Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victoria Care Center during CMS and state inspections, most recent first.
Two residents had inaccurate MDS coding. One resident was discharged home under home health with RN, PT, and OT services, but the MDS coded the discharge as home/community instead of home with organized home health services. Another resident had documented chronic hearing loss and was observed to have difficulty hearing, yet the MDS coded hearing as adequate. The MDS Nurse, MDS Coordinator, and DON acknowledged the coding errors and stated the assessments should have been coded accurately for CMS reporting.
The facility failed to develop and implement specific, resident-centered care plans for three residents. One resident at very high risk for pressure injuries remained on the same side during repeated observations despite a care plan for q2h turning and repositioning. Another resident with chronic hearing loss and an active gabapentin order had no care plan addressing either need. A third resident receiving continuous GT feeds had a care plan that only said to provide tube feeding as ordered, without identifying the specific formula. The DON, LVN, CNA, and MDSC all confirmed the care plans were not specific to the residents’ needs.
Care plans were not revised for two residents after changes in treatment and condition. One resident's CP still listed GT feeding and water flushes after the GT was removed, while another resident's CP still directed staff to provide edema medication even though there was no active order. The MDSC and DON stated the CPs should reflect current needs and changes in condition.
Improper labeling of oxygen supplies for two residents was identified when nasal cannula tubing, humidifiers, and oxygen storage bags were observed with outdated dates while both residents were receiving oxygen via NC. One resident had acute respiratory failure with hypoxia, severe cognitive impairment, and dependence on staff, while the other had COPD, chronic respiratory failure, and dependence on supplemental oxygen. The DON and nursing staff stated the oxygen items were to be changed weekly and labeled with the date changed, and the facility policy required weekly changes of oxygen tubing and humidifier components.
Nurse staffing information was not posted in a prominent, readily accessible location and did not reflect actual hours worked. The staffing sheet was only found in the nurse station, posted on the side of a shelf behind medication carts, and could not be easily read from the hallway. The DSD reviewed the staffing sheets and stated the hours listed were projected rather than actual, while the DON stated the information should be visible and show the actual hours of licensed and unlicensed staff working each shift.
Improper labeling and storage of refrigerated food items were observed in two kitchen refrigerators. A tray of lettuce lacked a received date, and open containers of 2% milk and prune juice were found past their use-by dates. The DS and DON stated food and beverages should be labeled and not consumed past the best-by or use-by date, and the facility’s food storage guidance listed recommended refrigerated storage times for lettuce, milk, and juice.
Call Light Not Within Resident’s Reach: A resident with hemiplegia, hemiparesis, blindness, and severely impaired cognition was observed lying in bed with the call light on the floor and out of reach. The resident stated help was needed with the cellphone and the call light could not be located. Staff and the DON confirmed the call light was not within reach, despite the care plan and facility policy requiring it to be placed within easy reach while the resident was in bed.
A resident with a GT, dysphagia, and supplemental O2 dependence was observed lying flat in bed while continuous tube feeding was running, despite the care plan and physician’s order requiring the HOB to be elevated 30 to 45 degrees during feeding. An LVN, RN, and the DON all stated the HOB needed to be elevated during GT feeding to prevent aspiration.
A resident with encephalopathy and dementia had a PRN diphenhydramine order on the MAR. The pharmacy consultant identified the Benadryl as potentially unnecessary and noted the MD agreed to discontinue it, but the order was not removed from the chart. The DON stated the MRR recommendation was supposed to be carried out by licensed nursing staff, and the LN may have forgotten to discontinue the medication order.
Insufficient Room Size in Multiple Resident Rooms: The facility failed to provide the required square footage in 12 of 13 resident rooms. The ADM said the room occupancy had not changed and requested a room waiver for the affected rooms. Surveyors observed that the rooms had space for wheelchairs, walkers, and Hoyer lifts, and a resident and CNA reported there was enough room for movement and care.
A resident with multiple medical conditions and under public conservatorship was inaccurately assessed as having intact cognition for daily decision making, despite being unable to make personal decisions. The Elopement Risk Assessment was also completed in a manner that did not reflect the resident's current status, leading to an incident where the resident left the facility without authorization.
