Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Town & Country during CMS and state inspections, most recent first.
A resident with documented lack of decision-making capacity and unclear, slurred speech on the MDS had multiple skilled nursing evaluations recorded over several days indicating clear speech, contrary to staff observations. During interviews, an LVN, a treatment nurse, and a CNA all reported that the resident’s speech was not clear and was difficult to understand, and the DON verified that the medical record entries documenting clear speech were inaccurate and inconsistent with the resident’s actual condition.
Food safety and sanitation failures were identified in the kitchen. Two boxes of thawing chicken thighs were not labeled with a freezer pull date or use-by date, expired cheese remained in refrigeration, a blender was stored with water inside instead of being air dried, the prep sink lacked a proper air gap, a sheet pan with food residue was stored with clean pans, and two cutting boards were stained and heavily marred.
Incomplete Bed Rail Entrapment Assessments: The facility failed to complete accurate and complete entrapment assessments for multiple residents with bed rails in use. Observations and record review showed residents had bilateral one-fourth rails elevated for bed mobility, repositioning, transfers, or security, but the safety assessments were missing documentation for Zone 7 in several cases, one resident’s assessment could not be located, and one resident’s record lacked both a physician order and an entrapment assessment. Staff interviews confirmed the missing or incomplete documentation.
A resident's record lacked the prescriber's clinical rationale for continuing PRN Xanax beyond the 14-day limit. The resident had repeated PRN orders for Xanax for anxiety, and the DON confirmed the chart did not document the required rationale for extending the psychotropic medication.
A facility failed to report a physical abuse allegation to local law enforcement for a resident who stated a CNA was too rough with him. The allegation was reported to the Administrator, but the abuse investigation did not show law enforcement notification, and the DON/Administrator later confirmed the event should have been reported as physical abuse.
The facility failed to follow its abuse protocol when an allegation was made that a CNA hit a resident with severe cognitive impairment. Although the CNA was told to clock out and leave, she returned to the resident’s room and spoke with the resident and family member twice before being escorted out. Interviews confirmed the alleged perpetrator should have been removed from the building immediately to protect the resident.
A resident receiving amlodipine and losartan for HTN was given both medications without a BP check, and the record did not show a physician order to monitor BP. The care plan included vital sign monitoring, but the chart lacked documentation that BP was obtained before the antihypertensives were administered, and an LVN confirmed no BP monitoring order was in place.
A resident with a Foley catheter for urinary retention had inconsistent urine output documentation between CNA task records and LVN MAR entries, along with inaccurate daily total calculations for urine output and fluid intake. The record also showed missing documentation on some days and incorrect shift totals, and an RN verified the discrepancies during concurrent review.
Unclear PICC Orders for A Resident: A resident had multiple IV-related orders for blood draws, dressing changes, saline flushes, connector changes, and monitoring, but only one order clearly identified the access as a PICC. The DON confirmed the orders were not clear and stated they should have specified the PICC line, including whether it was single or double lumen; the DON also noted the catheter site and length could be confused with a urinary catheter.
Two residents with PRN nebulizer orders had their nebulizer masks and medication chambers left improperly cleaned and stored. Surveyors observed one resident’s nebulizer mask connected to the machine and resting on a birthday card with clear liquid still in the chamber, while another resident’s uncovered mask was left on a bedside drawer with the storage bag touching the floor. Staff described inconsistent cleaning and storage practices, including leaving equipment to air dry on tissue paper or a pillowcase.
A resident had bilateral one-fourth bed rails elevated on the bed, and staff verified the rails were used for repositioning. The resident was cognitively intact, but the record lacked a bed rail assessment, physician order, consent, and care plan. The IP and DON both verified the missing documentation.
Incorrect Transcription of Aspirin Order: A resident with thrombocytopenia and on Plavix had an aspirin order discontinued, then later documented to resume when antibiotics were completed or when PLT was >100 k. The EHR order was transcribed incorrectly to say PTT >100 k instead, and RN confirmed the order should have been clarified because it did not make sense as written. The prescriber’s written order sheet was unsigned and undated, and the DON stated the paper orders were being used as a communication tool and treated like verbal orders.
Medication Storage and Handling Deficiencies: An LVN left prepared meds unattended at the bedside for one resident and another resident, including oral meds, an injection, a nasal spray, and an inhaler. Surveyors also found compromised bubble packs for gabapentin and zolpidem, an opened single-use calcium alginate pack, an expired bottle of sterile water, and a medication refrigerator at 50 degrees F with IV antibiotics inside.
A resident on an SB6 diet was served Cheerios on the breakfast tray even though the facility’s diet manual and menu spreadsheet specified only SB6-appropriate items for that meal. The resident said she was surprised to receive the cereal, and the RD stated the resident should not have received Cheerios with the diet order.
Failure to honor a resident's no-pork dietary preference: A resident with a physician order for no pork and a stated Muslim religious preference was served a lunch tray containing pork barbecue. The tray was observed with another resident's name on it, and an LVN stated she did not know why it was served to the resident. The DON acknowledged the findings.
No Storage or Reheating Available for Visitor-Brought Food: The facility had no microwave or refrigerator available for residents to store or reheat food brought in by family or visitors. Staff stated outside food had to be consumed right away, and residents reported the facility no longer allowed food storage and had no separate refrigerator for that purpose.
Failure to follow hand hygiene and EBP practices occurred for two residents. For one resident with severe cognitive impairment and a Foley catheter for wound management, a CNA provided incontinence and catheter care, then placed a new brief using the same gloves without changing them or performing hand hygiene. For another resident on EBP due to a history of colonized MDRO, a COTA transferred the resident from a wheelchair to bed while wearing a mask and gloves but no gown, despite an EBP sign outside the room directing staff to wear gown and gloves for high-contact care.
The facility failed to keep two glucometers in safe operating condition. One glucometer in Medication Cart B had test strips whose lot number and range information did not match the QC log, and one glucometer in Medication Cart A did not match the serial number listed in the QC log; its memory also did not show the ctl icon for prior QC testing, and there was no documentation that QC testing had been performed for that device. The Administrator and DON verified the findings.
Call light system not audible at Nurse Stations A and B. Staff observed call lights activated in multiple resident rooms while passing by without responding, and the console at Nurse Station B had no audible sound until the volume was adjusted. At Nurse Station A, call lights in several rooms flashed without an audible alert, and the Unit Secretary reported the console should alert regular and emergency call lights from SNF rooms at both stations.
A facility failed to honor the choice of two cognitively intact residents when staff entered their room early in the morning, turned on the lights, and moved wheelchairs and personal items without asking permission. Both residents said they wanted to keep sleeping and felt disrespected, and staff confirmed they entered the room to prepare them for breakfast without first asking if they could turn on the lights or move items.
Missing Care Plan for Bed Rail Use: A resident who was cognitively intact and used bilateral one-fourth bed rails for repositioning was observed with the rails elevated on the bed. The medical record did not include a care plan addressing the bed rails, and the IP and DON both verified that no care plan had been developed to reflect the resident's individual needs.
A resident’s comprehensive care plan was not revised when the physician ordered apixaban to be resumed after it had been held for a positive stool occult blood result. The resident had no capacity to make decisions, and the existing care plan still reflected holding the medication until further order even though the resident was receiving apixaban via GT every 12 hours. An LVN and the DON both verified that the care plan should have been updated when the order changed.
