Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 West Anaheim Medical Center D/p Snf during CMS and state inspections, most recent first.
GT Feeding and Medication Administration Errors: A resident with GT feeding had the HOB below the ordered elevation while formula was infusing, another resident with a GT also had the HOB below the ordered level during feeding and flushes, a third resident’s enteral feeding bag was labeled with the wrong rate, and an LVN administered a crushed GT medication without mixing it with water first. The DON confirmed the ordered HOB elevation and labeling requirements, and the facility policy required GT medications to be crushed and dissolved with water before administration.
A facility failed to provide ordered respiratory care for four residents. One resident had an opened Yankauer suction device that had not been changed within the ordered timeframe, two residents had Yankauer suction tips left at the bedside without opened dates despite orders to change them daily, and a ventilator-dependent resident had no documented cleaning and disinfecting of the ventilator machine per the manufacturer’s instructions. Staff interviews showed uncertainty and inconsistent practice regarding suction and ventilator equipment care.
Opened sterile supplies and irrigation fluid were found improperly stored in the facility. A bottle of sterile water used for a resident’s Foley catheter flush was left at the bedside after opening, and Medication Cart A contained opened sterile alginate dressings with antimicrobial silver plus an opened sterile Puracol (Collagen) Plus dressing. The DON verified the findings and stated the dressings should remain unopened until use and unused portions should be discarded after use.
Kitchen sanitation and food handling deficiencies were observed during survey. Surveyors found blenders with visible water and food particles, unlabeled and undated food items in the refrigerator, expired food in a freezer, and a staff member’s personal food stored in the walk-in refrigerator. A Maintenance Manager entered the kitchen with uncovered facial hair, cutting boards were heavily discolored, the ice machine had scale and buildup, a Kitchen Aid failed to perform hand hygiene before putting on new gloves after handling trash, and dirt was observed near the kitchen floor drain.
A resident with severely impaired cognitive skills was observed in bed with the upper body exposed while the room curtain was not pulled, allowing visibility from the doorway and hallway. The resident's family member had requested that the resident not be covered or wear a shirt, and facility policy required curtains and draping to provide full visual privacy and dignity. IP verified the observation, and the DON was informed of the findings.
Failure to Care Plan Anticoagulant Use: A resident had an order for Xarelto via GT for DVT prophylaxis, but the comprehensive care plan did not include an individualized plan for the anticoagulant. During record review, an RN confirmed no care plan had been developed for the medication, and the DON verified the finding.
Care plans were not revised to match current orders and care needs for three residents. Two residents who were GT and ventilator dependent had physician orders for HOB elevation to 35 degrees at all times for aspiration precautions, but their care plans still listed different HOB ranges and did not fully reflect the order; one resident was observed with the HOB below the ordered level. Another resident with a trach and ventilator had a care plan for ventilator dependency that did not include cleaning and disinfecting the ventilator per the manufacturer’s manual.
A resident who was bedbound, nonverbal, and mechanically ventilated did not receive a consistently documented individualized activity program aligned with the care plan. The resident’s preferences included watching Korean movies and using a Tobii device for communication, but observations showed the resident lying awake in bed without engagement in activities, and staff confirmed the resident was not participating. Activity notes were missing for multiple days, and the Activity Director confirmed there was no documentation that preferred activities were offered or refused.
A resident with no responsible party had a POLST indicating DNR, comfort-focused treatment, and no invasive or non-invasive mechanical ventilation, but the record showed the resident was receiving mechanical ventilation with active ventilator orders. The IDT/Care Plan Conference documentation only reflected DNR and did not show discussion of the comfort-focused goals or ventilation limits, and the DON verified there was no documentation that the POLST was reviewed with the IDT and Council on Aging representative or clarified with the physician.
Failure to Notify Physician of Significant Weight Changes: A resident with altered nutrition and tube feeding intolerance had repeated significant weight losses and gains, including a 20-lb loss in one month. The care plan and facility policy required physician notification for excessive weight changes, but the record did not show that the physician was notified when the weight changes occurred or that the resident was monitored for the documented change-of-condition periods.
A resident receiving IV cefepime was observed with NS infusing through a right hand IV access, but the record did not show physician orders for the NS IV fluid or for peripheral IV site rotation every 72 hours and as needed. An RN verified the missing orders during interview, and the DON was informed and confirmed the findings.
An LVN failed to follow the MAR instructions for GlycoLax by mixing the powder with pudding instead of water, and another LVN did not administer a scheduled Pro-Stat supplement via GT during a med pass. The DON stated meds should be given per MD orders and within the ordered time window.