The facility failed to provide adequate supervision and monitoring at the main entrance during the night shift, allowing an unknown visitor to enter and access the room of two residents—one with moderate cognitive impairment and mobility issues—without staff awareness or proper logbook documentation, in violation of facility policy and resident safety protocols.
The facility failed to ensure that two residents were provided with information and documentation regarding Advance Directives (AD), as per policy. One resident's AD Acknowledgement Form was missing, and another's was incorrectly completed, potentially leading to treatment against their wishes. The facility's policy requires that residents or their representatives be informed about their rights to refuse treatment and formulate an AD.
Two residents in the facility did not receive oxygen as ordered, potentially leading to adverse consequences. One resident, with acute respiratory failure, was found with their oxygen turned off, despite a continuous oxygen order. Another resident, also with respiratory failure, had a nasal cannula improperly placed, affecting oxygen delivery. Staff acknowledged the errors, which were inconsistent with the facility's oxygen administration policy.
The facility failed to follow its policy on bed rails and grab bars for two residents, risking entrapment and injury. One resident with peripheral vascular disease had siderails installed without attempting alternatives, while another with hemiplegia had grab bars without documented consent or alternatives. The DON acknowledged the need for least restrictive alternatives and informed consent.
The facility failed to manage psychotropic medications properly for two residents. A resident's Lorazepam order lacked a stop date, violating policy requiring a 14-day limit unless reassessed. Another resident's behavior was not monitored for 10 days while on Haloperidol, contrary to policy requiring documentation of target symptoms. These deficiencies could lead to unnecessary medication use.
The facility failed to ensure proper use of PPE for two residents on Enhanced Barrier Precautions (EBP). A CNA did not wear a gown while caring for a resident with ulcers, and a TN did not wear a gown while administering medication to a resident with a gastrostomy tube. Both residents required EBP, and the facility's policy mandated gowns and gloves for high-contact care activities to prevent infection spread.
A resident with epilepsy and high fall risk had their call light out of reach, violating the facility's policy on call light accessibility. The resident, who was dependent on staff for daily activities and had severely impaired cognition, confirmed they could not see the call light. Both the Director of Staff and Development and the DON acknowledged the importance of having the call light within reach for safety and communication.
A facility failed to provide a dialysis resident with an emergency kit (E-kit) at bedside, necessary for immediate intervention in case of complications like unexpected bleeding from the hemodialysis access site. The resident, dependent on hemodialysis due to end-stage renal disease, did not have an E-kit available, as confirmed by the MDS Coordinator. The DON acknowledged the requirement for E-kits, and the facility's policy emphasized the need for monitoring and intervention, yet the kit was absent, indicating a lapse in adherence to procedures.
The facility failed to meet the federal requirement of 80 square feet per resident in 12 out of 13 multiple resident rooms, each measuring 304 square feet and housing four residents. Despite this, residents and staff reported no issues with space for movement and care. The facility requested a waiver, but the deficiency remains.
A resident with end-stage renal disease eloped from a dialysis center, and the LTC facility failed to locate them, compromising their safety. The resident left against medical advice and was not found by the facility. The LVN and DON did not fully execute required actions, such as searching the area or contacting hospitals, as per the facility's elopement policy.
A resident was not readmitted to the facility after hospitalization despite being medically stable and expressing a desire to return. The facility's policy required readmission to the first available bed, but communication failures and procedural lapses led to a two-day delay, even though there were no staffing or bed availability issues.