Palatability of Shrimp Scampi Meal Not Maintained: Two residents were served shrimp scampi that was dry and lacked the sauce or butter expected with the meal. One resident said she was waiting for sauce and wanted butter, but neither was served with her tray, and she ate pie instead. Another resident said the shrimp needed sauce because it was dry; an LVN confirmed there was no sauce and later brought ketchup after the kitchen did not respond to a request for butter. The Exec Chef stated the dish was cooked with butter, lemon juice, garlic, and parsley, but the sauce may have separated during tray line service.
A resident admitted with an ileostomy did not have a baseline care plan initiated within 48 hours, as required by facility policy. Despite clear hospital discharge instructions for ostomy care, hydration, and monitoring intake/output, staff did not document or implement these interventions, and the DON confirmed the omission.
A resident experienced nausea, vomiting, poor meal intake, and significant weight loss, but staff did not develop or update a care plan to address these changes in condition. Despite facility policy requiring care plan updates for such changes, interviews with the LVN, DON, and RD confirmed that no care plan was initiated for the resident's poor appetite and weight loss.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required.
The facility failed to ensure CNAs followed infection control practices by not wearing gowns during high-contact resident care activities, despite facility policies and signage indicating the requirement. This was observed when CNAs wore only masks and gloves while repositioning a resident, contrary to the guidelines for preventing MDRO transmission. Interviews confirmed the oversight, and the facility administrator acknowledged the findings.
The facility's kitchen failed to meet food safety and sanitation standards, with issues such as unclean ice machines, improperly stored ice scoopers, expired food items, and unsanitary utensils and equipment. Staff did not consistently wear hair and beard restraints, and hand hygiene practices were not followed, increasing the risk of foodborne illnesses among residents.
The facility failed to implement proper infection control measures for a resident with shingles, as a family member was not adequately informed about necessary precautions. Personal items were found in the laundry's clean folding area, violating infection control standards. Additionally, the facility lacked recent documentation for testing Legionella in water systems, with the last assessment completed in 2018.
The facility failed to properly clean two kitchen ice machines according to the manufacturer's instructions, potentially leading to unsanitary ice. The service provider used a sanitizing solution that did not contain the required active ingredient, resulting in residue and particles inside the machines. The DON acknowledged the need to follow the correct cleaning instructions.
The facility failed to conduct entrapment assessments and record measurements for residents using bed rails, affecting 16 out of 53 residents. Observations and interviews revealed that assessments were not performed, and necessary documentation was missing. The Director of Facilities admitted to not being familiar with entrapment zones, and inspections were only conducted upon discharge and quarterly, not upon admission or as needed.
A facility failed to obtain informed consent from a resident's responsible party for the use of side rails and alprazolam, a psychotropic medication. The resident, who lacked decision-making capacity, was observed using side rails without proper consent, and there was no documented consent for alprazolam in the medical records. Interviews with staff confirmed these deficiencies, highlighting a breach in the facility's policies and procedures.
The facility failed to obtain and maintain advance directives for six residents, despite acknowledgments in their records. Interviews and medical record reviews revealed that the facility did not follow up to secure these documents, and POLST forms were incomplete for two residents. This deficiency indicates a failure to adhere to the facility's policy on managing advance directives, potentially impacting residents' healthcare decisions.
A resident with severe cognitive impairment did not receive an individualized activity program to meet their interests, such as group activities and independent pursuits like watching TV and music-related activities. The facility documented the resident's participation in activities only three times, and observations showed the resident often remained in bed without sensory stimulation. The Director of Activities confirmed the lack of documented evidence for daily activities, despite the resident's care plan indicating a need for such engagement.
The facility failed to properly administer medications and monitor residents' conditions, leading to deficiencies in care. A resident received medications simultaneously against physician orders, another resident's significant weight changes were not reported to the physician, and a third resident's blood pressure was not documented when administering hypertension medication. These issues were confirmed by staff during interviews and record reviews.
The facility failed to ensure proper reconciliation and disposal of controlled medications for two residents. One resident's morphine and oxycodone/acetaminophen records did not match the actual count, and the LVN admitted to not signing the records immediately. Another resident's discontinued hydrocodone/acetaminophen was found in the medication cart. The DON confirmed that discontinued medications should be removed promptly, highlighting potential risks for drug diversion and medication errors.
The facility failed to adhere to physician-ordered parameters for medication administration for two residents. One resident received losartan potassium despite having a systolic blood pressure (SBP) below the prescribed threshold, while another received midodrine hydrochloride when their SBP was above the specified limit. These errors were confirmed by staff and acknowledged by the DON.
A facility failed to monitor side effects for a resident prescribed alprazolam for anxiety, as required by their policy. Despite a care plan intervention to monitor behaviors and side effects every shift, there was no documented evidence of such monitoring. This oversight was confirmed by an RN during an interview, highlighting a lapse in adherence to the facility's procedures for psychotropic drug use.
The facility failed to ensure proper storage and labeling of medications, leading to potential cross-contamination. Orally administered medications were stored with external use products, and disinfectant wipes were not separated from treatment supplies. Additionally, a medication bottle was found with sticky residue. These issues were confirmed by nursing staff and acknowledged by the DON.
The facility did not adhere to pureed diet recipes for three residents, potentially compromising their nutritional needs. During an observation, a staff member was seen preparing pureed biscuits and rice without following the specified recipes, using incorrect amounts of hot water. The RD, DSS, Executive Chef, and DON acknowledged the oversight.
The facility failed to provide palatable green beans to four residents, as observed during dining. The residents reported the green beans were tough and not easy to chew, which did not meet their dietary requirements. This issue was confirmed by staff, including an LVN and an RD, who acknowledged the problem with the texture of the green beans.
The facility failed to update its policy on the use and storage of foods brought by visitors and did not educate visitors on safe food handling. The facility lacked a designated refrigerator for resident use, and visitors were not informed about maintaining perishable foods at safe temperatures. This oversight could lead to foodborne illnesses among residents.
The facility failed to ensure resident privacy and confidentiality when the Director of Activities used her personal cell phone to take pictures of residents during activities, violating the facility's policy. The Director admitted to this action, and the Administrator confirmed that staff should use facility-provided devices for such purposes.
The facility failed to remove a CNA from resident care areas pending an alleged abuse violation. After a resident reported being hit by the CNA, the CNA was reassigned to care for another resident and remained at work until the end of her shift, contrary to the facility's policy. This was confirmed through interviews with the CNA, an LVN, and the Administrator.
