Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Valley Vista Post Acute during CMS and state inspections, most recent first.
Unnecessary Psychotropic Medication Use Without Documented NPIs: The facility failed to document or implement resident-specific NPIs for several residents receiving psychotropic medications. A resident with orders for clonazepam, mirtazapine, risperidone, buspirone, and sertraline had no NPI documentation on the MAR, and another resident with duloxetine, lamotrigine, trazodone, and clonazepam also lacked NPI documentation. Two other residents had psychotropic regimens without documented NPIs, and one resident’s PRN lorazepam order had no stop date. The DON acknowledged NPIs were expected before routine or PRN psychotropic use.
Controlled meds were signed out for several residents but not documented on the MAR, two residents did not have ordered meds available at the time of administration, and one resident with diabetes received meds in a manner that did not match the order. The DON confirmed the missing MAR entries, the out-of-stock meds, and insulin doses given despite blood sugars below the ordered hold parameter.
Medication administration errors exceeded the allowed rate when surveyors observed five errors in 42 opportunities, including a nurse crushing pancrelipase DR and gabapentin capsules before giving them via G-tube to a resident, and two other nurses failing to administer ordered meds because hydralazine, calcium carbonate, and diclofenac gel were out of stock. The DON and consultant pharmacist were interviewed, and facility policy required checking medication availability and contacting the pharmacy when meds were not available.
The facility failed to identify and develop an effective QAPI plan related to pharmacy services and ADL care. Record review showed the CDR did not match the MAR for controlled drugs for five of six residents reviewed, and nail care assistance was not provided for two of 17 residents reviewed. In a QAPI meeting, the ADM stated the fingernail trimming issue and the CDR/MAR mismatch were new to the facility, and the DON stated it was important to identify issues affecting residents.
Dust from a ceiling air vent was observed falling into the dining room during meals while residents were seated nearby and meal trays were being passed out. The AD swept up dust balls from the floor, and the vent remained visibly dusty on later observation. The FD stated the vent was dusty and had no filter, and the DON stated residents could inhale the dust, which could lead to respiratory distress.
Failure to provide an alternative call light system for a resident with Parkinson's Disease, generalized weakness, and moderate cognitive impairment. The resident was observed in bed with both hands bent and unable to fully open, and a standard push-button call light was present even though the family member, OT, and DON stated he could not consistently use it because of hand contractures and needed something he could tap.
A resident with chronic kidney disease was transferred to the acute hospital for buttock wounds, but the record had no documentation that the resident was given written bed-hold notice or the duration of the bed hold at the time of transfer. The resident’s BIMS was 15, indicating intact cognition. The DSD and DON stated bed-hold options should be offered to the resident or family representative, and the facility policy required written bed-hold information at transfer.
Failure to develop baseline care plans for two residents with psychotropic medication orders. Both residents had intact cognition on MDS and diagnoses including mood and psychotic disorders, but their records did not show care plans for medications such as antidepressants, anxiolytics, antipsychotics, and mood stabilizers. The DON stated care plans were expected to be developed and documented in the medical record.
Two residents who required help with ADLs were found with long fingernails that had not been trimmed. One resident with dementia and chronic pain had long, dirty nails and a jagged fingernail after stating she had asked for nail care, while another resident with fibromyalgia and dyspnea also had long nails and said no one had offered to trim them. Staff stated nail care was supposed to be done on shower days and Sundays for hygiene and infection control.
Failure to Document Ordered I & O: A resident with CHF and Parkinson's disease, who was dependent on staff for eating/drinking and toileting and had moderate cognitive impairment, had an order and care plan intervention for intake and output monitoring. The DSD said CNAs were responsible for tracking fluid intake each shift and the LPN was responsible for documenting total I & O in the EMR, but an LPN stated the resident's I & O had not been checked or documented since admission.
Failure to order and document hand splints for a resident with Parkinson's Disease and hand contractures. The resident was observed with stiffened, semi-closed hands, and family members were placing a device in the resident's hands during visits. The LPN stated there was no MD order and no care plan entry for the splints, while the OT said the resident could not fully extend his hands and should have had splints ordered for both hands to prevent further loss of movement and protect against skin breakdown.