Inaccurate MDS Coding for Discharge Status and Hearing Assessment
Penalty
Summary
The facility failed to ensure accurate MDS coding for two residents. For Resident 51, the record showed admission with diagnoses including difficulty walking, hypertension, and other musculoskeletal symptoms. The discharge order summary and post-discharge plan of care indicated the resident was to be discharged home under home health services, including a licensed nurse for medication reconciliation and PT/OT for safety evaluation. However, the MDS coded the discharge as home/community rather than discharge to home under care of an organized home health service organization. During interview, the MDS Nurse and DON acknowledged the resident was discharged under home health and that the MDS should have been coded that way to provide accurate information to CMS. For Resident 6, the record showed admission with polyneuropathy and hearing loss, and the history and physical indicated the resident lacked capacity to understand and make decisions. An ENT progress note documented chronic hearing loss. Despite this, the MDS coded the resident as having adequate hearing. During observation, the resident pointed to both ears and stated they could not hear well, and the surveyor had to remove a mask and speak loudly next to the resident’s ears. During interview, the MDS Coordinator stated the hearing assessment was not accurate and should have been coded based on the MDS nurse’s observation and the ENT note. The facility policies cited required comprehensive assessment using the CMS RAI and accurate, complete documentation.
Incomplete and Non-Specific Care Plans for Turning, Hearing Loss, Medication, and GT Feeding
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized care plans for three sampled residents. Resident 31 was admitted with diagnoses including dementia, contracture of the right hand, and generalized muscle weakness. The resident’s care plan identified total care needs and included turning and repositioning every 2 hours and keeping skin clean and dry. The resident’s MDS showed severely impaired cognition, dependence on staff for multiple ADLs, and risk for pressure ulcers, and the Braden Scale score was 9, indicating severe or very high risk for pressure injuries. Despite the documented turning and repositioning intervention, Resident 31 was observed lying on the right side repeatedly during multiple observations over several hours. During interview, CNA 1 stated the resident should have been turned and repositioned every 2 hours to prevent bed sores, and LVN 1 stated the resident was at risk for pressure ulcers and should be turned and repositioned every 2 hours to prevent skin breakdown and pressure injuries. The DON stated dependent and total care residents needed to be turned and repositioned every 2 hours and as necessary. The facility policy on turning and repositioning described routine schedules every 2 to 4 hours on the even hour. Resident 6 was admitted with polyneuropathy and hearing loss, had chronic hearing loss documented by ENT, and lacked capacity to understand and make decisions. The MDS showed severely impaired cognition and varying levels of dependence for ADLs. The MDSC stated there was no specific care plan to address Resident 6’s hearing loss and no specific care plan to address the active gabapentin order for neuropathy, and stated the licensed nurse should have initiated the hearing-loss care plan after the ENT note identified chronic hearing loss. Resident 38 was admitted with dysphagia and gastrostomy, had severely impaired cognition, and was receiving continuous GT feeding with Peptamen AF 1.2 via GT. The care plan for GT feeding stated only that licensed nursing staff should provide tube feeding as ordered, and the MDSC and DON stated this was not specific because it did not identify the actual formula. The facility policy required comprehensive, resident-centered care plans with specific interventions reflecting the resident’s needs and preferences.
Care plans not updated after GT removal and edema medication discontinuation
Penalty
Summary
The facility failed to revise the care plans for two residents when their conditions and treatments changed. One resident was admitted with Parkinson's disease and dysphagia, was documented as lacking capacity in the H&P, and had a gastrostomy tube removed by the physician. Although the resident's care plan for nutritional problems still listed tube feeding and water flushes as interventions, the OSR showed no active tube feeding or water flushing orders. During record review and interview, the MDSC stated the licensed nurse should have revised the care plan when the GT was removed to reflect the resident's current health condition and dietary needs, and an LVN stated it was not acceptable for the care plan to continue to include GT feeding when the resident no longer had a GT. A second resident was admitted with cerebral palsy and hydronephrosis, had impaired cognition and lacked capacity to understand and make decisions, and had a care plan for edema that directed licensed nursing staff to provide medication as ordered. The OSR showed the resident did not have an active medication order for edema, yet the care plan still included the medication intervention. The MDSC stated the licensed nurse should have removed that intervention because the resident was not taking any edema medication and should have revised the care plan as soon as the physician discontinued the medication. The DON stated the resident's care plan should reflect the plan of care based on current needs and should be revised when residents have a change in condition.
