Above average — CMS composite of the measures below.
The next survey window likely opens 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 Victoria Post Acute Care during CMS and state inspections, most recent first.
Food was not plated in an appetizing or presentable manner. Two residents stated the food presentation could be better, and one resident also reported meals sometimes were cold. During tray line observation, the DM and CDM saw plates that were haphazard, unbalanced, and messy, with sauce spilling off the edges. The CDM and DON both stated the food should have been more presentable and made with care.
Missing Documentation for Self-Administration of Eye Drops: A resident with glaucoma was observed during a med pass, but the LPN did not administer the resident’s morning eye drops because the resident self-administered them. The resident and the DON confirmed there was no IDT documentation or physician order in the chart showing that self-administration of the eye drops was clinically appropriate, despite the facility policy requiring the determination to be documented in the record and care plan.
Failure to Provide Nail Care Assistance: Two residents who needed help with ADLs were observed with long fingernails, and one had black debris under the nails. One resident with a fracture and need for personal care said she needed help trimming her nails, and another resident with dementia and dependent personal hygiene said she wanted her fingernails trimmed. The DSD stated nail care was done on Sundays, while the DON said staff were expected to trim and clean fingernails every shower day if needed.
Medication services were not properly managed when an opened, undated Aplisol vial was found in a med refrigerator and a discontinued Advair Diskus inhaler for a resident remained in a med cart. The DON acknowledged the Aplisol vial was opened and undated, and the discontinued inhaler was still available for use long after the stop order. The facility’s records and staff statements showed the medications were not handled according to labeling and discontinuation requirements.
Opened inhaler devices were found in a med cart without the required open dates and without resident-specific labeling. An LPN observed an undated Advair Diskus and Trelegy Ellipta for one resident and three opened inhalers that were not labeled on the device itself for multiple residents, even though the cartons were labeled. The DON and other nurses stated the inhalers should have open dates and resident-specific labels on both the box and the device.
Expired food was found in a residents' refrigerator, including a food item dated 1/17/26 that an LN said should have been discarded. The LN stated food without a name or date should also have been discarded and that expired foods could cause foodborne illness or stomach upset. The DON stated staff were expected to follow the Food Brought by Family or Visitor policy, which required foods to be labeled with the resident name, location, and date and discarded after 72 hours of storage.
A resident with a history of alcohol abuse had a thiamine order that did not include a dosage amount. During med pass, an LN administered the medication, and later confirmed the order lacked milligrams. The DON stated complete medication orders are important to prevent overdosing or underdosing, and facility policy requires orders to include dosage.
Improper Storage of Respiratory Equipment: Two residents had respiratory equipment stored improperly. One resident’s nebulizer mask was left uncovered on the bedside table, and another resident’s CPAP nasal mask was found on the floor. An LPN stated the tubing and masks should be stored in a plastic bag when not in use to prevent contamination, and the DON confirmed respiratory equipment should be stored properly for infection control.
A resident with diabetes, who was alert and on long-term insulin, did not have their blood sugar checked or documented before lunch as ordered. The DON confirmed that there was no record of the check or insulin coverage, and no documentation of refusal, which did not follow physician orders or facility policy.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences, resulting in a deficiency related to proper planning and preparation for transition.
The facility failed to maintain food safety and sanitation practices, including the absence of a proper air gap system for the ice machine and sinks, a poorly maintained prep sink, and the lack of a splash guard on the mixer. Additionally, unpasteurized eggs were initially used in a meat recipe, posing a risk of food-borne illness to residents.
The facility failed to provide palatable and nutritious meals, with residents reporting issues such as cold, tasteless food and lack of variety. A meat recipe was improperly prepared using unpasteurized eggs, posing a health risk. The facility's policies on menu planning and food preparation were not effectively implemented, leading to dissatisfaction and potential health risks for residents.
The facility failed to maintain proper infection control practices, including improper storage of respiratory equipment for a resident, lack of cleaning for another resident's CPAP machine, and CNAs not following PPE protocols for residents on transmission-based precautions. Additionally, hand hygiene was not performed during dining observations, increasing infection risk.