Failure to provide feeding supervision for a resident with dementia and Parkinson's disease was observed when the resident was seated reclined in a wheelchair at lunch, with the tray placed out of reach and left untouched. The resident's MDS and care plan identified the need for supervision and touching assistance with eating, and both an LN and the DON stated that this assistance was important due to the resident's severe cognitive impairment and need for meal support.
Failure to provide urology follow-up was identified for a resident with a long-term suprapubic catheter and a history of UTI, sepsis, and bladder-related issues. Staff and record review showed no current urology consult order and no documented follow-up after a prior urology visit, while nursing staff reported the catheter was being changed monthly without a physician order. The DON stated the resident needed routine urology follow-up due to the long-term SPC use and history of pain.
Failure to implement nutrition interventions for a resident with Parkinson's disease, dysphagia, nutritional anemia, and moderate cognitive impairment led to unplanned weight loss. A CNA observed the resident eating only oatmeal at breakfast and stated he usually ate less than half of breakfast and lunch. The resident's record showed declining weights, an IDT recommendation to increase a nutritional shake to BID, and the RD stated the order was never entered into the EHR.
Missing Physician Order for Oxygen: A resident with chronic respiratory failure with hypoxia and recent pneumonia was observed receiving oxygen at 6 L/min via NC, but the Order Summary Report did not show a physician's oxygen order. The resident stated she used oxygen continuously and could not breathe without it, and an LPN confirmed the order was missing while the DON stated any care provided required a physician's order.
A resident on a puree diet with GERD and swallowing difficulty received meals that were not palatable and were described as gritty and lacking flavor. The resident complained that the kitchen did not prepare the puree foods correctly, and a tray observation found mashed potatoes that were not smooth. The RD noted the resident was at risk for altered nutrition, and the DS stated kitchen staff did not follow the puree recipe.
Pureed Food Recipes Not Followed: Kitchen staff prepared pureed mashed potatoes, chicken, and bread without using the available recipes, instead guessing at water and thickener amounts. A dietary supervisor observed grainy mashed potatoes and chicken with small chunks during food sampling and stated the texture was due to excessive thickener; he also stated recipes were expected to be followed for consistency in flavor, quality, texture, and swallowing safety.
Insufficient Resident Room Square Footage: The facility failed to meet the minimum 80 sq ft per resident requirement in three rooms. Room 6 and room 8 each housed 3 residents in 216 sq ft, and room 11 housed 2 residents in 138 sq ft, resulting in less than the required space per resident. Surveyors observed no quality of care or quality of life concerns affecting the residents in those rooms.
A resident with a history of atrial fibrillation and ongoing oxygen needs was observed using oxygen continuously, yet there was no active care plan addressing this therapy. Despite physician orders for oxygen as needed and facility policy requiring care plan documentation, staff confirmed that the care plan for oxygen use had been marked as resolved and was not updated to reflect the resident's current needs.
Unnecessary Psychotropic Medication Use Without Documented NPIs
Penalty
Summary
The facility failed to ensure that four sampled residents were free from unnecessary psychotropic medications when non-pharmacological interventions were not documented or implemented, and when one resident’s PRN lorazepam order did not have a stop date. The report identified Residents 10, 49, 2, and 19 as affected. The facility policy titled Psychotropic Medication Use stated that non-pharmacological approaches are used unless contraindicated to minimize the need for medications and that PRN psychotropic orders are limited to 14 days. For Resident 10, the medical record showed orders for clonazepam, mirtazapine, risperidone, buspirone, and sertraline for anxiety, depression, schizophrenia, and related behaviors. The MAR for 9/2025 did not show documentation of NPIs by nursing staff for these five psychotropic medications. The care plan listed general therapeutic activities such as dance, music, art, exercise, leisure, recreation, orientation, education, skill building, movies, and pet therapy, but during interview the DON confirmed there were no NPIs on the MAR and that the facility did not implement NPIs for the resident’s psychotropic medications. For Resident 49, the record showed orders for duloxetine, lamotrigine, trazodone, and clonazepam for depression, schizoaffective disorder bipolar type, insomnia, and anxiety. The MAR did not document NPIs for these medications, and the care plan again listed general therapeutic activities rather than resident-specific interventions. For Resident 2, the record showed fluoxetine, PRN lorazepam, and trazodone, but there was no documented NPI and no stop date for the PRN lorazepam order; an LN stated the stop date was missing and was important to evaluate effectiveness. For Resident 19, the record showed aripiprazole, lorazepam, sertraline, and divalproex, but there were no NPIs in the medical record, MAR, order summary, or care plan. The DON stated NPIs were important and expected to be used before routine or PRN psychotropic administration, and that Resident 2’s lorazepam should have had a stop date.