Inaccurate Documentation of Resident Speech Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, relevant, and complete documentation in the medical record for one resident, as required by its policy on medical record documentation. The facility’s policy, revised on 8/23/23, states that licensed staff and interdisciplinary team members must document all assessments, observations, and services in accordance with state law and facility policy, and that documentation must be accurate and contain sufficient detail about residents’ care and responses to care. For Resident 1, who was admitted on an unspecified date, the history and physical dated 1/11/26 documented that the resident had no capacity to understand and make decisions. The Minimum Data Set (MDS) assessment for this resident documented unclear speech characterized as slurred or mumbled words. Despite the MDS assessment indicating unclear speech, multiple skilled nursing evaluations dated 2/16, 2/18, 2/20, 2/21, 2/22, 2/24, 2/25, 2/27, and 3/1/26 documented that the resident’s speech was clear. During interviews on 3/9/26, LVN 1 stated that the resident was able to answer yes or no when asked about pain, but confirmed that the resident’s speech was not clear as documented. LVN 2, a treatment nurse, reported that when she assessed the resident’s skin, the resident’s speech was not clear. CNA 1 stated that the resident talked a little but was very hard to understand. In a subsequent interview, the DON reviewed the record and verified these findings, confirming that the documentation indicating clear speech was inaccurate in relation to the resident’s actual speech status.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow food safety and sanitation guidelines in multiple areas of kitchen operations. During observation of the walk-in refrigerator, two 40-lb boxes of chicken thighs were found thawing without a use-by date or freezer pull date, even though the facility’s food handling guidelines required raw meat removed from the freezer to be labeled with the date it was pulled and the date by which it must be used. The Executive Chef stated the thawing meat should have been labeled, and the RD later verified the same finding. Additional kitchen observations identified an opened and sealed package of cheese labeled with a facility expiration date of 9/21/25 and another opened and sealed package of cheese labeled with a facility expiration date of 9/9/25, both of which were still present in the refrigerator. The Executive Chef stated the food should have been discarded. Staff also observed a blender stored with water inside instead of being air dried, a preparation sink without a proper air gap, a sheet pan stored with other clean pans but still containing food residue, and two cutting boards that were stained black and heavily marred. The facility’s policies required food-contact items to be clean, properly dried, and stored appropriately.
Incomplete Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed rails were accurate and complete for 10 of 10 sampled residents who had bed rails in use. The deficiency was based on observation, interview, medical record review, facility document review, and policy review. The facility’s policies required assessment of a resident’s risk for entrapment before bed rails were installed or used, including evaluation of the bed frame, mattress, and rail compatibility and inspection for possible entrapment areas. For multiple residents, the records showed physician orders for bilateral one-fourth bed rails to assist with bed mobility, repositioning, transfers, or sense of security, and staff observations confirmed the rails were elevated in the residents’ beds. Several residents were described as having capacity to understand and make decisions, while others were documented as having no capacity. In each reviewed case, the residents were observed using the bed rails for turning, repositioning, or bed mobility, and staff interviews confirmed the rails were in use for those purposes. The entrapment assessments were incomplete or missing. For Residents 1, 3, 7, 8, 10, 37, and 43, the Bed Rail and Mattress Safety assessments documented Zones 1 through 6, but there was no documented evidence that Zone 7, the area between the head or foot board and the mattress end, was assessed. For Resident 29, the Bed Rail Assessment and Consent was present, but the Bed Rail and Mattress Safety Assessment showed no documented evidence that the entrapment zones were assessed. For Resident 58, the Maintenance Staff could not locate the Bed Rail and Mattress Safety Assessment, and the forms reviewed with him also did not show Zone 7. For Resident 11, the record failed to show a physician’s order for the bed rails and failed to show an entrapment assessment had been conducted. The Maintenance Staff stated he did not complete that resident’s assessment and had not received a request through the facility’s application. The Administrator and DON were informed and acknowledged the findings.
Lack of Prescriber Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that one of five sampled residents reviewed for unnecessary medications, Resident 45, was free from unnecessary psychotropic medications. Resident 45 was readmitted to the facility and had multiple physician orders for Xanax 0.25 mg by mouth PRN at night for anxiety, including orders dated 8/20/25, 9/4/25, 9/11/25, and 9/21/25. The facility's Use of Psychotropic Drugs policy, revised 11/13/23, stated that when PRN psychotropic medications extend beyond 14 days, the prescriber shall document the rationale in the resident's medical record. Review of Resident 45's medical record did not show the prescriber's clinical rationale or indication for continuing the PRN Xanax beyond 14 days. On 9/24/25 at 0722 hours, the DON was interviewed and the concurrent record review confirmed that the medical record lacked the prescriber's clinical rationale for extending the PRN Xanax past 14 days.
Failure to Report Physical Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse to local law enforcement for one of three sampled residents investigated for abuse. Resident 32 stated during an interview at the bedside that a CNA was too rough with him, and the allegation was reported to the Administrator. Review of the facility’s abuse investigation did not show that local law enforcement was notified of the allegation. The facility’s Abuse, Neglect, and Exploitation policy stated abuse allegations are to be reported to the required agencies, including law enforcement when applicable, no later than 24 hours, and the California Welfare and Institutions Code required all allegations of physical abuse to be reported to local law enforcement verbally as soon as practically possible and in writing within 24 hours. During a later interview, the Administrator confirmed that Resident 32’s statement about staff being too rough was a physical abuse allegation and verified that local law enforcement was not notified.
Failure to Remove Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to follow its abuse investigation protocol for a resident with severe cognitive impairment and no capacity to understand or make decisions. Resident 46 had a BIMS score of 4 and was involved in an abuse allegation reported by Family Member 1, who stated that CNA 2 allegedly hit the resident. The facility policy required immediate protection of the alleged victim and removal of the alleged perpetrator from the facility premises during the investigation. According to the record and interviews, CNA 2 was told to clock out and leave the facility, but she returned to Resident 46's room and spoke with the resident and Family Member 1. LVN 1 stated CNA 2 was able to enter the room twice after being instructed to leave, and Family Member 1 reported that CNA 2 was still able to access the room after the allegation was reported. CNA 2 also stated she went back to the room after being told to go home and apologized for not following the facility's policies and procedures. The Administrator, DON, DSD, and LVN 1 acknowledged that the alleged perpetrator should have been removed from the building immediately to protect the resident.
Missing BP Monitoring Order for Antihypertensive Medications
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for one resident who was receiving amlodipine and losartan potassium for hypertension. During a medication administration observation, the LVN administered both antihypertensive medications without checking the resident’s blood pressure. The resident’s care plan for cardiac distress related to hypertension with CKD and CAD included monitoring vital signs, and the resident’s H&P showed the resident had the capacity to understand and make decisions. Medical record review showed physician’s orders for amlodipine 10 mg daily and losartan potassium 50 mg daily, but there was no physician’s order to monitor the resident’s blood pressure. The record also did not show documented evidence that the resident’s blood pressure was checked before receiving the antihypertensive medications. An LVN later verified that no order existed to take the resident’s blood pressure while on these medications and stated the resident should have had an order to check BP before taking antihypertensive medications because the resident could be at risk for low BP.
Inaccurate Intake and Output Documentation for Resident with Foley Catheter
Penalty
Summary
The facility failed to provide accurate intake and output monitoring for a resident with an indwelling urinary catheter ordered for urinary retention. The resident was observed in bed with the Foley catheter drainage bag hanging on the side of the bed on multiple occasions during the survey. The physician ordered the catheter to gravity drainage and directed staff to record intake and output every shift, with the 2300 to 0700 shift responsible for recording the 24-hour total and completing weekly evaluations. Review of the resident’s catheter care documentation showed urine output entries recorded by CNAs on the Task form, while the MAR contained separate urine output entries documented by LVNs. The two sources did not match. The record also showed that some days had missing urine output documentation, including a day with no urine output documentation and another day where the response was documented as not required. The surveyor compared the Task form and MAR entries across multiple days and found that the shift totals and daily totals were not consistent with each other. The MAR also contained inaccurate daily total calculations for urine output on several dates. Examples included a documented daily total of 1810 ml when the correct total was 1360 ml, 895 ml when the correct total was 440 ml, 1600 ml when the correct total was 900 ml, 1600 ml when the correct total was 1450 ml, and 2000 ml when the correct total was 1950 ml. The surveyor also found inaccurate daily total fluid intake calculations in another resident’s MAR. During interview and concurrent record review, an RN verified that CNAs and LVNs both documented intake and output, that the CNA documentation did not match the LVN documentation, and that the 2300 to 0700 LVN was responsible for calculating the daily totals.
