to ensure that documentation regarding the coordination of care during the discharge process was entered into the medical record in a timely manner for one resident. The resident, who had diagnoses including Parkinsonism and End Stage Renal Disease, was discharged to an assisted living facility and required transportation to dialysis. Although the case manager communicated the resident's needs to the receiving facility via email and text message, this communication was not documented in the resident's electronic health record at the time of discharge. The case manager acknowledged that all relevant information was kept in personal emails and text messages rather than being properly charted in the resident's medical record. A review of the records showed that the case manager's progress note documenting the coordination of care was created and signed several weeks after the resident's discharge. The facility's policy required that details of transfers or discharges be documented in the medical record and communicated to the receiving provider. The DON confirmed that documentation should have been entered into the resident's record and stated that, despite the late entry, the expectation was for timely documentation of such communications.
Inadequate Discharge Planning Leads to Re-hospitalization
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to the resident's re-hospitalization. The resident, who had a history of cerebral infarction with left hemiplegia and hemiparesis, was discharged home without adequate caregiver support. The Social Service Director (SSD) had initially discussed the discharge with the resident's son, who requested a 24-hour caregiver due to his inability to provide the necessary care. However, the resident did not qualify for such services, and the SSD relied on a care management company that did not provide 24-hour care. Upon discharge, the resident found herself without the promised caregiver support, as her former roommate, who was supposed to assist, was not capable of providing the required care. The SSD failed to confirm the son's availability on the discharge date and did not document attempts to ensure a safe discharge plan. The resident required significant assistance with daily activities, including toileting, transfers, and dressing, and was unable to walk, necessitating a wheelchair. The lack of proper caregiver arrangements and training for the resident's son or former roommate contributed to the resident's re-hospitalization. The facility's discharge care plan was outdated and did not reflect the resident's current needs or the arrangements for her care. The Director of Nursing (DON) noted the absence of documentation supporting an updated discharge plan and emphasized the importance of thorough planning and caregiver training to prevent re-hospitalizations. The facility's policy required teaching and discharge instructions for residents being discharged home, which were not adequately provided in this case.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks and inconsistent care. Resident 264, who was on fluid restrictions due to emphysema and arteriosclerotic heart disease, did not have a care plan addressing fluid overload or non-compliance with fluid restrictions. This oversight resulted in the resident exceeding the fluid limit on multiple occasions without proper documentation or physician notification, increasing the risk of respiratory and heart problems. Resident 283, identified as a smoker requiring supervision, lacked a care plan for safe smoking. Despite an initial smoking assessment indicating the need for a plan of care, no documented evidence of such a plan was found. This omission posed a risk to the resident's safety, as confirmed by interviews with nursing staff and the Director of Nursing. Resident 95 experienced two deficiencies: the failure to remove an old medication patch before applying a new one, and the incorrect setting of a pressure-relieving mattress. The presence of two rivastigmine patches on the resident's shoulder indicated a lapse in medication administration protocol. Additionally, the mattress was set to an incorrect setting, contrary to the physician's order, which could affect the resident's comfort and wound management. Lastly, Resident 145's care plan did not reflect personalized activities, such as music and outdoor activities, which the resident enjoyed. This lack of personalization contributed to the resident's social isolation and dissatisfaction with the facility's activity offerings.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure safe food handling practices in several instances. In the kitchen's reach-in refrigerator, containers of cut and peeled cantaloupe and watermelon were found without labels or dates, making it impossible to determine when the fruit was received, cut, or prepared. This was against the facility's policy, which requires all prepared foods to be covered, labeled, and dated. Additionally, in one of the resident refrigerators, a jar of cheese dip was not labeled with the date it was opened, and the resident's name on the jar did not match any current resident, indicating it should have been discarded. The facility's policy mandates that resident food be labeled and monitored, with unused food discarded within two days. Furthermore, the temperature log for another resident refrigerator was incomplete, with no entries for specific shifts, which could lead to food spoilage if the refrigerator temperature was not properly maintained. Additionally, two dishwashers failed to perform hand hygiene after disposing of trash, risking cross-contamination. One dishwasher returned to cleaning dishes without removing gloves or washing hands, while the other handled pots with bare hands after trash disposal without performing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of handwashing to prevent infection spread.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention practices for several residents, leading to potential health risks. Resident 218's urinary catheter tubing was observed to be in contact with the floor, which was against the facility's policy and increased the risk of infection. Both a Certified Nursing Assistant and a Licensed Nurse acknowledged the issue, and the Director of Nursing confirmed that the tubing should never have been on the floor. Resident 75's wrist splint was not maintained in a sanitary manner, as it was observed to be dirty with dark smudges. Despite being aware of the condition, the nursing staff did not contact the physician in a timely manner to address the issue, which could have led to cross-contamination. The Director of Nursing admitted that the splint should have been replaced or cleaned to prevent potential infection. For Residents 65 and 8, the oxygen tubing was not dated, which is a critical step in infection control to ensure timely replacement. The facility's policy required nasal cannulas to be changed every two weeks, but the lack of dating made it impossible to track when replacements were due. Additionally, staff failed to use disposable gowns for residents on Enhanced Barrier Precautions, increasing the risk of spreading multidrug-resistant organisms. The facility's policies and training emphasized the importance of gown use during high-contact activities, but staff did not adhere to these guidelines.