The facility failed to maintain resident dignity during feeding, as two residents were fed by staff standing over them, contrary to expectations for maintaining dignity. Additionally, a resident with cognitive deficits was served food in a Styrofoam container, which was not their preference and hindered their ability to feed themselves. The DON confirmed that meals should be served on appropriate dishware to promote independence and dignity.
Several residents experienced safety and comfort issues due to maintenance failures. A resident's sliding door and overhead light were not repaired promptly, causing safety concerns. Another resident faced a dangling telephone jack, posing a fall risk. Additional residents dealt with room maintenance issues, highlighting the facility's failure to maintain a safe and homelike environment.
A resident with end-stage renal disease did not receive a comprehensive assessment within the required 14 days after admission. The MDS and CAA were completed late, delaying the care planning process. Interviews with staff confirmed the importance of timely assessments to prevent care delays and financial penalties.
A facility failed to accurately code the MDS for a resident reviewed for dementia care. The resident, with a history of bipolar disorder, was incorrectly coded as having dementia due to the MDSC following previous assessments without a current diagnosis. This led to the submission of inaccurate health status information to databases, potentially affecting the resident's care.
The facility failed to provide adequate assistance with ADLs for three residents, including nail care and grooming. A resident with hemiplegia had long, jagged nails, while another with Alzheimer's was unshaven. Staff interviews revealed confusion about responsibilities, with some CNAs unsure if they could trim nails. The facility's policy emphasized cleanliness and assistance, but these were not consistently followed.
A resident with a history of hemiplegia was found with unsecured medications at their bedside, including eye drops and antifungal powder. The facility failed to conduct safety evaluations or create care plans for the resident's self-administration of medications, contrary to their policy requiring secure storage and assessments.
The facility's QAA Committee did not identify or include trends in grooming and CPAP/BIPAP cleaning in their QAPI plan, as noted during a recertification survey. The ADM and DON acknowledged the oversight, emphasizing the importance of these trends for maintaining resident dignity and minimizing infection risks.
A resident with dysphagia and cognitive deficits was left unsupervised during a meal, contrary to their care plan requiring 1:1 feeding assistance. The resident was observed coughing after eating alone, and staff interviews confirmed the necessity of supervision to prevent aspiration. The facility's policy mandates assistance by qualified staff, which was not followed in this instance.
A resident reported being handled roughly by a nurse, but the facility failed to remove the nurse from care duties as per their abuse policy. The Social Services Director did not conduct a thorough investigation or report the incident to the State Agency, believing a grievance was sufficient. The resident, who had no cognitive deficits, felt unsafe and requested a transfer. The facility's administrator admitted the grievance process did not meet reporting obligations, and the nurse continued to care for the resident despite the complaint.
A resident with a history of intracranial hemorrhage reported being mishandled by a nurse, but the facility failed to report the alleged abuse to the State Agency or law enforcement as required by policy. The Social Services Director did not complete a full investigation, citing a grievance resolution and the resident's mental disorder. The facility's administrator mistakenly believed a grievance was sufficient, despite policy requirements for external reporting.
A resident with severe cognitive impairment and dementia was inappropriately discharged to an independent living facility (ILF) despite requiring moderate assistance with ADLs and lacking the capacity to make decisions. The discharge plan did not consider the resident's mental capacity or safety needs, and the decision was made based on cost and mistaken beliefs about the ILF's care capabilities.
Food Plating Was Not Presentable
Penalty
Summary
Food served to residents was not plated with an appetizing presentation. On 1/26/26, Resident 100 stated the food could have a better presentation and that the look on the plates sometimes did not look good. Later that morning, Resident 21 stated the food sometimes would be cold and that the presentation could be better. On 1/28/26, a concurrent observation and interview with the Dietary Manager and Consultant Dietary Manager during tray line service showed the food plated in a haphazard manner, with several plates lacking intentional design and appearing unbalanced and messy, with sauce spilling off the edges of the plates. The Consultant Dietary Manager stated the plating should have been more presentable in appearance. On 1/29/26, the DON stated plating of resident food should have been presentable and made with care for residents, and that this could have caused residents not to want to eat. The facility policy titled Food Preparation stated food shall be prepared by methods that conserve nutritive value, flavor, and appearance.