Unclear IV Orders for PICC Line Care
Penalty
Summary
Facility failed to ensure the physician's orders for Resident 32's IV care were clear and concise. Resident 32 was admitted to the facility and had a PICC line, with orders for blood draws through the PICC, daily administration set changes, weekly and PRN catheter site dressing changes, saline flushes before and after ceftriaxone and daptomycin administration, needleless connector changes, use of the catheter for blood draws, measurement of external catheter length, and monitoring for infiltration or extravasation every shift. Review of the Order Summary Report showed that only one of the 12 IV-related orders specifically identified the access as a PICC. The remaining orders did not clearly state that they were related to the PICC line. During interview and concurrent record review, the DON stated the resident had a PICC line, the orders were not clear to show they were related to the PICC line, and the orders should have identified the PICC line, including whether it was single or double lumen. The DON also stated the catheter site and length could be confused with a urinary catheter and that nursing staff should have clarified the orders with the physician.
Nebulizer Equipment Left Uncleaned and Improperly Stored
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two sampled residents who had nebulizer treatments ordered. Facility policy for nebulizer therapy stated that when treatment is complete, the nebulizer equipment should be rinsed and disinfected or washed with water, allowed to air-dry, and then stored in a plastic bag with the resident’s name and date. For Resident 29, who had an order for albuterol sulfate nebulizer solution as needed for shortness of breath or wheezing, surveyors observed the nebulizer mask connected to the machine and placed on top of a birthday card on the nightstand, with the medication chamber containing clear liquid. A nurse stated the mask and medication chamber were cleaned with soap and water and left on tissue paper to air dry, and another nurse later confirmed the mask was on the nightstand with the chamber still containing clear liquid and said it could be placed on a pillowcase as a barrier. For Resident 11, who had an order for ipratropium-albuterol nebulizer solution as needed for shortness of breath or wheezing, surveyors observed an uncovered nebulizer mask on top of the bedside drawer and a plastic bag touching the floor. The resident stated the nebulizer was used for chest congestion and had been received a few days earlier. A nurse verified the mask was left uncovered and stated it should be placed in a bag that does not touch the floor to prevent germs. The DON later stated that after licensed nurses clean and dry the mask, it must be stored in a plastic bag.
Missing Assessment, Order, Consent, and Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 11 remained free from accident hazards associated with elevated bed rails. During the initial tour, Resident 11 was observed sitting in a wheelchair while the bed had bilateral one-fourth bed rails present and elevated. Resident 11 stated the bed rails were used for pulling up and repositioning while in bed, and also stated the rails were already present when she was admitted to the facility. Resident 11’s record showed she was admitted to the facility and had the capacity to understand and make decisions. Her H&P dated 9/14/25 showed she had capacity to understand and make decisions, and her MDS assessment showed a BIMS score of 13, indicating she was cognitively intact. Review of the Order Summary Report failed to show a physician’s order for the bilateral one-fourth bed rails. The medical record also failed to show bed rail assessments, care plan documentation, or consent for the use of the bilateral one-fourth bed rails. During interviews, LVN 6 verified the bed rails were present and elevated and stated Resident 11 used them for repositioning while in bed. The IP verified the absence of documentation for the bed rail assessments, physician’s order, care plan, and consent. The DON also verified the resident had bilateral one-fourth bed rails and stated the process required assessment, least restrictive measures, consent, a physician’s order, maintenance application, entrapment assessment, and a care plan; the DON further verified Resident 11 did not have the bed rail assessment, consent, order, or care plan documented.
Incorrect Transcription of Aspirin Order
Penalty
Summary
The facility failed to ensure one of five sampled residents reviewed for unnecessary medications was free from unnecessary psychotropic medications, and failed to ensure the resident’s physician’s orders were appropriate and properly clarified. Resident 32 had an order related to aspirin, which had been discontinued because of thrombocytopenia while the resident was also receiving antibiotics and Plavix. The facility’s Medication Orders policy stated handwritten physician’s orders were to be transcribed into the EHR and clarified before the physician left the nursing station whenever possible. The resident’s NP note stated to discontinue aspirin and resume it when antibiotics were completed or when platelets were greater than 100 k. However, the transcribed EHR order stated to resume aspirin when antibiotics were completed or when PTT was greater than 100 k. During interview and record review, RN 2 stated the PTT instruction did not make sense and should have been clarified, and verified the EHR order was entered incorrectly. The written order sheet obtained from medical records was unsigned and undated by the prescriber, and the DON stated the written order sheets were being used as a communication tool for orders and should be treated like verbal orders.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to provide proper pharmacy services for medication storage and handling. During medication administration observations, an LVN left prepared medications unattended at the bedside for Resident 15, including tramadol, loratadine, enoxaparin injection, duloxetine, hydroxychloroquine sulfate, and calcium with vitamin D3. The LVN placed the medications on a tray at the bedside, left the room to return to the medication cart, and left the oral medications and later the enoxaparin injection unattended and unsupervised before administering them. The LVN verified these findings during interview. A similar observation was made for Resident 3, when an LVN prepared oral medications along with fluticasone nasal spray and Trelegy Ellipta inhalation powder and left the nasal spray and inhaler on the bedside table unattended while leaving the room and while turning away to discard a cup and check the resident’s oxygen equipment and oxygen saturation. The LVN later verified these findings. In addition, inspection of Medication Cart B showed the foil backing of the bubble pack containing gabapentin for Resident 3 was not intact along the perforated line, and the bubble pack containing zolpidem for Resident 21 had been torn open and taped over. Inspection of Medication Cart C found an opened individual pack of calcium alginate labeled single use only and an opened bottle of sterile water with an expiration date of 2/9/25. Inspection of Medication Room A found Refrigerator A at 50 degrees F, above the facility’s stated range of 36 to 46 degrees F, while it contained unopened ceftriaxone and daptomycin for Resident 32. The refrigerator temperature log showed readings between 38 and 40 degrees F from 9/1/25 through 9/23/25, and the IP verified the findings.
Inappropriate Food Served to Resident on Soft and Bite Sized Diet
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of one resident receiving a soft and bite sized diet. Resident 45 was on a physician-ordered SB6 diet and was observed at breakfast with Cheerios cereal added to the meal tray. The resident stated awareness of the soft and bite sized diet and said she was surprised to receive Cheerios on the tray, noting that she had handwritten the request on the meal ticket. The facility’s diet manual described the soft and bite sized diet as food that is soft, tender, and moist throughout, with no separate thin liquid, and the menu spreadsheet for the breakfast meal listed specific SB6 items such as diced pears, oatmeal or cream of wheat, scrambled egg, chopped sausage patty, and slurried pancake or slurried toasted wheat. During interview, the RD stated that Resident 45 should not have received Cheerios with an SB6 diet order.