Medication documentation, availability, and administration errors
Penalty
Summary
Controlled medications were signed out of the controlled drug record for several residents, but the administrations were not documented on the MAR. For one resident with an active order for oxycodone, the CDR showed a dose signed out without MAR documentation on one occasion. For another resident with an order for oxycodone-acetaminophen, the CDR showed doses signed out on two occasions without MAR documentation. A third resident with an active order for hydrocodone-acetaminophen had six occasions where the CDR showed the medication was signed out but the MAR did not show administration. A fourth resident with an active order for oxycodone-acetaminophen had nine such occasions, and a fifth resident with an active order for morphine had five such occasions. The DON reviewed these records and confirmed the missing MAR documentation, and the facility policy stated that when a controlled substance is administered, the licensed nurse must immediately enter the date, time, and initials on both the accountability record and the MAR. Two residents did not have medications available when they were due to be administered. During medication administration observation, one nurse stated that a resident’s morning hydralazine was not in stock for the scheduled dose. Another nurse stated that two of a second resident’s medications, calcium carbonate and diclofenac gel, were out of stock for the evening dose. The DON stated nurses were expected to check medication availability when accepting the med cart and to contact the pharmacy if a medication was unavailable. The facility policy stated that residents should have sufficient supplies of prescribed medications and receive medications in a timely manner. For one resident with diabetes, the timing and administration of medications did not match the medication directions. The resident had orders for glipizide twice daily with food and metformin twice daily, and the MAR showed both were administered at the scheduled times. The consultant pharmacist stated glipizide is preferred to be given 20 to 30 minutes before a meal and metformin is advised to be taken with food. The same resident also had an order for insulin lispro to be held for glucose below 150, but the MAR showed the insulin was administered when blood sugars were 137 and 135. The DON verified those administrations and stated the doses should have been held because the order said less than 150.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed 5 percent. During observation of 42 medication administration opportunities, surveyors identified five errors, resulting in a calculated medication error rate of 11.9%. The report states this failure placed residents at risk in several instances, including improper administration of medications for digestion, pain, blood pressure, indigestion, and pain management. For one resident with a G-tube, a nurse prepared and administered ten medications and was observed opening pancrelipase delayed-release capsules, crushing the contents, mixing them with water, and giving them through the tube. The same nurse also opened gabapentin capsules and crushed them before mixing with water and administering them through the G-tube. The resident had orders for pancrelipase DR particles for digestive enzyme supplement and gabapentin 400 mg via G-tube for leg pain. The DON stated nurses should refer to the package insert or call the pharmacy if unsure how to administer a medication, and the consultant pharmacist stated pancrelipase should be sprinkled, not crushed, and gabapentin capsules can be opened and dispersed in purified water, but not crushed. Two additional medication administration observations found medications not given because they were out of stock. One nurse did not administer hydralazine 25 mg to a resident with an active order for hypertension because it was not in stock for the morning dose. Another nurse did not administer calcium carbonate 600 mg and diclofenac gel 1% to another resident because both were out of stock for the evening dose. The DON stated nurses should check medication availability when accepting the med cart and should call the pharmacy and, if needed, the physician when a medication is unavailable. The facility policy stated residents should have sufficient supplies of prescribed medications and receive them in a timely manner, and nursing staff are responsible for contacting the pharmacy if a resident's medication is not available for administration.