Missing Documentation for Self-Administration of Eye Drops
Penalty
Summary
The facility failed to ensure the interdisciplinary team documented in the medical record that it was clinically appropriate for one resident to self-administer medications. Resident 89 was admitted after a fall that resulted in a fracture, and the history and physical noted the resident lived alone and had to maneuver to reach a phone to call for help. Physician orders dated 1/7/26 included three ophthalmic solutions for glaucoma: brimonidine twice daily, dorzolamide hydrochloride-timolol twice daily, and latanoprost at bedtime. During a medication pass observation, a nurse was observed administering medications to Resident 89, but no eye drops were observed being given at that time. In a later interview and record review, the nurse stated the resident self-administered the morning eye drops. The resident also stated they self-administered the eye drops. The DON stated there was no IDT documentation or physician orders in the medical record regarding the resident's self-administration of the eye drops. The facility policy stated that if a resident is a candidate for self-administration, this should be indicated in the chart and documented in the care plan.
Failure to Provide Nail Care Assistance
Penalty
Summary
The facility failed to ensure two residents who were unable to perform activities of daily living received assistance with nail care. Resident 79 was admitted with diagnoses including a fracture of the right pubis and need for assistance with personal care. During an observation and interview, Resident 79 was in bed with a breakfast tray nearby and was observed with long fingernails and black debris under the nails. Resident 79 stated she needed assistance with trimming her nails. The MDS dated 1/8/26 indicated Resident 79 required moderate assistance with personal hygiene. Resident 138 was re-admitted with diagnoses including dementia and need for assistance with personal care. The care plan dated 1/16/26 indicated Resident 138 was dependent with personal hygiene. During observations on 1/27/26 and 1/28/26, Resident 138 was in bed and observed with long fingernails, and stated she would like her fingernails trimmed. The DSD stated nail care for residents was completed on Sundays and later stated Resident 138's fingernails were long and should have been trimmed for infection control. The DON stated staff were expected to trim and clean residents' fingernails every shower day if needed.
Medication Storage and Discontinued Drug Removal Deficiencies
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when an opened and undated multiple-dose Aplisol vial was found stored in the North Medication Room refrigerator and available for use. During observation with the ADON, the vial was seen opened and without a date. The ADON acknowledged it was stored in the refrigerator, and the DON later acknowledged the vial had been opened and undated. The facility’s Aplisol package insert stated that vials in use more than 30 days should be discarded due to possible oxidation and degradation that may affect potency, and the facility’s Medication Labels policy required medications to be labeled in accordance with facility requirements and state and federal laws. The facility also failed to remove a discontinued medication from the Southwest Medication Cart for Resident 76. The resident had a physician’s order discontinuing Advair Diskus inhaler, yet the inhaler remained in the medication cart approximately 59 days after the discontinue date. During the cart inspection, the Advair Diskus inhaler, along with its carton and mouthpiece, was still present and labeled with an opened date of 11/1/25. The LN acknowledged the medication was still stored in the cart, and the DON stated the staff should have pulled the medication when the order was discontinued.