Failure to Maintain Resident Dignity with Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 218, who was readmitted with a urinary tract infection and had an indwelling urinary catheter. During an observation, it was noted that the urinary catheter bag was visible and not covered with a dignity bag, as required by the facility's policy and the resident's care plan. The catheter bag was clipped to the bed frame and contained cloudy, pale-colored urine, which was visible upon entering the room. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the dignity bag was not in place, and it should have been used to protect the resident's privacy. The CNA mentioned that Resident 218 had returned from the hospital the previous night, and the dignity bag should have been placed upon their return. The facility's policy explicitly prohibits practices that compromise dignity and mandates that urinary catheter bags be covered to maintain residents' dignity.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of the residents reviewed for closed records. This deficiency was identified during an interview and record review, which revealed that Resident 296 was transferred to the hospital for evaluation after being found unconscious. However, there was no documentation indicating that a written notice of transfer was provided to the resident's RP or sent to the Long-Term Care Ombudsman. The director of nursing (DON) confirmed during an interview that Resident 296's clinical record lacked documentation of the required written notice of transfer. According to the facility's policy, a written notice should have been completed by the nursing staff and provided to both the resident's RP and the Long-Term Care Ombudsman. The policy specifies that in cases of immediate transfer due to urgent medical needs, the notice should be given as soon as practicable, including details such as the reason for transfer, effective date, location, and the resident's right to appeal the transfer.
Failure to Report Significant Change in Condition
Penalty
Summary
The facility failed to report a significant change in condition for a resident to the Centers for Medicare and Medicaid Services (CMS). The resident, who was readmitted to the facility with a sprain to the left wrist following a fall, was observed with a splint on the wrist. The clinical record indicated an unwitnessed fall occurred, resulting in wrist pain and a subsequent emergency room visit that confirmed soft tissue swelling and severe osteoarthrosis. However, the Minimum Data Set (MDS) assessment did not capture this fall, and it was not reported to CMS as required. Interviews with the MDS Nurse and the Director of Nursing revealed that the fall should have been included in the Significant Change of Condition report but was missed. The MDS Nurse acknowledged that the omission meant CMS did not have an accurate picture of the resident's current health status. The facility's policy and the Resident Assessment Instrument require that any fall, including those with minor injuries, be reported to CMS, but this protocol was not followed in this instance.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 273, to include a positioning aide to prevent falls. Resident 273 was admitted with diagnoses including dementia, weakness, and repeated falls, indicating a high risk for falling. During an observation, it was noted that a pillow was placed under the sheet at the exit of the bed, but there were no orders or care plans documenting this intervention. Interviews with staff revealed inconsistent use of the pillow as a positioning aide, with some staff members using it and others not. The Director of Nursing acknowledged that the care plan should have been updated to include the use of a pillow as a positioning aide. The facility's policy on comprehensive, person-centered care plans requires that the care plan describe the services to be furnished to maintain the resident's highest well-being. The lack of documentation and inconsistent application of the positioning aide could lead to the resident not receiving the necessary intervention to prevent falls.