Improper Labeling of Oxygen Supplies for Two Residents
Penalty
Summary
Failure to provide safe and appropriate respiratory care was identified for two residents receiving oxygen therapy because the facility did not ensure their nasal cannula tubing, oxygen humidifiers, and oxygen storage bags were properly labeled. Resident 10 was admitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, and records showed severely impaired cognition and dependence on staff for multiple activities of daily living. During observation, Resident 10 was receiving oxygen at 2 LPM via nasal cannula, and the DON stated the tubing, storage bag, and humidifier were dated 3/5/2026 even though they should have been dated 4/5/2026. The DON stated the facility changed these oxygen supplies every Sunday of the week, and LVN 4 stated the items needed to be changed and labeled by the RN every Sunday and that the 3/5/2026 dates were not acceptable. Resident 8 was admitted with COPD, chronic respiratory failure, and dependence on supplemental oxygen. The resident had intact cognition and required partial/moderate assistance with several activities of daily living. During observation, Resident 8 was lying in bed receiving oxygen at 2 LPM via nasal cannula, and LVN 3 stated the nasal cannula tubing, plastic bag, and humidifier were dated 3/5/2026. LVN 3 stated these items should be changed every Sunday of the week or as needed for infection control. RN 1 and the DON both stated licensed nurses were responsible for changing the oxygen tubing, humidifier, and oxygen bag every Sunday of the week and that the items should be labeled with the date they were changed. The facility policy stated oxygen tubing and mask/cannula should be changed weekly and as needed if soiled or contaminated, and the humidifier bottle should be changed when empty, weekly, or per facility policy.
Nurse Staffing Information Not Posted Clearly or Reflecting Actual Hours
Penalty
Summary
The facility failed to ensure that the actual nurse staffing information was posted at the beginning of each shift in a prominent location readily accessible to residents, visitors, and staff on two of three recertification survey days. On 4/7/2026, during observation in the lobby, hallways, and reception area, no daily nurse staffing information was posted. The Facility Receptionist stated the staffing information was only posted in the nurse station, and the facility had only one nurse station. During observation in the nurse station, the staffing information was found posted on the side of a shelf, with two medication carts parked in front of the nurse station. The print was not readable from the hallway, and LVN 1 stated residents and visitors would have a hard time seeing and reading it and could not move closer because of the carts. On 4/8/2026, the Director of Staff Development reviewed the staffing sheets for 4/7/2026 and 4/8/2026 and stated the hours shown were projected hours, not actual hours worked for each shift. The DON stated the staffing information should be posted in a prominent, visible, and accessible location and should reflect the actual hours of licensed and unlicensed staff working each shift.
Improper Labeling and Storage of Refrigerated Food Items
Penalty
Summary
Safe food storage and handling practices were not maintained in two facility kitchen refrigerators. During an observation in the kitchen with the Dietary Supervisor, a tray containing four heads of lettuce in Refrigerator 1 did not have a received date. In Refrigerator 2, an open plastic container of 2% milk was about one-fourth full and had a preparation date of 3/31/2026 with a use-by-date of 4/4/2026, and an open plastic container of prune juice was about half full and had a preparation date of 2/24/2026 with a use-by-date of 3/24/2026. During interview, the Dietary Supervisor stated all food items received should be labeled with a received date to determine when they were of highest quality and when they needed to be discarded so foods served to residents were safe and palatable. The DON stated all food and beverages should be labeled with received date and not consumed past the best-by date and use-by-date to prevent stomach reaction like diarrhea and vomiting. The facility's Reference Guide for refrigerated storage stated washed and thoroughly drained lettuce should be kept for 3 to 5 days, opened low-fat milk for 1 week, and opened juices for 1 week. The facility's policy on Food Safety and Food Storage stated food safety practices begin when food is received from the vendor and end with delivery to the resident, including labeling, dating, and monitoring refrigerated food.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one sampled resident. Resident 45 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions, had right eye blindness and a left eye cataract, and the MDS indicated severely impaired cognition, supervision needed for mobility, and moderate assistance needed with oral hygiene, toileting hygiene, showering/bathing, and personal hygiene. The resident’s fall risk care plan included an intervention for nursing staff to place the call light within reach. During observation, Resident 45 was awake and lying in bed, and the call light was found on the floor near the left side of the bed. The resident stated help was needed with the cellphone and that the call light could not be located. LVN 2 stated the call light should be within easy reach so the resident could call for help when needed, and CNA 3 stated the call light was on the floor and the resident could not reach it. The DON stated the call light was not within Resident 45’s reach and that staff could not attend to the resident’s needs timely if the resident needed to look for the call light. The facility policy stated staff should ensure the call light was within reach while the resident was in bed.