Opened inhalers were left undated and unlabeled
Penalty
Summary
Two opened inhaler devices in the medication cart were not dated according to the manufacturers’ instructions. During observation with LN 1, an opened and undated Advair Diskus inhaler mouthpiece for Resident 109 and an opened and undated Trelegy Ellipta inhaler tray for Resident 29 were found stored in the Southwest Medication Cart. The package insert for Advair Diskus stated it should be discarded one month after opening the foil pouch or when the counter reads 0, whichever comes first, and the patient information guide for Trelegy Ellipta stated it should be thrown away 6 weeks after opening the tray or when the counter reads 0, whichever comes first, with the open date written on the inhaler. LN 1 stated both inhaler devices were opened and undated, and the DON stated staff were expected to label inhaler devices with the open date so they know when to discard the medications. Three opened inhaler devices were also not labeled with sufficient resident-specific information. During the same observation, an opened and unlabeled Advair Diskus inhaler mouthpiece for Resident 76, an opened and unlabeled Advair Diskus inhaler mouthpiece for Resident 109, and an opened and unlabeled Trelegy Ellipta inhaler tray for Resident 29 were found in the medication cart. LN 1 stated the inhaler cartons were labeled with resident information, but the inhaler devices themselves were not labeled and could get confused. LN 6 and LN 22 stated both the inhaler box and the inhaler device had to be labeled with resident-specific information, and the DON stated the importance of labeling the inhaler devices was due to infection control risk and potential for medication errors. The facility policy stated medications are to be labeled in accordance with facility requirements and state and federal laws.
Expired Food Left in Residents' Refrigerator
Penalty
Summary
Food was left in a dedicated residents' refrigerator past the allowed storage time and was not discarded as required. During observation on 1/26/26, LN 11 saw a food item dated 1/17/26 in the residents' refrigerator and stated it should have been discarded, along with any food items that had no name or date. LN 11 stated there should not be any expired foods in the residents' refrigerator and that expired foods could cause foodborne illness or stomach upset such as nausea and vomiting. During interview on 1/29/26, the DON stated the expectation was for staff to follow the Food Brought by Family or Visitor policy and acknowledged that residents eating expired foods could have caused GI upset and/or foodborne illness. The facility policy reviewed by surveyors stated that all foods shall be labeled with the resident name, location, and date, and discarded after 72 hours of storage.
Incomplete Thiamine Medication Order
Penalty
Summary
A complete medication order was not ensured for one sampled resident who was receiving thiamine (Vitamin B1). The resident’s H&P noted a history of alcohol abuse, and a physician order dated 12/01/25 at 8:58 P.M. ordered Vitamin B1 oral tablet, give 1 tablet by mouth one time a day. During a medication pass observation on 1/27/26 at 7:51 A.M., an LN was observed administering thiamine to the resident. During interview and record review, an LN stated that when a thiamine order is received, the dose is needed to ensure the correct dose is given and the physician order is followed. The LN later stated that for this resident there was no dose in the thiamine order and no milligrams were listed. The DON stated that a complete medication order is important to prevent overdosing or underdosing residents. The facility policy titled Physician Orders - Administration of Medications/Treatments stated that orders must include dosage.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to implement infection control standards of practice for two residents reviewed for infection control. Resident 104, who had diagnoses including COPD and an order for Ipratropium-Albuterol nebulizer treatments as needed for shortness of breath or wheezing, was observed in bed with a nebulizer machine on the bedside table. The tubing and mask were connected to the machine, and the mask was sitting uncovered on top of the bedside table. During a later observation, licensed nurse 21 stated the tubing and mask should be changed weekly and as needed and stored in a plastic bag to prevent contamination. Resident 137, who had diagnoses including OSA and an order for CPAP at bedtime and removal in the morning, was observed sitting in bed with the CPAP machine on the bedside table. The tubing was hanging down and the nasal mask was on the floor. Resident 137 stated she used the CPAP machine for sleep apnea and applied the nasal mask herself. During a later observation, licensed nurse 21 stated the CPAP nasal mask should be stored in a plastic bag to prevent contamination, and the DON stated respiratory equipment such as oxygen tubing, mask, and CPAP mask should be stored in a plastic bag when not in use. The facility policy titled CPAP/BIPAP Monitoring / Management / Storage stated to store tubing and mask appropriately when not in use, and the Infection Prevention and Control Program stated staff will provide care in a way that minimizes the spread of infection.