QAPI Program Failed to Identify Pharmacy and ADL Care Deficiencies
Penalty
Summary
The facility failed to identify and develop an effective QAPI plan related to pharmacy services and ADL care. Based on interview and record review, the facility did not ensure the control drug record matched the medication administration record for controlled drugs for five of six residents reviewed, and it did not provide nail care assistance for two of 17 residents reviewed. During a QAPI meeting with the DON and ADM, the ADM stated that fingernail trimming and the controlled drug record not matching the MAR were new issues to the facility, and the DON stated it was important to identify issues affecting residents in the facility. Review of the facility’s QAPI policy, dated 2/2020, showed that the QAPI process includes identifying and prioritizing quality deficiencies.
Dust from Dining Room Air Vent During Meals
Penalty
Summary
The facility failed to implement infection control standards of practice when a round air vent in the dining room blew out dust balls during meals. During a dining room meal observation, 15 residents were seated at eight tables while the air conditioner was on and the ceiling vent directly above a resident table released three dust balls onto the floor. The Activity Director swept up the dust balls, and the vent was observed with gray dust above the table. Later, a meal cart was brought near the same dusty vent, and staff passed out meal trays while the cart was wide open and the vent continued blowing air from the ceiling. A follow-up observation showed the dining room air vent still had gray dust. The Facilities Director stated the air vent was dusty, that the air conditioning unit had been installed the prior Friday, and that the round vent did not have a filter. He also stated he had notified staff to let him know when residents would be in the dining room so he could shut off the round vent. The AD stated she swept the dust bunnies that fell from the vent and that residents should be in a clean environment. The DON stated residents could inhale the dust from the air vent in the dining room, which could lead to respiratory distress. The facility policy stated the infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.
Failure to Provide Alternative Call Light for Resident With Hand Contractures
Penalty
Summary
The facility failed to provide an alternative call light system for Resident 68, who had Parkinson's Disease, generalized muscle weakness, and moderate cognitive impairment with a BIMS score of 9. During observation, Resident 68 was lying in bed and stated that he was ready to get up and waiting to eat breakfast, but could not use his hands. He was observed with both hands bent and unable to fully open, and a push-button call light was present on his bed. Resident 68's family member stated that he was unable to use the call light because of hand contractures and could not always press the button. The OT stated that Resident 68 had contractures to both hands due to increased tone related to Parkinson's Disease and was not able to consistently use the push-button call light when he needed assistance. The DON stated that if Resident 68 was unable to consistently use the push-button call light, the facility should have accommodated his needs and that he needed something he could tap. The facility policy stated that residents with a disability preventing use of the call system should have an alternative means of communication usable for the resident and documented in the care plan.
Failure to Provide Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to provide written notice and the duration of bed hold for Resident 65 when the resident was transferred to the acute hospital. Resident 65 was admitted with diagnoses including chronic kidney disease, and progress notes dated 6/25/25 indicated the resident was transferred to the acute hospital due to wounds on the buttocks. The medical record contained no documentation confirming that Resident 65 was notified of the bed hold at the time of transfer. Resident 65’s MDS dated 6/7/25 showed a BIMS score of 15, indicating intact cognition. During interviews, the DSD stated it was important to offer Resident 65 and the family representative options for a bed hold, and the DON stated nursing staff or the Social Service Director would follow up and offer a bed hold when residents were transferred to the acute care facility. The facility policy titled Bed-Holds and Returns stated that all residents or representatives are provided written information regarding bed-hold policies at the time of transfer.
Failure to Develop Baseline Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a baseline care plan was developed for 2 of 17 residents reviewed for baseline care plans. Resident 2 was admitted with diagnoses including Schizoaffective Disorder and Major Depressive Disorder. The resident’s MDS dated 7/22/25 showed a BIMS score of 15, indicating intact cognition. The order summary listed psychotropic medications including Fluoxetine 20 mg daily for depression, Lorazepam 0.5 mg every 12 hours as needed for anxiety, and Trazodone 50 mg at bedtime for depression. The medical record did not indicate a care plan for these psychotropic medications. Resident 19 was admitted with diagnoses including Bipolar Disorder and Major Depressive Disorder. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. The order summary listed psychotropic medications including Aripiprazole 15 mg at bedtime for Schizophrenia, Lorazepam 0.5 mg twice a day for Anxiety, Sertraline 150 mg daily for Depression, and Divalproex 500 mg 3 tablets twice a day for Schizoaffective Disorder. The medical record did not indicate a care plan for these psychotropic medications. During interview and record review, the DON stated care plans were important and that licensed staff were expected to develop and document them in the residents’ medical records. The facility policy stated the comprehensive person-centered care plan is developed within 7 days and no more than 21 days after admission.