Failure to Elevate Head of Bed During GT Feeding
Penalty
Summary
Facility staff failed to elevate Resident 32’s head of bed while the resident was receiving continuous gastrostomy tube feeding, despite the resident’s care plan and physician’s order requiring the head of bed to be elevated 30 to 45 degrees during tube feeding and for 30 minutes afterward. Resident 32 was admitted with diagnoses including attention to gastrostomy, dysphagia, and dependence on supplemental oxygen, and the Minimum Data Set indicated severely impaired cognition and dependence on staff for multiple activities of daily living. On observation, Resident 32 was found lying flat in bed in a supine position while formula was running through the GT at 40 ml per hour. A CNA was at the bedside during one observation, and during a concurrent observation and interview, the resident remained awake and flat in bed with ongoing GT feeding and the head of bed not elevated. LVN 3 stated the head of bed should have been elevated 30 to 45 degrees during GT feeding to prevent aspiration and that the licensed nurse should turn off the feeding if the resident was flat. RN 1 and the DON also stated the head of bed needed to be elevated while the resident was receiving GT feeding.
Failure to Act on Pharmacy Consultant MRR Recommendation
Penalty
Summary
The facility failed to ensure that a medication regimen review irregularity identified by the pharmacy consultant was acted upon for one resident. The resident was admitted with diagnoses including encephalopathy and unspecified dementia, and the MDS indicated severely impaired cognition for daily decision making as well as maximum assistance needed for toileting, showering, dressing, and footwear. The resident's order summary included diphenhydramine hydrochloride 25 mg by mouth every six hours as needed for itchiness. A facility note to the attending physician/prescriber dated 3/6/2026 documented the pharmacist consultant's review of the resident's PRN Benadryl use and stated that diphenhydramine could be viewed as unnecessary because of its anticholinergic and sedative side effects, with topical treatment or other alternatives suggested if needed. The note indicated the physician agreed to discontinue Benadryl PRN. During interview, the DON stated the MRR was a monthly recommendation from the pharmacy consultant that licensed nurses should carry out, and stated the MD agreed to discontinue Benadryl PRN, but the diphenhydramine order was not discontinued as recommended and the LN may have forgotten to discontinue it. The facility policy stated that the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes review of the resident's medical chart, and that staff shall act upon all recommendations according to procedures for addressing MRR irregularities.
Insufficient Room Size in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in 12 of 13 resident rooms, specifically Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14. During the survey, the Administrator stated the facility wanted to request a room waiver for these rooms and confirmed that nothing had been changed and the number of bed occupancies remained the same in the 12 rooms. A review of the facility’s waiver request letter dated 4/7/2026 showed the facility stated there was ample room for wheelchairs, medical equipment, mobility, and movement of ambulatory residents, and that there was adequate space for nursing care and resident privacy. During the Health Recertification Survey, surveyors observed that the affected rooms had adequate space for nursing care and comfort, and residents were able to move freely inside the rooms. The rooms were observed to have room for wheelchairs, walkers, and Hoyer lifts, and each resident had a bed and bedside table with drawers. In a concurrent observation and interview, Resident 7 was sitting in a wheelchair in the room while two CNAs moved a Hoyer lift out of the room without concern. Resident 7 stated there was enough space to move around, and a CNA stated there was enough space to provide resident care in all of the rooms and that there had been no incidents of bumping into furniture or getting hurt in residents’ rooms.