Missed Blood Sugar Check and Documentation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with diabetes, who was alert, oriented, and able to make complex medical decisions, did not have their blood sugar checked as ordered before lunch on a specific day. The resident was on long-term insulin therapy and had physician orders for blood sugar monitoring four times daily (before meals and at bedtime). Documentation showed that the blood sugar was checked in the morning after breakfast, but there was no record of a blood sugar check or insulin coverage before lunch, nor was there documentation that the resident refused the check. The Director of Nursing confirmed that the expectation was for licensed nurses to follow physician orders and document all medication and treatment administration in the resident's clinical record. The facility's policy required that all medications and treatments be administered as prescribed and recorded on the appropriate administration record. The failure to check and document the resident's blood sugar before lunch represented a lapse in following physician orders and facility policy for diabetes management.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. There are no additional details provided regarding the specific actions or inactions of staff, the medical history or condition of the resident at the time, or any direct observations beyond the failure to meet the requirements for a safe and appropriate transfer or discharge.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as observed during a survey. The ice machine and two three-compartment sinks lacked a proper air gap system, which is essential to prevent backflow contamination. The Dietary Supervisor (DS) and the Director of Maintenance (DOM) confirmed the absence of an air gap, which is a violation of the 2022 Federal FDA food code. This oversight could potentially lead to contamination of food and water supplies, posing a risk to the health of the 110 residents receiving food from the kitchen. Additionally, the facility's prep sink was found to be in poor condition, with white-stained deposits, rust, and a discolored, rock-like substance embedded on its surface. Despite a sign indicating that the sink should not be used for thawing meats due to a slow drain, it was still used for preparing vegetables. The Dietary Supervisor acknowledged that the sink was not clean or sanitary for food preparation, and the use of a red sanitation bucket with an incorrect disinfectant concentration further increased the risk of chemical contamination. The facility also failed to use a splash guard on the industrial mixer, resulting in food splashing onto the kitchen floor and surrounding surfaces during preparation. This lack of equipment could lead to cross-contamination. Furthermore, the dietary cook initially used unpasteurized eggs in a meat recipe, contrary to the recipe's requirement for pasteurized eggs. Although the Registered Dietician initially approved the use of unpasteurized eggs, the cook later retrieved the correct pasteurized eggs, recognizing the potential risk of food-borne illnesses to the residents.
Deficiencies in Food Quality and Preparation
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value. Multiple residents expressed dissatisfaction with the meals, citing issues such as cold food, lack of taste, and unappealing presentation. Some residents reported that the food was dry, tasteless, or not identifiable, and there was a lack of variety and cultural food alternatives. The Resident Council meeting minutes also highlighted ongoing concerns about food preferences and the lack of variety in meals. Additionally, the facility did not adequately address food complaints, as the Registered Dietitian did not use a tracking system to identify and resolve issues. During the preparation of a meat recipe, the facility failed to follow the specified recipe, which required the use of pasteurized eggs. The dietary cook mistakenly used unpasteurized eggs, despite the recipe's clear instructions to use pasteurized eggs to ensure safety and maintain the nutritional value of the meal. The Registered Dietitian acknowledged the mistake but allowed the cook to continue using the unpasteurized eggs, which could pose a health risk to residents. This oversight in food preparation was observed during a test tray observation, where the apple glazed meatballs were found to be undercooked and sour, and the brown rice lacked flavor. The facility's policies on menu planning and food preparation were not effectively implemented, as evidenced by the failure to consider residents' cultural and ethnic needs and the improper handling of food preparation. The lack of a policy and procedure for test trays further contributed to the deficiency. The Registered Dietitian and Dietary Supervisor acknowledged the importance of following recipes to preserve the nutritive value and taste of meals, but the facility's practices did not align with these standards, leading to dissatisfaction and potential health risks for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to several deficiencies. For Resident 261, the BIPAP machine was improperly stored with tubing touching the floor and without a mask, posing an infection risk. The facility's policy did not provide guidance on proper storage, and there were no physician's orders indicating how the equipment should be stored. Observations