Failure to Honor No-Pork Dietary Preference
Penalty
Summary
The facility failed to ensure that food preferences were honored for one resident who received food prepared in the kitchen. Resident 17 had a physician's order for no pork and also stated that she was Muslim and did not eat pork. The facility's policy stated that individual food and dining preferences, including religious preferences, are to be obtained from residents and/or resident representatives within 72 hours of admission and include dislikes, allergies, cultural, religious, and ethnic preferences. During a lunchtime observation, Resident 17's tray was found with another resident's name on it and included three ounces of pork barbecue, chicken wonton miso soup, and Asian salad with dressing. When interviewed, an LVN stated she did not know why the tray containing pork was served to Resident 17. The DON acknowledged the findings.
No Storage or Reheating Available for Food Brought by Visitors
Penalty
Summary
The facility failed to ensure residents had the ability to store and reheat food brought from outside the facility. During review of the facility policy and procedure titled "Use of Food Brought into the Facility," revised 10/1/24, it was found that food items already prepared by family or visitors and brought into the facility were required to be for immediate consumption. Survey observations and interviews showed there was no microwave or refrigerator available for residents to store or reheat food brought from outside the facility. On 9/23/25, LVN 9 stated there was no microwave or refrigerator available for residents' food brought from outside the facility and that any such food had to be consumed right away. RN 2 also stated there was no microwave or refrigerator available for residents' food brought from outside the facility to be stored, and said she would tell family members they could keep food at bedside for one to two hours after checking the resident's diet and educating on the diet. During the Resident Council Meeting, Resident 60 and Resident 31 stated the facility used to allow residents to store food from outside the facility, but that the kitchen could no longer store it and there was no separate refrigerator for that purpose.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for one final sampled resident and one nonsampled resident reviewed for infection control. The facility's hand hygiene policy stated staff are to perform hand hygiene when indicated, including before and after handling soiled items, before and after providing care to residents in isolation, and after removing gloves. The policy also stated gloves do not replace hand hygiene and that staff should perform hand hygiene immediately after removing gloves. For Resident 7, who had no capacity to understand and make decisions and had severe cognitive impairment with a BIMS score of zero, the record showed a physician's order for a Foley catheter for wound management. During an observation of incontinence and indwelling urinary catheter care, CNA 1 was observed providing care while wearing a gown and gloves. After the care was completed, CNA 1 placed a new brief on the resident using the same gloves and verified she did not change gloves. CNA 1 stated that changing dirty gloves and performing proper hand hygiene after incontinence and catheter care was important to prevent the spread of infection. For Resident 96, whose care plan identified a need for Enhanced Barrier Precautions due to a history of colonized MDRO, an EBP sign was posted outside the room directing staff to perform hand hygiene and wear gloves and a gown for high-contact care activities. During an observation, COTA 1 transferred the resident from a wheelchair to bed while wearing a mask and gloves but not a gown. COTA 1 verified the transfer and stated he did not wear a gown during the high-contact activity. The IP stated that when a resident is on EBP, staff providing high-contact care activities or close contact should wear gloves and a gown.
Glucometers Not Properly Calibrated or Documented
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition by not ensuring two glucometers currently used and stored in Medication Carts A and B were properly calibrated. The report states that the glucometers were used for blood glucose monitoring for eight residents in Nurse Station A. Review of the EvenCare G2 Blood Glucose Monitoring System User's Guide showed that control solution testing is used to confirm the meter and test strips are working properly, and that control test results are identified by a ctl icon in the meter memory. During inspection of Medication Cart B, the glucometer in use was EG970038, and the glucose test strips in the cart had Lot Number 16824112001, while the facility's Blood Glucose Quality Control Results Log listed Lot Number 16824112010 with different low and high ranges. LVN 10 verified that the strip lot number and range information did not match the quality control log. During inspection of Medication Cart A, the glucometer in use was EG870842, but the quality control log listed a different glucometer serial number, EG743466. When the glucometer memory was checked, the ctl icon from prior quality control testing did not appear, and LVN 9 verified there was no documentation showing a quality control test had been performed for glucometer EG870842. The Administrator and DON verified these findings.
Call Light System Not Audible at Nurse Stations
Penalty
Summary
The facility failed to ensure the call light system was fully functional at Nurse Stations A and B, including the audible sound from the call light panel console. The facility policy stated that call lights should be available at each resident’s bedside, toilet, and bathing facility and should directly relay to staff or a centralized location so residents can call for assistance. During observation, a call light in Room D was on while staff passed by and no one answered it, and the call light system at Nurse Station B did not produce an audible sound when the light was activated. The IP confirmed that an audible sound should have been heard and stated the night staff had lowered the sound at Nurse Station B. Additional observations showed that Nurse Station A also did not produce an audible sound when call lights were activated in Rooms A, B, and C, even though staff were observed passing by and were also present in the station without responding. The Unit Secretary stated the console should alert regular and emergency call lights from SNF rooms at both nurse stations, but only a faint beep was heard until the volume was adjusted. The DON acknowledged that the call light panel at the nurse’s station should have an audible sound when a call light was turned on, and the IP later observed that Nurse Station A had more audible sound than Nurse Station B, with LVN 11 able to adjust the volume at Nurse Station B.
Failure to Honor Resident Choice During Morning Care
Penalty
Summary
The facility failed to honor resident choice and self-determination for two cognitively intact residents who were sleeping in their room during early morning hours. Staff entered the room, turned on the lights, and moved the residents’ wheelchairs and other personal items without first asking permission or informing the residents. One resident stated she preferred to continue sleeping and was awakened by staff, while the other stated she usually had a hard time falling asleep and wanted to keep sleeping. Both residents reported feeling disrespected by the staff’s actions. The record review showed both residents had the capacity to understand and make decisions. Resident 66’s H&P documented capacity to understand and make decisions, and her MDS showed she was cognitively intact and needed staff assistance with ADLs. Resident 45’s H&P also documented capacity to understand and make decisions, and her MDS showed she was cognitively intact and needed staff assistance with ADLs. Staff interviews confirmed that CNA 5 and LVN 13 entered the room to prepare the residents for breakfast, turned on the lights, and moved the wheelchairs, and LVN 13 stated she did not ask the residents before doing so.
Missing Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to develop a comprehensive person-centered plan of care to reflect the individual care needs of one resident, including the use of bilateral one-fourth bed rails. The resident was admitted with capacity to understand and make decisions, and the H&P and MDS showed the resident had a BIMS score of 13, indicating the resident was cognitively intact. During the initial tour, the resident was observed sitting up in a wheelchair and verbally responsive, and the resident's bed was observed with bilateral one-fourth bed rails elevated. The resident stated the bed rails were already on the bed when admitted to the facility. Review of the medical record showed no care plan addressing the resident's bilateral one-fourth bed rails. During observation and interview, LVN 6 verified the resident used the bilateral one-fourth bed rails for repositioning while in bed. The IP later reviewed the record and confirmed the bed rails were in place and that the medical record failed to show a care plan had been developed for them. The DON also verified the bilateral one-fourth bed rails were in place and stated a care plan must be developed by licensed staff to reflect the resident's needs.