Inaccurate Cognitive and Elopement Risk Assessment
Penalty
Summary
The facility failed to conduct an accurate assessment for a resident regarding cognitive skills for daily decision making. The resident, who had a history of bipolar disorder, diabetes mellitus, dysphagia, hypertension, and a below-knee amputation, was under a public conservatorship due to being unable to make legal, financial, medical, or care decisions. Despite this, the Minimum Data Set (MDS) assessment indicated the resident had intact cognition for daily decision making. Additionally, the Elopement Risk Assessment for the resident was completed with 'No' responses to all questions, as the tool was designed to assess elopement risk based on history at home, not within the facility. The Director of Nursing confirmed that the assessment did not account for the resident's current situation in the facility. The resident subsequently eloped from the facility, an event considered absence without leave (AWOL) by the public guardian, highlighting the inaccuracy of the assessments conducted.
Failure to Monitor Nighttime Visitation Allows Unauthorized Entry
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, as required by its own policies and procedures. During the night shift, an unknown visitor was able to enter the facility through the main entrance without staff awareness or proper monitoring. The visitor subsequently entered the room shared by two residents, one of whom had moderate cognitive impairment and required supervision for activities of daily living and functional mobility. The facility's main entrance was observed to be locked, with a security camera and a doorbell in place, but no receptionist or staff was present at the front desk during the night shift. One resident involved had a history of hemiplegia and hemiparesis following a stroke, type 2 diabetes mellitus, and difficulty walking. This resident's care plan indicated impaired cognitive function and required reorientation and supervision as needed. The resident's progress notes documented that a female visitor, unknown to staff and the resident, was found in the room late at night. The visitor did not sign the visitor logbook, and staff were unaware of how she gained entry. The incident led to family members being notified and law enforcement being called to the facility. Interviews with staff and residents confirmed that the unknown visitor's presence was not detected until after she had already entered the residents' room. Staff acknowledged that visitors should not be present during the night shift without proper authorization and that the logbook was not signed. The facility's policies required the facility to be locked at night and for a system to be in place to allow only approved visitors, but these procedures were not effectively implemented, resulting in a breach of resident safety and supervision.
Failure to Ensure Advance Directives Discussed and Documented
Penalty
Summary
The facility failed to ensure that an Advance Directive (AD) was discussed and written information was provided to two residents, as per the facility's policy. For Resident 145, who was admitted with diabetes mellitus and congestive heart failure, the facility did not have an AD Acknowledgement Form indicating that information was provided to the resident or their family about their rights to accept or refuse treatment and how to formulate an AD. The Director of Nursing confirmed that there was no AD in the resident's chart, which is necessary for staff to provide care according to the resident's wishes. For Resident 5, who was admitted with cardiomyopathy and epilepsy and had impaired cognition, the AD Acknowledgement Form was completed incorrectly. The Social Service Director stated that although Resident 5 did not execute an AD, the form incorrectly indicated that they had. This error could lead to staff being unaware of the resident's treatment preferences during an emergency. The facility's policy requires that residents or their representatives be provided with information about their rights to refuse treatment and formulate an AD, which was not adhered to in these cases.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for two residents, leading to potential adverse consequences. Resident 3, who was readmitted with acute respiratory failure and hypoxia, was observed sitting in a wheelchair with the oxygen tank turned off, despite a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. Licensed Vocational Nurse 2 confirmed that the oxygen should not have been turned off, as Resident 3 had a history of desaturation requiring continuous oxygen to maintain adequate oxygen saturation levels. Similarly, Resident 193, admitted with acute respiratory failure and dependent on supplemental oxygen, was found with a nasal cannula not placed in both nostrils, contrary to the physician's order for oxygen administration at 2 liters per minute. The Director of Staff and Development and the Director of Nursing both acknowledged that the nasal cannula needed to be properly placed to ensure the resident received the correct amount of oxygen. The facility's policy on oxygen administration, revised in May 2024, indicated that oxygen should be administered consistent with professional standards of practice.