Failure to Provide Nail Care for Two Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure that two residents who needed assistance with ADLs received nail care. Resident 10, who had diagnoses including dementia and chronic pain and whose care plan indicated one-person assistance with ADLs and personal hygiene, was observed with long fingernails, gray debris under the nails, and a jagged right forefinger nail. During interview, Resident 10 stated the nail was sharp and that she had asked someone to trim her nails but nobody had done it. On a later observation, Resident 10’s fingernails were still long with gray debris underneath. Resident 49, who had diagnoses including fibromyalgia and dyspnea and whose care plan indicated one-person assistance with personal hygiene, was observed sitting up in bed with long fingernails and stated that nobody had offered to trim them and that she would like them trimmed. Staff interviews confirmed that fingernails were supposed to be trimmed weekly on shower days and Sundays, and staff stated the long and dirty fingernails could lead to infection and scratching. The DON and DSD both stated nail care should be provided on shower days and Sundays for hygiene, dignity, and infection control, and the facility policy stated nail care was intended to clean the nail bed, keep nails trimmed, and prevent infections.
Failure to Document Ordered Intake and Output
Penalty
Summary
The facility failed to ensure intake and output (I & O) was documented and monitored for Resident 68. Resident 68 was admitted and later readmitted with diagnoses including CHF and Parkinson's disease. The MDS dated 8/29/25 showed a BIMS score of 9, indicating moderate cognitive impairment, and also indicated the resident was dependent on staff for eating/drinking and toileting. The care plan dated 8/28/25 identified Parkinson's disease and included the intervention to monitor and document intake and output as ordered. During interview, the DSD stated the assigned CNAs were responsible for tracking and documenting the resident's fluid intake every shift, and the assigned licensed nurse was responsible for documenting total intake and output in the EMR on the P.M. shift. The DSD stated this was important because the resident had CHF and a history of dehydration and could not drink by himself. LN 12 stated the resident's intake and output should have been documented in the EMAR, but she did not see that it had been documented since admission, and stated, "For [Resident 68] we haven't been checking or documenting his intake and output." The DON stated it was her expectation that licensed nurses tracked intake and output as ordered by the physician, and that documentation was important to ensure the resident was not retaining fluids or getting dehydrated. The facility policy stated the facility will monitor intake and output as ordered by the physician.
Failure to Order and Document Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to provide restorative nursing assistant program intervention with a hand splint for Resident 68, who was admitted and readmitted with diagnoses including Parkinson's Disease and generalized muscle weakness. On 9/8/25, Resident 68 was observed in his room with a red plastic device in his right hand, and both hands were noted to be stiffened and maintained in a semi-closed position. Resident 68's family member stated the resident's hands were contracted because of Parkinson's Disease and that family members visited daily and placed splints in his hands to prevent further contractures. During interview and record review, the licensed nurse stated the family applied the hand splints when they visited, but Resident 68 did not have a physician's order for the splints and they were not addressed in the care plan. The occupational therapist stated a joint mobility screen showed Resident 68 was unable to fully extend his hands due to contractures and that splints should have been ordered for both hands to prevent further loss of movement and protect the hands from skin breakdown. The DON stated that if a resident was admitted with contractures, OT needed to assess and a hand splint should have been ordered, and that the physician's order and care plan for the hand contractures had been missed. The facility policy stated residents assessed with a need would be screened by rehab, the physician would be notified and an order obtained, and the device would be applied as ordered and documented on the care plan and RNA notes.