confirmed that the equipment was not stored in a sanitary manner, and the Director of Nurses acknowledged the infection control issue. Resident 33's CPAP machine and accessories were not cleaned according to professional standards, as there were no physician's orders or care plans for CPAP maintenance. The resident reported that the CPAP had not been cleaned recently, and the Infection Prevention Nurse was unaware of the need for cleaning. The Director of Nurses confirmed the lack of orders for CPAP maintenance and acknowledged the risk of harmful microbes growing in uncleaned equipment. Three CNAs failed to adhere to infection control protocols by not performing hand hygiene or wearing PPE when entering rooms of residents on transmission-based precautions. This included residents with COVID-19 and C. difficile, both of which require strict infection control measures. Additionally, during a dining observation, staff did not perform hand hygiene for residents before or after meals, increasing the risk of spreading infections. The facility's policies and procedures were not followed, as confirmed by interviews with the Director of Nursing and the Infection Prevention Nurse.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat two residents with dignity during feeding, as observed by surveyors. Resident 63, who has Alzheimer's disease and dementia, was fed by a staff member standing over them, which was against the facility's expectations for maintaining resident dignity. The Licensed Nurse (LN) 11 noted that standing while feeding could be intimidating for residents. The Director of Nurses (DON) confirmed that staff should assist residents at an appropriate height to maintain dignity, as per the facility's policy on resident rights. Similarly, Resident 67, diagnosed with unspecified dementia, was also fed by a staff member standing at their bedside. This practice was again observed by LN 11, who reiterated the expectation for CNAs to sit while feeding residents to avoid intimidation. The DON supported this expectation, emphasizing the importance of maintaining dignity in accordance with the facility's policy. Additionally, Resident 65, with a history of traumatic brain injury and severe cognitive deficits, was served food in a Styrofoam container, which was not their preference and hindered their ability to feed themselves. The resident expressed difficulty in using their adaptive fork due to the container's edges and stated a preference for regular dishware. Staff interviews revealed that Styrofoam containers were used for convenience, but the Dietary Supervisor confirmed that Resident 65 was not on the list of residents preferring such dishware. The DON acknowledged that meals should be served on appropriate dishware to promote independence and dignity, aligning with the facility's policy on resident rights.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, leading to safety concerns and emotional distress. Resident 33 experienced issues with a sliding door that could not fully open or close, a damaged closet door, and a non-functional overhead bed light. These issues were reported to the Director of Maintenance (DOM) but were not addressed in a timely manner, causing Resident 33 to feel anxious about safety, especially in case of an emergency. The DOM admitted to not contacting an outside contractor for repairs until much later, despite being aware of the issues for over a month. Resident 80 faced a similar situation with a telephone wall jack that was detached and hanging from the wall, exposing wires and creating a potential safety hazard. The resident expressed discomfort and concern about pests and the risk of falls due to the dangling wires. Despite multiple reports to the maintenance department, the issue remained unresolved, contributing to the resident's unease and dissatisfaction with the living conditions. Additionally, other residents, including Residents 9, 14, and 54, experienced discomfort due to maintenance issues in their rooms. Resident 9 had a telephone jack dangling from the wall, Resident 54's room had multiple areas of repaired drywall, and Resident 14's room had a discolored wall covered by a temporary panel. These conditions were acknowledged by the facility's staff, including the Director of Nursing and the Administrator, who recognized the need for repairs but had not yet implemented a permanent solution.
Failure to Timely Complete Comprehensive Assessment for Dialysis Resident
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 calendar days after admission for a resident who was reviewed for dialysis. The resident was admitted with a history of end-stage renal disease, and the Minimum Data Set (MDS) assessment, which is crucial for developing a care plan, was completed late. The MDS Coordinator acknowledged that the MDS and Care Area Assessment (CAA) were completed after the required timeframe, which is essential for triggering a comprehensive person-centered care plan. Interviews with the MDS Coordinator and the Director of Nursing highlighted the importance of timely completion of the MDS and CAA to prevent delays in care planning and potential financial penalties. The Centers for Medicare and Medicaid Services (CMS) RAI Manual specifies that the Resident Assessment Instrument (RAI) must be completed within 14 days of admission, and the facility's failure to adhere to this requirement resulted in a deficiency.