Failure to Provide Low Air Loss Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to provide a low air loss (LAL) mattress for Resident 105, who was admitted with multiple pressure injuries and a physician's order for such a mattress. On observation, Resident 105 was found lying on a regular mattress, contrary to the physician's order dated 10/22/24, which specified the use of a LAL mattress for wound management and preventive measures. The Treatment Nurse acknowledged that Resident 105 should have had a LAL mattress upon admission, as it was a physician's order, but was overlooked. Interviews with the Wound Nurse Practitioner and the Director of Nursing confirmed the importance of a LAL mattress for Resident 105 to help distribute weight and relieve pressure points, which are crucial for preventing further skin breakdown. The facility's policy also indicated that individuals at risk for pressure ulcers should be placed on a redistribution support surface like a LAL mattress. Despite these guidelines and the resident's care plan, the necessary equipment was not provided, leading to a potential risk for the resident's condition to worsen.
Failure to Conduct Smoking Assessment and Ensure Safe Eating Environment
Penalty
Summary
The facility failed to conduct a quarterly safe smoking assessment for a resident, which is required to ensure the resident's ability to smoke safely. Resident 283, who was admitted with chronic kidney disease and had an intact cognitive score, was identified as a smoker needing supervision. However, the quarterly smoking assessment due in October 2024 was not completed. Interviews with the Licensed Nurse, Minimum Data Set Nurse, and Activities Director revealed that the assessment was missed, which could have led to potential harm due to the resident's health possibly declining without reassessment. Additionally, the facility did not ensure a safe eating environment for Resident 259, who had mild neurocognitive disorder, malnutrition, and gout. The resident, who had balance issues and primarily used a wheelchair, was observed eating while standing in a hunched position because the meal tray was placed on a low table without a seating arrangement. The CNA responsible did not adjust the table or inquire about the resident's preference for eating while seated, leading to an unsafe situation where the resident had to maintain balance while eating. The Director of Nursing acknowledged that the lack of a quarterly smoking assessment and improper meal setup could pose safety risks to the residents. The facility's smoking policy required quarterly evaluations, but there was no policy for setting up meal trays, contributing to the oversight in Resident 259's case.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a physician's order was followed during medication administration for a resident diagnosed with hypertensive chronic kidney disease. On the observed date, a Licensed Nurse (LN) did not administer prazosin, a medication prescribed to manage high blood pressure in patients with kidney disease, to the resident. The medication was scheduled to be given at 9 A.M., but the LN held the medication without any hold parameters or physician's order to do so. The LN did not notify the physician about holding the medication, which was against the facility's policy. The Director of Nursing (DON) confirmed that it was expected for nurses to notify the physician immediately if a medication was held without hold parameters to prevent delays in medication administration. The facility's policy on administering medications emphasized that medications should be administered according to prescriber orders and within one hour of the prescribed time.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medication for one of the sampled residents, identified as Resident 145. During an observation, a licensed nurse (LN 56) found an unlabeled medication cup containing an oval-shaped yellow pill left unattended on the bedside table of Resident 145, who was asleep at the time. LN 56 acknowledged that leaving medication unattended was not a safe practice and could pose a safety concern for other residents or visitors who might take the pill without permission, potentially leading to an allergic reaction. LN 56 emphasized the importance of adhering to the five rights of medication administration to ensure the medication is taken correctly and monitored for side effects. Further interviews with another licensed nurse (LN 52) and the Director of Nursing (DON) confirmed that medications should not be left unattended for any reason. LN 52 reviewed a picture of the unattended medication and reiterated the importance of witnessing the resident take the medication for safety reasons. The DON stated that leaving medications unattended could lead to medication divergence or allergic reactions if taken by someone other than the prescribed resident. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 51, who was readmitted with a history of congestive heart failure. Despite having a documented dislike and intolerance for coffee, Resident 51 was served coffee on his meal tray. This oversight was observed during an interview and record review, where Resident 51 expressed dissatisfaction with receiving coffee, which was clearly listed as a food intolerance on his nutritional evaluation. Additionally, Resident 51 mentioned that his preference for two butter packets with pancakes was often overlooked by the facility staff. Interviews with facility staff, including CNAs and a Licensed Nurse, revealed that the responsibility for checking meal tickets and ensuring preferences were honored lay with the CNAs. However, the CNAs admitted to failing to adhere to Resident 51's preferences, acknowledging that coffee should not have been placed on his tray. The Director of Nursing confirmed that it was expected for the nursing staff to honor Resident 51's food preferences and recognized that the failure to do so led to Resident 51's understandable frustration.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the medical status of two residents, leading to deficiencies in their care. Resident 183, who was admitted with acute kidney failure, had a central line for dialysis. However, the post-dialysis assessments inaccurately documented the presence of a thrill and bruit, which are characteristics of a shunt, not a central line. Interviews with licensed nurses revealed a lack of understanding and training regarding the differences between central lines and shunts, resulting in incorrect documentation. Resident 105, admitted with hemiplegia and pressure ulcers, was prescribed a low air loss mattress to manage and prevent wounds. Despite this, the resident was observed on a regular mattress, and the electronic Medication Administration Records inaccurately documented the presence and functionality of the low air loss mattress for over a month before it was actually provided. Licensed nurses admitted to documenting the mattress's presence and settings without verifying them, acknowledging the potential harm this could have caused to the resident. The Director of Nursing emphasized the importance of accurate documentation to reflect the actual care and interventions provided to residents. The facility's policies on hemodialysis access care and charting and documentation were not adhered to, as evidenced by the inaccurate records for both residents. This lack of accurate documentation could have significant implications for the residents' health and safety.