Care Plan Not Revised After Apixaban Was Resumed
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident 10 was revised after the physician ordered apixaban to be resumed. Resident 10 was readmitted to the facility and had no capacity to understand and make decisions. The resident’s physician ordered apixaban 5 mg via GT every 12 hours for CVA prophylaxis, and the care plan already addressed the resident’s risk for signs and symptoms of side effects related to apixaban, noting the medication had been on hold since 7/15/25 after a positive stool occult blood result. The care plan interventions included holding apixaban until further order, but the physician later resumed the medication on 8/13/25. During interview and record review, the LVN verified the resident was receiving apixaban every 12 hours and stated the care plan should have been revised when the medication was resumed. The DON also verified and acknowledged that the licensed nurse who received the physician’s order should have updated the resident’s care plan.
Palatability of Shrimp Scampi Meal Not Maintained
Penalty
Summary
The facility failed to ensure food served was palatable for two nonsampled residents when shrimp scampi was served dry and without the sauce or butter expected with the meal. The facility's Meal Quality and Temperature policy stated food and drinks are to be palatable, attractive, and served at a safe and appetizing temperature. The lunch menu for 9/22/25 included shellfish shrimp scampi, and the recipe reviewed described shrimp scampi prepared with butter, lemon juice, garlic, and parsley, but did not specify how it should be served. During dining observation, one resident stated she had not eaten because she was waiting for sauce for the shrimp and wanted butter for it; her meal ticket included butter, but butter was not served with the tray. An LVN verified there was no sauce and no butter served with the shrimp, and the resident pushed her plate aside and ate blueberry pie instead. A second resident was observed eating the same shrimp scampi meal in her room and stated the shrimp needed sauce because it was dry. When an LVN entered the room, the resident asked for shrimp sauce, and the LVN verified the shrimp scampi was not served with sauce and was just dry shrimp. The LVN attempted to obtain butter from the kitchen but, after no response, returned with ketchup to provide some sauce for the shrimp. The Executive Chef later stated the shrimp scampi was cooked with butter and lemon juice with garlic and parsley, and suggested the lack of sauce may have been due to serving the shrimp with a slotted spoon during tray line service, which could have separated the shrimp from the sauce.
Failure to Initiate Baseline Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who had an ileostomy, as required by facility policy and procedure. Upon admission, the resident's medical records, including a hospital discharge summary, indicated specific instructions for ostomy care, hydration, and monitoring of intake and output to prevent dehydration. Despite this, the facility did not develop a baseline care plan addressing the resident's ileostomy care or the necessary nutritional interventions to maintain or prevent weight loss. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's intake and output were not monitored and that a baseline care plan for ileostomy care was not initiated. The lack of a baseline care plan meant that essential information for the resident's care was not documented or implemented, contrary to the facility's own admission policy and procedures.
Failure to Develop Care Plan for Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who experienced a significant change in condition, specifically nausea, vomiting, poor meal intake, and notable weight loss. The facility's policy required that all changes in a resident's condition be communicated to the physician, documented in the nursing progress notes and twenty-four hour report, and that the resident's care plan be updated as indicated. Despite these requirements, the medical record review showed that the resident lost 17 pounds over four days and had complaints of nausea, but no care plan was initiated to address these issues. Interviews with facility staff, including an LVN, the DON, and the RD, confirmed that the resident's care plan was not updated to reflect the new problems of poor appetite and weight loss. The RD acknowledged that the resident was at risk for weight loss and verified that no care plan had been initiated to address the resident's poor intake and weight loss. The RD also stated that she did not initiate a care plan problem until the MDS was completed.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in accordance with established directives, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse was observed during the survey process, but the report does not specify the number of residents affected, their medical histories, or their conditions at the time of the deficiency.
Inadequate PPE Use by CNAs During Resident Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) adhered to evidence-based practices (EBP) for infection prevention and control, specifically regarding the use of personal protective equipment (PPE). The deficiency was observed when CNAs 2 and 3 were seen wearing only surgical masks and gloves while repositioning a resident in bed, despite a sign outside the resident's room indicating that both gloves and gowns were required for high-contact activities. This oversight was confirmed during interviews with CNA 2, who admitted uncertainty about the necessity of wearing a gown for such activities, and the Infection Preventionist (IP), who stated that a yellow gown was required. The facility's policies and procedures (P&P) for Enhanced Barrier Precautions and Infection Control Prevention and Control of Multidrug-Resistant Organism (MDRO) Transmission were reviewed, indicating that gowns should be worn during high-contact activities that pose a risk for transmission of MDROs. Despite these guidelines, the CNAs did not comply with the requirement to wear gowns, as verified by the Minimum Data Set (MDS) Registered Nurse (RN) and Director of Staff Development (DSD). The facility administrator acknowledged these findings, highlighting a lapse in adherence to infection control protocols designed to prevent the spread of infections.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The ice machines were not properly cleaned, with white residue and hardened crusts noted on their surfaces. Ice scoopers were not stored in a manner that protected them from contamination, contrary to the facility's policy. Additionally, several food items, including boiled eggs, hoagie breads, fries, and milk, were found to be past their best-by dates, posing a risk of serving expired products to residents. The kitchen equipment and utensils were not maintained in a sanitary condition. Multiple cutting boards were heavily marred, and various utensils such as spatulas, frying pans, measuring cups, scoopers, and a peeler were observed with discoloration and residue. A hot tray transportation warmer also had brown streak residue inside. Furthermore, kitchen staff were not adhering to dress guidelines, as observed with staff not wearing hair and beard restraints, which could lead to contamination of food. Hand hygiene practices were not consistently followed by the kitchen staff. Instances were noted where staff entered the kitchen and handled food without washing their hands or changing gloves, increasing the risk of cross-contamination. Additionally, water liners were transported uncovered in the hallway, contrary to facility protocol. These deficiencies collectively had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Infection Control Deficiencies in Resident Care, Laundry, and Water Management
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with shingles, as evidenced by the lack of adherence to contact and droplet precautions. A family member visiting the resident was observed wearing inadequate personal protective equipment (PPE), including an untied gown and personal eyeglasses instead of goggles, and was not wearing gloves. The family member was not informed of the necessary precautions before entering the room, and the signage indicating the required precautions was not noticed by the visitor. The Licensed Vocational Nurse (LVN) on duty did not ensure the visitor was properly instructed on the precautions, which could have prevented the spread of infection. In the laundry room, the facility failed to maintain infection control standards by allowing personal items, such as a cellphone and body lotion, to be present in the clean folding area. This was confirmed by the Laundry Aide, who acknowledged that the items belonged to her. The Housekeeping Manager stated that the clean folding area should be free of personal belongings to prevent contamination of linens and the spread of infection. The facility also failed to maintain accurate documentation of its water management program, specifically regarding testing protocols for Legionella and other opportunistic pathogens. The last documented risk assessment was completed in 2018, and there was no recent documentation available. The Director of Facilities confirmed this oversight, acknowledging that testing was conducted by an outside company. The Administrator also acknowledged the findings, indicating a lapse in maintaining the required documentation for infection control in the water systems.