Inaccurate MDS Coding for Dementia Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident reviewed for dementia care. The resident, who was admitted with a history of bipolar disorder, had an MDS assessment indicating moderate cognitive deficits. However, the MDS Coordinator (MDSC) was unable to find a physician-documented diagnosis of dementia in the resident's medical records within the required timeframe. Despite this, the MDSC followed previous MDS assessments and incorrectly coded the resident as having dementia. The MDSC acknowledged the error, stating that only active diagnoses within the last seven days should be coded on the MDS. The Director of Nursing (DON) emphasized the importance of accurate MDS coding, as it triggers the resident's plan of care. The inaccurate coding led to the submission of incorrect health status information to state and federal databases, potentially resulting in inappropriate care for the resident.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who were unable to perform self-care activities such as grooming and nail care. Resident 7, who was readmitted with hemiplegia and hemiparesis following a stroke, was observed with long, jagged fingernails and faded nail polish. Despite the resident's inability to communicate verbally, they indicated a desire for nail care. Interviews with staff revealed confusion about responsibilities, with some CNAs stating that only licensed nurses could trim nails, while others indicated it was a CNA responsibility. Resident 63, diagnosed with Alzheimer's disease and dementia, was observed unshaven and expressed a desire to be shaved. The CNA present acknowledged the need for shaving and stated that grooming was supposed to occur on shower days. The Director of Staff Development confirmed that CNAs were expected to provide grooming on shower days, emphasizing the importance of personal well-being. Resident 67, admitted with dementia, was also observed with long fingernails and indicated a desire for them to be trimmed. The licensed nurse confirmed that nail care was the responsibility of CNAs. The facility's policy on ADLs and hygiene emphasized promoting cleanliness and assisting residents as necessary, but the observations and interviews highlighted a failure to adhere to these policies, potentially affecting the residents' personal well-being.
Unsecured Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by the observation of unsecured medications left at the bedside of a resident. The resident, who was admitted with a history of hemiplegia and hemiparesis following a cerebral infarction, was found to have two eye medications and an antifungal powder left unattended on their bedside and nightstand tables. The resident stated that the nurses left the eye drops for self-administration, but there was no documented assessment or evaluation to confirm the resident's ability to safely self-administer these medications. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there were no safety evaluations or care plans in place for the resident's self-administration of medications. The staff acknowledged that medications should be stored in a locked container and that safety evaluations should be conducted before allowing self-administration. The facility's policy indicated that drugs should not be left unsecured or unattended, yet this protocol was not followed, leading to the potential for medication misuse or allergic reactions.
QAA Committee Fails to Identify Key Trends in Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and include certain trends in their Quality Assurance Performance Improvement (QAPI) plan, as observed during a recertification survey. Specifically, the surveyors identified deficiencies in basic grooming, such as nail and beard care, and the cleaning of bi-level positive airway pressure (BIPAP) and continuous positive airway pressure (CPAP) machines. These trends were not recognized by the QAA Committee and were absent from the QAPI plan, which primarily focused on areas like falls, abuse, staffing and retention, and infection control. Interviews with the Administrator (ADM) and the Director of Nursing (DON) revealed that the expectation was for the QAA Committee to have identified these trends and included them in the QAPI plan. The ADM and DON both acknowledged the importance of identifying such trends to maintain resident dignity and minimize infection risks. The facility's policy on Quality Assurance and Performance Improvement emphasized the committee's role in identifying and prioritizing performance improvement plans (PIPs) for high-risk, high-volume, or problem-prone issues, which was not adhered to in this instance.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to provide adequate supervision for a resident who required 1:1 feeding assistance during meals. The resident, who was admitted with diagnoses including dysphagia, cognitive communication deficit, and pneumonia, was observed eating alone in his room without staff supervision. Despite the presence of a sign above the resident's bed indicating the need for 1:1 assistance and specific swallowing guidelines, the resident was left unsupervised, which led to coughing after taking a bite of fish. The resident's care plan and Kardex also specified the need for 1:1 supervision during meals due to aspiration precautions. Interviews with facility staff, including a CNA, LN, ST, and the DON, confirmed that the resident required supervision during meals to prevent aspiration and potential health decline. The CNA acknowledged the need for 1:1 feeding assistance, and the ST emphasized the importance of supervision due to the resident's cognitive impairment and poor meal intake. The DON admitted that the resident should not have been served lunch without a staff member present, highlighting the risk of aspiration and weight loss. The facility's policy on meal services and assistance also mandated that residents receive meals as ordered and be assisted by qualified staff as necessary.