Infection control was not followed during medication administration for two residents. An LVN administered GT medication to a resident on enhanced barrier precautions without wearing a gown and did not disinfect the stethoscope before leaving the room. In a separate observation, an RN administered eye ointment to both eyes of another resident without changing gloves and performing hand hygiene between eyes, despite the facility’s policy requiring glove changes and hand hygiene during eye medication administration.
The facility failed to follow proper procedures for enteral feeding and medication administration for two residents. One resident's feeding formula was not labeled with the start time, and another resident's gastric residual was not checked before administering medications through the GT. These actions were contrary to the facility's P&P and posed risks for complications.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as marred cutting boards, improperly stored wet utensils, and damaged kitchenware. The Dietary Director acknowledged these deficiencies, which included dirty utensils and an unsanitary stove hood. These failures posed a risk of cross-contamination and foodborne illnesses to residents.
The facility failed to maintain infection control practices, as staff did not disinfect stethoscopes after resident use and did not follow proper gown and glove protocols between residents. Additionally, linen cart covers were found dirty and stained, indicating lapses in cleanliness. These deficiencies were acknowledged by the facility's DON and IP.
The facility failed to administer pneumococcal vaccines to two residents despite obtaining consent. The medical records lacked documentation of vaccine administration or explanations for the oversight. Infection Preventionists confirmed the vaccines were offered and consents obtained, but not administered.
The facility failed to maintain a clean and homelike environment, as evidenced by stained walls, curtains, and medical equipment in several residents' rooms. The DSD/MDS Coordinator and DON acknowledged that staff should have cleaned these areas promptly and reported stains to EVS staff. However, a communication gap led to the deficiencies, impacting the residents' living conditions.
A facility failed to store medications properly, as two tubes of Zinc Oxide paste were found on a resident's bedside table instead of being locked in the treatment cart. The DSD/MDS Coordinator confirmed this was against the facility's policy, which requires medications to be stored in lockable areas accessible only to authorized personnel.
The facility failed to maintain accurate medical records for two residents, leading to potential care issues. A resident's weekly wound assessment was not documented, and treatments did not match physician orders. Another resident's skin assessment was incomplete upon readmission. These documentation failures indicate non-compliance with facility policies.
A resident reported verbal and physical abuse by a CNA, but the facility failed to immediately remove the CNA from the care assignment, waiting seven hours to take action. This delay was contrary to the facility's policy, which required immediate protective measures. Interviews confirmed the CNA should have been removed immediately.
A facility failed to report an alleged abuse incident involving a CNA and a resident to the CDPH within the required 24-hour timeframe. The resident, who was cognitively intact, sustained a scratch on the left temple, and the family accused the CNA of causing the injury. The CNA reported the injury to an LVN, and the charge nurse overheard the accusation, but the DON was not informed timely, resulting in a five-day delay in reporting.
GT Feeding and Medication Administration Errors
Penalty
Summary
The facility failed to provide appropriate care and services for residents with gastrostomy tubes by not following ordered feeding and medication administration practices for four residents. The report states that the facility did not ensure the head of bed was elevated above 35 degrees while enteral feeding was infusing for two residents, did not ensure one resident’s enteral feeding formula bag was labeled with the correct feeding rate, and did not ensure a crushed medication was mixed with water before being administered via GT for another resident. The facility’s policy for enteral feeding required the head of bed to be elevated at a 30-to-45-degree angle during pump or infusion controller feeding, and the medication administration policy required crushed medications to be mixed with water before GT administration. Resident 3 was GT dependent and had a physician’s order to elevate the head of bed 35 degrees at all times for aspiration precautions. During observation, the resident was found in bed with Jevity 1.2 infusing at 50 ml/hr while the head of bed was measured at 26 degrees, and later observations showed the head of bed at 30 degrees while feeding continued. Resident 4 had a GT and a physician’s order to elevate the head of bed 35 degrees at all times for aspiration precautions. The resident was observed receiving Jevity 1.2 and water flushes via GT while the head of bed was at 30 degrees, and later the head of bed was observed at less than 30 degrees while the water flush was infusing. Resident 12 had an order for tube feeding with [NAME] Farms 1.4 via GT at 35 ml/hr continuously for 24 hours, with an alternate formula allowed at the same rate if needed. The resident was observed receiving [NAME] Farms 1.4 at 35 ml/hr, but the feeding bag was labeled with a rate of 5A instead of the ordered rate. Resident 8 received baclofen via GT, and the LVN was observed crushing the medication, placing it in a medication cup, then pouring it into a syringe and adding water afterward rather than mixing the crushed medication with water before administration. The DON reviewed the findings and acknowledged them.