Failure to Provide Feeding Supervision
Penalty
Summary
The facility failed to provide supervision with feeding for Resident 43, who was admitted with diagnoses including dementia and Parkinson's disease. During a lunchtime observation, Resident 43 was seated in a reclined position in a wheelchair, and the lunch tray was placed far from her reach with the cover removed and left untouched. The resident's record showed a BIMS score of 04, indicating severe cognitive impairment, and the MDS section GG and care plan both identified the need for supervision and touching assistance with eating. During interview and record review, an LN stated that Resident 43 gets agitated if staff get close to her, but also stated that the resident required supervision and touching assistance with eating. The LN explained that assistance with meals was important to prevent weight loss and other complications such as choking. The DON also stated that Resident 43 needed supervision and touching assistance with eating and that the speech therapist had been asked to reevaluate the resident regarding assistance with eating and speech. The facility policy on ADL support stated that appropriate care and service would be provided for residents unable to carry out ADLs independently, including dining.
Failure to Provide Urology Follow-Up for Resident with Suprapubic Catheter
Penalty
Summary
Failure to provide urology follow up was identified for one resident with a suprapubic catheter. The resident was admitted with diagnoses including obstructive and reflux uropathy and had an order for a suprapubic catheter 18 French with a 10 mL balloon to gravity drainage every shift. During observation, the resident was seen sitting in a wheelchair with a urine bag hanging at the back of the chair and stated she had the urine tube because she could not control her urine and was not able to walk to the bathroom. The resident also stated she wanted a physician to check whether the tube could be removed so she could practice walking again, and said she was also urinating on her brief. Staff interviews and record review showed there was no order for a urology consultation and no documented follow-up after a urology appointment in 2023 related to a UTI. A case manager stated the resident had no other follow-up after that appointment. Nursing staff stated the resident’s suprapubic catheter was changed monthly, but there was no physician order for catheter changes. The DON stated the resident needed urology follow up because of the long-term use of the suprapubic catheter and history of pain, and that routine urology follow up was needed to assess bladder issues. The resident’s record also included prior hospital and facility documentation of UTI, sepsis, catheter transfer events, vaginal bleeding, and pressure in the vaginal area.
Failure to Implement Nutrition Interventions for Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not ensured for one sampled resident with Parkinson's disease, dysphagia, nutritional anemia, and moderate cognitive impairment. The resident's MDS showed he was dependent on staff for eating and drinking, and the nutritional assessment documented a fair appetite with oral intake of 25-50%, risk for malnutrition, and a goal to maintain weight within 158-168 pounds without unintended weight change. The care plan identified a nutritional problem related to dysphagia and CHF with a goal weight range of 160-170 pounds. On observation, a CNA was seen leaving the resident's room with his breakfast tray and stated he only ate the oatmeal and usually ate less than half of breakfast and lunch. The resident's weights showed a decline from 163 pounds to 159 pounds, then to 149 pounds over a short period. The IDT noted unplanned weight loss and recommended increasing the nutritional shake to twice daily, but the RD stated the physician's order for the shake was never entered into the electronic health record and that the recommendation was missed. The DON stated the shakes should have been implemented and that further weight loss could lead to additional decline in health.
Missing Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen was in place for one of three residents reviewed, Resident 2. Resident 2 was admitted with chronic respiratory failure with hypoxia and, after returning from the hospital on 9/5/25 for pneumonia, was observed on 9/8/25 at 8:26 A.M. receiving oxygen at 6 liters per minute via nasal cannula. During the observation and interview, Resident 2 stated she used oxygen continuously and could not breathe without it. Record review showed Resident 2's MDS dated 7/22/25 indicated a BIMS score of 14, reflecting intact cognition. On 9/8/25, LN 2 stated Resident 2 had been on oxygen when she left for the acute hospital and returned the prior Friday, but there was no oxygen order on the Order Summary Report and that Resident 2 should have an oxygen order in place. The Order Summary Report dated 9/5/25 did not indicate an oxygen order. On 9/11/25, the DON stated any care provided to a resident needed a physician's order and that a physician's order would have prevented possible complications for Resident 2. The facility policy titled Oxygen Administration stated to verify that there is a physician's order for the procedure and to review the physician's orders.