Failure to Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from potential abuse when a complaint was made against a licensed nurse (LN) for handling the resident roughly. Despite the resident's report of being mishandled, the facility did not immediately remove the nurse from providing care to the resident, as required by their abuse policy. The Social Services Director (SSD) did not complete a thorough investigation or report the incident to the State Agency, believing that filing a grievance was sufficient. The resident, who had no cognitive deficits, expressed feeling unsafe and requested a transfer to another facility. The facility's administrator acknowledged that the grievance process did not fulfill their obligation to report the alleged abuse to the appropriate authorities. The facility's policy required the immediate removal of the employee from resident care during an investigation, which was not followed. The resident reported being physically grabbed by the neck and forcefully put back on the bed by the nurse, yet the nurse continued to be assigned to the resident's care. There was no documented evidence of a head-to-toe assessment being conducted on the resident following the complaint.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse complaint to the State Agency, protective services, and/or law enforcement entities as required by their policy. Resident 1, who was admitted with a history of non-traumatic intracranial hemorrhage and had no cognitive deficits, reported being mishandled by a licensed nurse during care. Despite the resident's complaint, the Social Services Director did not complete a five-day report or notify the appropriate authorities, citing that a grievance was completed and the resident and his daughter were satisfied with it. The Social Services Director also mentioned that the allegation could not be verified due to the resident's mental disorder causing hallucinations, and the nurse in question was not suspended during the investigation. The facility's administrator believed that addressing the complaint through a grievance was sufficient, despite acknowledging that such a report does not replace the obligation to report to the State Agency and other authorities. The facility's abuse policy clearly states that allegations of abuse, neglect, or exploitation must be reported to the appropriate State or Federal agencies. However, there was no documentation indicating that the resident's abuse allegation was reported as required. Interviews with the involved staff and review of the facility's communication system further confirmed the lack of appropriate reporting and investigation of the incident.
Inappropriate Discharge of Resident with Dementia
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident diagnosed with dementia and severe cognitive impairment. The resident was discharged to an independent living facility (ILF) despite having a history of dementia with behavioral disturbances, severe cognitive loss, and requiring moderate assistance with activities of daily living (ADLs). The resident's medical records indicated that they did not have the capacity to understand and make decisions, and there was no documentation of an evaluation for safe self-medication administration. The decision to discharge the resident to an ILF was made because it was the cheapest option, and the case manager mistakenly believed the ILF provided 24-hour care. Interviews with the social services director, case manager, and director of nursing revealed that the resident's discharge plan did not adequately consider the resident's mental capacity, ADL needs, or safety concerns. The facility's discharge policy required the identification and documentation of discharge needs and plans based on the resident's condition, which was not followed in this case. Both the case manager and the director of nursing acknowledged that the safest discharge option would have been a locked unit or an assisted living facility specializing in dementia care, but these options were not pursued due to availability and cost concerns.
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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 El Cajon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Las Palmas Healthcare Center | 0 mi | ★★★★★ | 2 | 0 |
| Magnolia Post Acute Care | 0.6 mi | ★★★★★ | 15 | 0 |
| Stillwater Post-acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Somerset Post Acute Care | 0.7 mi | ★★★★★ | 2 | 0 |
| San Diego Post-acute Center | 0.9 mi | ★★★★★ | 13 | 1 |
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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.