Failure to Implement Bed Rail and Grab Bar Policy
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails and grab bars for two residents, placing them at risk for entrapment and injury. Resident 145, who was admitted with peripheral vascular disease and ulcers, was observed with half siderails up on both sides of the bed without documented evidence of alternative interventions being attempted prior to their installation. The resident required assistance with daily activities and had intact cognition, yet the facility did not follow the necessary steps to ensure safety and compliance with their policy. Similarly, Resident 9, admitted with hemiplegia, hemiparesis, and a history of falling, was found with grab bars installed on both sides of the bed. The resident had moderately impaired cognition and required substantial assistance with daily activities. There was no documented evidence of alternative interventions being attempted or consent obtained for the use of grab bars. The facility's Director of Nursing acknowledged that least restrictive alternatives should have been attempted and consent obtained to inform the resident or their representative of the risks and benefits associated with the use of bedrails or grab bars.
Failure to Manage Psychotropic Medications Properly
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for two residents, leading to potential unnecessary medication use. For Resident 94, the facility did not include a stop date for a PRN order of Lorazepam, contrary to the facility's policy which requires a 14-day limit unless reassessed by a physician. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the importance of limiting PRN psychotropic medication to prevent unnecessary administration that could affect residents' mental processing and safety. For Resident 10, the facility did not monitor the target behavior associated with the use of Haloperidol, as required by the facility's policy. The resident's medical records lacked documentation of behavior monitoring for a period of 10 days, which was necessary to assess the effectiveness of the medication. This lapse was confirmed by a Licensed Vocational Nurse, who emphasized the importance of monitoring to determine the medication's impact. The facility's policy mandates documentation of non-pharmacological interventions and target symptoms for monitoring, which was not adhered to in this case.
Inadequate Use of PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for two residents on Enhanced Barrier Precautions (EBP). For Resident 145, who was admitted with peripheral vascular disease and ulcers on the lower extremities, the facility did not ensure that Certified Nurse Assistant 1 (CNA 1) wore the required gown while providing care. Despite the care plan indicating the need for EBP due to unhealed ulcers, CNA 1 was observed only wearing gloves during care activities, which was against the facility's policy for infection control. Similarly, for Resident 2, who was on EBP due to a gastrostomy tube, the Treatment Nurse (TN) failed to wear a gown while administering medication. The facility's policy required the use of gowns and gloves for high-contact care activities, which include medication administration. The TN acknowledged the oversight, and the Infection Preventionist Nurse confirmed that the gown should have been worn to prevent cross-contamination. These lapses in following EBP protocols had the potential to spread infections within the facility.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 194, which was a violation of the facility's policy titled 'Call Lights: Accessibility and Timely Response.' Resident 194 was admitted with diagnoses including epilepsy and dependence on supplemental oxygen, and was assessed as high risk for falls due to being chair-bound, requiring assistive devices, taking multiple medications, and having a predisposing disease condition. The resident's care plan indicated a need for an agreed method to call for assistance, such as a call light or bell, due to their severely impaired cognition and dependence on staff for various activities of daily living. During an observation, it was noted that Resident 194's call light was hanging on the left side of the bed, out of reach, which the resident confirmed they could not see. The Director of Staff and Development acknowledged that the call light was not within reach and emphasized the importance of having it accessible at all times for the resident's safety and communication with staff. The Director of Nursing also confirmed that the call light should be within reach to ensure residents can call for assistance, as per the facility's policy. This oversight had the potential to delay care or services needed by the resident.