Room Size Deficiency Without Adverse Impact
Penalty
Summary
The facility was found to have 113 resident rooms that did not meet the minimum requirement of 80 square feet per resident in multiple occupancy rooms. This deficiency was identified during a survey that included both observation and record review. The rooms in question varied slightly in size, with each providing less than the required space per resident, ranging from approximately 73.88 to 78.91 square feet per resident. Despite this deficiency, the survey did not observe any adverse effects on the residents' health, safety, quality of care, or quality of life. The report notes that the variations in room size did not appear to impact the residents negatively during the survey period. This suggests that while the facility did not meet the regulatory space requirements, the residents' well-being was not compromised as a result. The report recommends the continuance of a room size waiver, indicating that the facility may have previously been granted an exception to the standard room size requirements. This recommendation is based on the lack of observed negative impact on residents, suggesting that the facility's current room sizes, although non-compliant, are deemed acceptable under the circumstances.
Failure to Implement Elopement Policy
Penalty
Summary
The facility failed to implement its elopement policy when a resident with a history of paranoid schizophrenia and moderate cognitive impairment eloped from the facility. The resident was admitted with a moderate risk for elopement, as indicated by an Elopement Risk assessment. On the night of the incident, the certified nursing assistant (CNA) did not see the resident during her shift and only realized the resident was missing during her final rounds. The licensed nurse/charge nurse (LN) also noticed the resident was not in the facility but did not initiate the facility-wide emergency procedure or notify the Director of Nursing (DON) immediately, as required by the facility's policy. The DON confirmed that the LN should have initiated a Code [NAME] and started searching for the resident as soon as it was noticed that the resident was missing. The facility's elopement policy clearly states that a missing resident is considered a facility-wide emergency, and immediate actions should be taken to locate the resident. The failure to follow these procedures delayed the search and notification process, potentially affecting the resident's health and safety.
Failure to Accurately Transcribe Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to accurately transcribe an admission order for an intravenous (IV) antibiotic for a resident admitted with diagnoses of sepsis and pyomyositis. The resident was transferred from another facility with medication orders that included Ertapenem 1 gram IV every 24 hours. However, upon admission, the order was incorrectly transcribed as Ertapenem 1 gram intramuscularly once a day. This discrepancy was identified during a concurrent interview and record review with the Assistant Director of Nursing (ADON), who confirmed that the report from the transferring facility included orders for IV antibiotics, not intramuscular injections. Further investigation revealed that the Registered Nurse (RN) responsible for transcribing the admitting orders did not know how the error occurred. The facility's policy on admission assessment and follow-up, which requires nurses to reconcile medication lists from the medication history, admitting orders, and discharge summary from the previous institution, was not followed. This failure had the potential to result in a medication error for the resident, as confirmed by the ADON and the Director of Nursing (DON).
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 629 citations issued within 25 miles in the last 12 months — including the 2 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
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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) |
|---|---|---|---|---|
| Helen Bernardy Center D/p Snf | 0.4 mi | ★★★★★ | 0 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 1.3 mi | ★★★★★ | 1 | 0 |
| Hillcrest Heights Healthcare Center | 3.3 mi | ★★★★★ | 1 | 0 |
| Mission Hills Post Acute Care | 3.6 mi | ★★★★★ | 0 | 0 |
| Balboa Nursing & Rehabilitation Center | 3.6 mi | ★★★★★ | 11 | 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 June 2026) and official state health department websites.