Improper Cleaning of Kitchen Ice Machines
Penalty
Summary
The facility failed to ensure that two ice machines in the kitchen were properly cleaned according to the manufacturer's instructions, which could lead to unsanitary ice being served. The Hoshizaki Instruction Manual, revised in November 2018, specifies the use of a sanitizing solution containing 5.25% sodium hypochlorite solution (chlorine bleach) for cleaning. However, the facility's service provider, Ram Air Engineering, used a different sanitizing concentrate that did not contain the specified active ingredient. During an observation, white and brown residue and gray particles were noted inside the ice machines, indicating improper cleaning. Interviews with the Maintenance Staff and the Registered Dietitian (RD) confirmed that the facility relied on an outside company to clean the ice machines every six months. The RD verified that the sanitizing solution used by the service provider did not comply with the Hoshizaki Instruction Manual's requirements. The Director of Nursing (DON) acknowledged these findings and confirmed that the current instructions from the manual should be followed to ensure the ice machines are properly sanitized.
Failure to Conduct Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments were completed and measurements were recorded during bed inspections for residents using bed rails. This deficiency was identified for 16 out of 53 residents who had bed rails, posing a potential risk of entrapment, serious injury, or death. The facility's policy required assessments to be conducted prior to the installation of bed rails, and periodically thereafter, to ensure the safety of residents. However, observations and interviews revealed that these assessments were not performed, and the necessary measurements were not documented. Several residents, including those with cognitive impairments and those requiring assistance with mobility, were observed using bed rails without documented evidence of entrapment assessments. Interviews with CNAs and LVNs confirmed the use of bed rails for mobility and repositioning, but also highlighted that the entrapment assessments were not part of the bed rail assessment process. The Director of Facilities admitted to not being familiar with the entrapment zones and confirmed that bed inspections were only conducted upon resident discharge and quarterly, rather than upon admission or as needed. The facility's documentation, including Bed Maintenance and Inspection forms, lacked evidence of entrapment zone assessments. The Director of Facilities acknowledged the absence of such documentation and the lack of knowledge regarding the use of the Bionix safety measuring device. The DON and Administrator were informed of these findings, which underscored the facility's failure to adhere to its own policies and procedures regarding bed rail safety and entrapment prevention.
Failure to Obtain Informed Consent for Psychotropic Medication and Side Rail Use
Penalty
Summary
The facility failed to ensure that Resident 43, who was deemed incapable of making medical decisions, was provided the right to self-determination regarding the use of psychotropic medication and side rails. Specifically, the facility did not obtain informed consent from Resident 43's responsible party for the use of side rails and the administration of alprazolam, an antianxiety medication. The facility's policies and procedures require informed consent to be obtained from the resident or their representative before initiating treatment with psychotropic drugs or installing side rails, but these protocols were not followed. Observations and medical record reviews revealed that Resident 43 was using bilateral 1/4 side rails without documented consent from a responsible party. Additionally, there was no evidence of informed consent for the use of alprazolam in the resident's medical records. Interviews with RN 1 and the DON confirmed these findings, indicating that the consent for bed rail use was incorrectly obtained from Resident 43, who lacked decision-making capacity, and that the consent for alprazolam was only signed by the physician and uploaded to the electronic medical record after the medication had already been administered.
Failure to Obtain and Maintain Advance Directives
Penalty
Summary
The facility failed to obtain and maintain copies of advance directives for six residents, which are legal documents stating a person's wishes about receiving medical care if they are no longer able to make decisions. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. Specifically, the facility did not have copies of advance directives for Residents 8, 37, 43, 44, 320, and 669, despite acknowledgments in their records indicating that these documents existed and should have been provided to the facility. For Residents 8, 37, 43, and 669, the medical records showed that they had executed advance directives, but the facility failed to obtain or document attempts to obtain these directives. Interviews with the Social Services Designee confirmed that although these residents had advance directives, there was no follow-up to secure copies for the facility's records. Additionally, for Residents 44 and 320, the facility not only failed to obtain advance directives but also did not complete the POLST forms, which are crucial for documenting medical orders for life-sustaining treatment. The facility's policy on advance directives requires verification and modification of these documents upon admission, ensuring that residents' healthcare preferences are respected. However, the facility did not adhere to this policy, as evidenced by the incomplete documentation and lack of follow-up. Interviews with the Director of Nursing and other staff confirmed these findings, highlighting a systemic issue in managing advance directives and POLST forms, which could potentially lead to residents' healthcare decisions not being honored.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident with severe cognitive impairment. The resident, who was admitted for short-term therapy, expressed interest in group and independent activities such as watching TV, visitations, planting orchids, fishing, camping, and music-related activities. However, the facility only documented the resident's participation in activities on three occasions since admission, and there was no evidence of daily activities being provided to meet the resident's identified interests. Observations revealed the resident often remained in bed without sensory stimulation, and interviews with staff indicated a lack of consistent activity engagement. The Director of Activities acknowledged the resident's limited participation and the absence of documented evidence for daily activities, such as providing the Daily Chronicles or turning on the TV. The resident's care plan included encouraging independent activities, but the facility did not adequately document or implement these interventions, leading to potential social isolation and frustration for the resident.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to provide appropriate medication administration for Resident 621, as observed during a medication administration session. LVN 3 did not adhere to the physician's order to administer furosemide 30 minutes before spironolactone-hydrochlorothiazide, instead giving both medications simultaneously. This oversight was confirmed during an interview with LVN 3, who acknowledged the error in following the prescription instructions. For Resident 37, the facility did not comply with the physician's order to notify the physician of significant weight changes. The resident experienced weight fluctuations of three pounds on multiple occasions, which should have triggered a notification to the physician as per the order. However, the medical records showed no evidence that the physician was informed of these changes, as verified by the DON during a review of the resident's records. Resident 52's care was compromised when the licensed nurse failed to document blood pressure readings before and after administering clonidine hydrochloride, a medication prescribed for hypertension. The medication was given as needed for high systolic blood pressure, but the necessary documentation to justify its administration and assess its effectiveness was missing. This lapse was acknowledged by the IP and the DON during interviews and record reviews.