Unpalatable Puree Meals Served to Resident on Texture-Modified Diet
Penalty
Summary
The facility failed to ensure that one of 17 residents reviewed for food palatability, Resident 6, was served meals that were palatable. Resident 6 was admitted with diagnoses including GERD and was on a puree diet due to difficulty swallowing. During an observation and interview, Resident 6 stated the puree food did not taste good and described the puree as gritty. The resident also reported that the puree eggs had no flavor and that the kitchen did not cook the puree foods correctly. Certified Nurse Assistant 3 stated the resident had complained about the food served because it was not prepared correctly. The Registered Dietician reviewed the resident’s care plan, which noted the resident was at risk for altered nutrition and that he liked to mix his own thickened liquids in his room occasionally due to being unsatisfied with preparation from the diet department. During a lunch tray observation, the resident’s tray contained two bowls of mashed potatoes and two bowls of puree eggs, and the mashed potatoes were observed to not have a smooth consistency. The Dietary Supervisor stated the kitchen staff did not follow the recipe for preparing puree food and staff should follow the recipe. The facility policy stated food and nutrition services will inspect food trays to ensure the correct meal is provided and that food appears palatable and attractive.
Pureed Food Recipes Not Followed
Penalty
Summary
The facility failed to ensure recipes were followed during preparation of pureed foods for residents on a pureed diet. During observation in the kitchen, a dietary staff member prepared instant mashed potatoes by pouring flaked potatoes into a stainless steel container and adding approximately 1000 ml of water, while stating she had put in about 2000 ml of water and was adding white powder to make the mixture thicker. She stated there was a recipe with instructions available but that she did not use it to prepare the mashed potatoes. The same staff member was observed preparing cooked chicken for pureed diets by placing five scoops of diced chicken into a blender, adding about 1000 ml of hot water and one teaspoon of broth mixture, and stating she did not use a recipe for pureed foods. She stated she added thickener if the mixture appeared too thin and that she usually guessed the amount, adding tablespoon by tablespoon until it had a jelly-type texture. Another dietary aide was observed placing 25 pieces of whole wheat bread into a blender, adding about 1000 ml of water, and stating she guessed the amount of thickener and did not have a recipe for bread. During food sampling, the pureed mashed potatoes had a grainy texture and the pureed chicken had small chunks and a grainy texture. The dietary supervisor stated the texture was due to an excessive amount of thickener and that it was his expectation that kitchen staff followed recipes to ensure consistency in flavor, quality, texture, and swallowing safety.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to meet the minimum square footage requirement of at least 80 square feet per resident in three resident rooms: room 6, room 8, and room 11. A record review conducted from 9/8/25 through 9/11/25 found that room 6 accommodated 3 residents in 216 square feet (72 square feet per resident), room 8 accommodated 3 residents in 216 square feet (72 square feet per resident), and room 11 accommodated 2 residents in 138 square feet (69 square feet per resident). Based on observation, interview, and review of the analysis of client accommodations, the facility did not meet the required minimum room size standard in these rooms. During the recertification survey visit, there were no observed quality of care or quality of life concerns that negatively affected the residents residing in the identified rooms.
Failure to Develop and Implement Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-focused care plan for a resident who was receiving oxygen therapy. The resident, who had a diagnosis of unspecified atrial fibrillation and was cognitively intact, was observed using oxygen via nasal cannula at 2 liters per minute and reported needing oxygen at all times due to difficulty breathing. Despite a physician's order for oxygen as needed for shortness of breath, there was no active care plan addressing the resident's oxygen use. The care plan related to oxygen had been marked as resolved, even though the resident continued to require and use oxygen. Interviews with facility staff, including the MDS nurse and the DON, confirmed that there was no current care plan in place for the resident's oxygen therapy. The facility's own policies required that care plans be developed, regularly evaluated, and updated to reflect the resident's needs, including measurable goals and target dates. The absence of a care plan for oxygen use was acknowledged by staff and was not in accordance with facility policy or standard care planning procedures.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Escondido
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redwood Terrace Health Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Ocean View Post Acute | 1.2 mi | ★★★★★ | 2 | 0 |
| Escondido Post Acute | 1.4 mi | ★★★★★ | 2 | 0 |
| Palomar Vista Healthcare Center | 1.5 mi | ★★★★★ | 32 | 0 |
| Palomar Heights Post Acute | 2 mi | ★★★★★ | 5 | 0 |
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