Failure to Provide Emergency Kit for Dialysis Resident
Penalty
Summary
The facility failed to provide a resident on hemodialysis with an emergency kit (E-kit) at bedside, which is necessary for immediate intervention in case of complications such as unexpected bleeding from the hemodialysis access site. This deficiency was identified for a resident who was admitted with end-stage renal disease and was dependent on hemodialysis. The resident's care plan indicated the need for immediate intervention should any signs and symptoms of complications from dialysis occur. However, during an observation, it was noted that the resident did not have an E-kit at bedside, which was confirmed by the Minimum Data Set Coordinator. The Director of Nursing acknowledged that all dialysis residents should have an E-kit at bedside to manage potential bleeding from the hemodialysis access site. The facility's policy and procedure for hemodialysis, revised in 2023, stated that care and services should be consistent with professional standards, including monitoring for complications and implementing appropriate interventions. Despite these guidelines, the absence of an E-kit at the resident's bedside represented a failure to adhere to the facility's own policies and procedures, potentially delaying necessary care and treatment.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide resident rooms that met the minimum requirement of 80 square feet per resident for multiple resident bedrooms. Specifically, 12 out of 13 rooms did not meet this requirement, as they were each 304 square feet and housed four residents, resulting in only 76 square feet per resident. This deficiency was identified during an initial tour of the facility, where it was observed that the rooms, although not meeting the federal requirements, had sufficient space for residents and staff to move around, store personal items, and accommodate necessary medical equipment. Interviews with residents and staff revealed that the space was adequate for their needs. Residents reported no issues with maneuverability within their rooms, and staff indicated that they could perform their duties without difficulty. Despite the facility's request for a waiver, the rooms did not comply with the federal square footage requirements, which could potentially impact the quality of life and care provided to the residents.
Failure to Locate Eloped Resident from Dialysis Center
Penalty
Summary
The facility failed to locate a resident who eloped from a dialysis center, which had the potential to compromise the resident's safety and well-being. The resident, who was admitted with diagnoses including end-stage renal disease and dependence on renal dialysis, was understood by others and required supervision for certain activities. The resident's care plan indicated a risk for falls and the need for hemodialysis. On the day of the incident, the resident left the dialysis center against medical advice and was not located by the facility. The Licensed Vocational Nurse (LVN) noticed the resident was not back from dialysis and contacted the dialysis center, which informed the LVN that the resident had finished dialysis earlier and refused to leave with the transportation service. The resident claimed someone else was there to pick them up. The facility reported the incident to the police but did not document any attempts to locate the resident after the elopement. The LVN stated that staff were required to notify the Director of Nursing (DON), search for the resident, and contact the police, family, and physician, but these actions were not fully executed. The Director of Nursing (DON) confirmed that after speaking with the resident's physician, no further actions were taken to locate the resident, such as contacting hospitals or following up with the police. The facility's policy on elopements required staff to search the premises and surrounding areas, notify the police, and inform the corporate office, physician, and family. However, these procedures were not adequately followed, as the facility did not conduct a thorough search or maintain communication with the police to locate the resident.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, as per its policy and procedure titled 'Readmission to Facility.' The resident, who had been admitted to the facility with diagnoses including asthma and dependence on renal dialysis, was medically stable for transfer back to the skilled nursing facility (SNF) after a hospital stay. Despite the resident's expressed desire to return to the SNF, the facility did not facilitate the readmission promptly, resulting in the resident remaining in the hospital for an additional two days. The hospital's discharge planning notes indicated that the case manager attempted to contact the SNF's administrator multiple times without success. The SNF's administrator later stated that they were not informed that the resident was ready to return. Interviews with the SNF's staff, including the Director of Nursing and the Director of Staff and Development, revealed that there were no staffing issues or bed availability problems that would have prevented the resident's readmission on the specified dates. The facility's policy stated that residents should be readmitted to the first available bed in their previous location or a semi-private room if their previous room was unavailable. Despite this policy, the resident was not readmitted until two days later, after further communication between the hospital and the SNF. The delay in readmission was not due to a lack of resources or space but rather a failure in communication and adherence to the facility's established procedures.
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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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Nursing homes near Baldwin Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Covina Healthcare Center | 0.5 mi | ★★★★★ | 17 | 0 |
| West Covina Medical Center D/p Snf | 0.7 mi | ★★★★★ | 15 | 0 |
| Garden View Post Acute Rehabilitation | 0.8 mi | ★★★★★ | 20 | 0 |
| West Haven Healthcare | 0.8 mi | ★★★★★ | 17 | 0 |
| Coast Care Convalescent Center | 1.2 mi | ★★★★★ | 18 | 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.