Failure in Controlled Medication Reconciliation and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the reconciliation and disposal of controlled medications for two residents. For one resident, a bubble pack of morphine was found with 10 tablets, but the controlled drug record indicated that 11 tablets should have been present after one was removed. Similarly, a bubble pack of oxycodone/acetaminophen was found with 103 tablets, while the record showed 104 tablets should have been present after one was removed. The Licensed Vocational Nurse (LVN) responsible admitted to not signing the controlled drug record or the Medication Administration Record (MAR) immediately after administering the medications, which is against the facility's policy. For another resident, a bubble pack of hydrocodone/acetaminophen was found in the medication cart despite the medication being discontinued. The LVN confirmed that the medication should not have been in the cart as it was discontinued. The Director of Nursing (DON) stated that nurses are required to remove discontinued medications at the end of their shift and bring them to the DON, or if discontinued on a weekend, remove them the following weekday. These lapses in procedure had the potential for drug diversion and medication errors.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the administration of medications outside of the physician's ordered parameters. Resident 2 was prescribed losartan potassium to manage hypertension, with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 120 mmHg. However, the medication was administered on multiple occasions when Resident 2's SBP was below this threshold, with readings as low as 110/61 mmHg. This oversight was confirmed during an interview with the Infection Preventionist (IP) and acknowledged by the Director of Nursing (DON). Similarly, Resident 56 was prescribed midodrine hydrochloride for hypotension, with instructions to hold the medication if the SBP exceeded 110 mmHg. Despite this, the medication was administered on several occasions when the SBP was above the specified limit, with readings reaching as high as 132/79 mmHg. This error was verified by LVN 6 during a concurrent interview and medical record review, and the findings were also acknowledged by the DON. These failures indicate a lack of adherence to physician orders, potentially exposing the residents to unnecessary medications and associated side effects.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically alprazolam, an antianxiety medication. The facility's policy required documentation of the resident's response to the medication, including progress towards goals and the presence or absence of adverse consequences. However, the medical record for the resident did not show documented evidence of monitoring for side effects related to the use of alprazolam. This oversight was confirmed during an interview with RN 1, who acknowledged the lack of documentation for side effect monitoring. The resident in question was admitted to the facility with no capacity to understand and make decisions. A physician's order was in place for alprazolam to be administered as needed for anxiety, and the medication was given on a specific date. The resident's care plan included interventions to monitor behaviors and side effects every shift, but the facility did not adhere to this plan. The failure to monitor side effects posed a potential risk to the resident's well-being, as the facility did not follow its own policy and procedures regarding the use of psychotropic drugs.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, posing a risk for cross-contamination. During an inspection of Medication Room A, it was observed that orally administered medications were not stored separately from externally used medications. Specifically, Fever All suppositories were stored with oral loperamide tablets, DHEA mood and stress tablets were stored with eye drops, and nasal moisturizing spray was stored with earwax removal drops. These findings were verified by RN 1. Additionally, disinfectant wipes were not stored separately from medications and treatment supplies. In Medication Cart A, hand sanitizing wipes were stored with ammonia lactate lotion, Optifoam Gentle EX, and tubular elastic retainer net dressing. In Medication Cart B, germicidal disinfectant wipes were stored with NexTemp thermometer strips and a spill kit. Furthermore, a bottle of potassium chloride on Medication Cart C was found with sticky residue around its neck. These storage issues were confirmed by LVN 2 and LVN 3, respectively. The DON acknowledged the improper storage practices and emphasized the need for separate storage of orally administered and external medications.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that pureed recipes were followed for three residents who were on a pureed diet. Specifically, the pureed recipes for biscuits and rice were not adhered to, which could potentially result in not providing nutritional meals that meet the residents' needs. The facility's policy and procedure for meal/tray assembly, revised in January 2024, requires that meals are prepared accurately to preserve nutrient content and that the current diet spreadsheet is followed at each meal period. However, during an observation on September 11, 2024, it was noted that the staff member responsible for preparing the pureed meals did not follow the recipes as outlined. During the preparation of pureed biscuits, the staff member added 34 oz of hot water to the blended biscuits, and for the pureed rice, 8 oz of hot water was added, deviating from the specified recipes. The staff member confirmed that no recipe was followed during the preparation. Subsequent interviews with the Registered Dietitian (RD), Dietary Services Supervisor (DSS), Executive Chef, and Director of Nursing (DON) confirmed the findings and acknowledged that the recipes should have been followed as per the instructions.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to ensure that the food provided to four residents was palatable, specifically regarding the texture of green beans served during dining observations. Residents 17, 26, 39, and 65 all reported that the green beans were tough and not easy to chew, which did not meet the dietary requirements for their respective diets. These observations were confirmed by staff, including a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), who acknowledged the issue with the texture of the green beans. Resident 17, who had the capacity to understand and make decisions, was on a regular diet with an easy-to-chew texture requirement. Resident 26, who lacked decision-making capacity, was on a no-restriction diet with the same texture requirement. Resident 39, with fluctuating decision-making capacity, was on a no-added-salt diet with regular texture requirements. Resident 65, who was on a regular diet, also found the green beans tough and refused to eat them. The facility's policy on modified texture foods was not adhered to, as the green beans did not meet the required easy-to-chew texture, potentially affecting the residents' nutritional intake.
Deficiency in Food Safety Policy and Visitor Education
Penalty
Summary
The facility failed to update its policy and procedures (P&P) regarding the use and storage of foods brought to residents by family and visitors, as well as to educate visitors on safe food handling practices. The facility's P&P, revised in July 2023, acknowledged the right of residents to receive food from outside sources but required that such food be for immediate consumption. However, the facility did not have a designated refrigerator for resident use, as confirmed by the Registered Dietitian (RD) and the Director of Nursing (DON). This lack of proper storage facilities for perishable food items brought by visitors could potentially lead to foodborne illnesses among the medically vulnerable resident population. Additionally, the facility did not provide visitors with information on safe food handling practices, such as maintaining perishable foods at temperatures below 41 degrees Fahrenheit. The RD confirmed that visitors were informed that food should be for immediate consumption but were not educated on safe handling practices, including proper hand hygiene. The DON acknowledged these findings, indicating a gap in the facility's responsibility to ensure food safety for residents consuming food from outside sources.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by allowing the Director of Activities to use her personal cell phone to take pictures of residents during activities. This action was in direct violation of the facility's policy and procedure (P&P) titled 'Resident Photos,' which was revised on 4/19/24. The policy clearly states that residents have a right to privacy and confidentiality, including through photographs, videos, and digital recordings, and that permission must be obtained from the resident or their representative before taking photographs during facility events. During an observation and interview on 9/12/24, the Director of Activities admitted to using her personal cell phone to take pictures of residents and staff during a scheduled activity. She acknowledged that she was not supposed to have pictures of residents on her personal device. The facility's P&P, revised on 4/5/24, also prohibits employees from using personal cell phones while on the clock, except during meal or rest breaks. The Administrator confirmed that the facility provides devices such as Apple tablets and cell phones for staff use and that personal cell phones should not be used to take pictures of residents.
Failure to Remove CNA Pending Abuse Investigation
Penalty
Summary
The facility failed to remove a Certified Nursing Assistant (CNA 1) from resident care areas pending an alleged violation of abuse for a resident (Resident 1). According to the facility's policy and procedure (P&P) for reporting allegations of abuse, the accused employee should be removed from resident care areas and suspended pending the completion of the investigation. However, after Resident 1 reported that CNA 1 hit her left shoulder, CNA 1 was reassigned to care for another resident and remained at work until the completion of her shift. This was confirmed through interviews with CNA 1, LVN 3, and the Administrator, who acknowledged that CNA 1 was not sent home after the abuse allegation was reported. The incident was reported on a SOC 341 form, and the facility's Nursing Assignment Sheet showed that CNA 1 was assigned to different rooms, including Resident 1's room, on the day of the incident. The Administrator confirmed that the facility's protocol for abuse allegations involving staff members requires the alleged staff to be immediately excused from the facility and suspended pending the investigation. Despite this protocol, CNA 1 completed her shift and clocked out at 2251 hours on the day of the incident. The Administrator acknowledged the potential risk of having the alleged perpetrator remain in the facility, which could create an opportunity for retaliation against the victim.
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 3,962 citations issued within 25 miles in the last 12 months — including the 8 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 Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orange Healthcare & Wellness Centre, Llc | 0.5 mi | ★★★★★ | 27 | 0 |
| Mainplace Post Acute | 0.7 mi | ★★★★★ | 29 | 0 |
| French Park Care Center | 1.2 mi | ★★★★★ | 51 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.3 mi | ★★★★★ | 18 | 0 |
| The Hills Post Acute | 1.3 mi | ★★★★★ | 29 | 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.