Respiratory Care and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents who were receiving suctioning and ventilator-related care. For Resident 2, the physician’s orders included oxygen therapy via trach collar, suctioning every two hours and as needed, and changing the Yankauer suction device every 24 hours and as needed. During observation, an opened Yankauer suction device was found at the bedside with a label showing it had been opened on 3/22/26, and the respiratory therapist stated it should have been changed after 24 hours once opened. For Residents 3 and 12, both had care plans and physician’s orders directing that the Yankauer suction be changed daily and as needed. During observation, each resident had an opened Yankauer suction tip stored in the original packaging at the bedside, and neither package was labeled with the opened date. The respiratory therapist stated the Yankauer suction tip should be labeled when opened and changed every shift for infection control purposes, and later discarded the suction tips for both residents. The DON reviewed the records and verified the orders and care plans called for changing the Yankauer suction every 24 hours. For Resident 15, who was admitted with a tracheostomy and ventilator support, the ventilator operator’s manual directed that device parts be cleaned with warm water and soap or mild detergent, rinsed thoroughly, and air dried. The resident’s record showed ventilator settings and respiratory treatment documentation, but there was no documented evidence that the ventilator machine had been cleaned and disinfected per the manufacturer’s instructions. During interviews, respiratory staff were uncertain who was responsible for cleaning the ventilator, and one RT stated the facility did not have a specific regular cleaning and disinfecting process for ventilator machines and instead cleaned them with bleach wipes as needed. The DON was informed and verified these findings.
Improper Storage of Opened Sterile Supplies and Irrigation Fluid
Penalty
Summary
Drugs and biologicals were not stored in a safe manner for one of two medication carts and for one sampled resident. At Resident 3’s bedside table, a bottle of sterile water was observed opened and labeled with the date 3/20/26. The bottle was identified as a sterile, single-dose container with instructions to discard the unused portion. During interview, an LVN stated the sterile water was used to flush Resident 3’s Foley catheter as needed and confirmed the bottle had been opened and labeled, then later stated it should be discarded 24 hours after opening. Medication Cart A also contained opened sterile wound care supplies. During inspection, two opened sterile alginate wound dressings with antimicrobial silver and one opened sterile Puracol (Collagen) Plus wound dressing were observed stored in the cart. The DON verified the findings and stated the sterile dressings should not be opened until ready for use due to infection control purposes, and later stated any remaining unused sterile dressings should be discarded after each use to prevent transmission of microorganisms or infections to the wound bed.
Kitchen sanitation, food storage, and staff hygiene deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during observations, interviews, and record review. Surveyors observed two heavy-duty blenders stored with lids on and visible water inside the blenders, and another blender with food particles on the base of the machine. The facility’s policy required food processors or blenders to be cleaned and allowed to air dry, and the FSS acknowledged the findings and stated the blenders would be washed again. Surveyors also observed multiple food storage and labeling issues. In the walk-in refrigerator, sliced carrots were opened in a plastic bag with no label and no date, and a rice bin had no label and no date. A container of ice cream sherbet with an expiration date of 12/2/25 was also found inside the freezer and was removed after being identified by the MDS Coordinator. The report also noted an unlabeled disposable food container in the walk-in refrigerator that the FSS identified as kitchen staff’s personal food and discarded. Additional kitchen sanitation concerns included staff hygiene and equipment condition. A Maintenance Manager was observed in the kitchen with uncovered facial hair while checking the ice machine, despite the facility policy requiring hair restraints. Two white cutting boards were heavily marred with black discoloration, and the inside of the ice machine had dried water scale and whitish to dark buildup around the motor and base. A Kitchen Aid was observed picking up trash from the floor while wearing disposable gloves, then putting on new gloves without performing hand hygiene first. The kitchen floor drainage area also had dirt near the drain, and the DON was informed and verified the findings.
Failure to Provide Privacy and Dignity During Bed Observation
Penalty
Summary
The facility failed to ensure staff provided care and services to promote dignity and respect for Resident 13. The report states the resident's family member preferred that Resident 13 not be covered or wear a shirt, but staff did not ensure the curtain was pulled to provide privacy. On 3/26/26 at 0810 hours, Resident 13 was observed lying in bed with the upper body exposed and a blanket at the waist, visible from the doorway of the room while multiple staff members walked past in the hallway from 0810 to 0816 hours. Facility policy titled Resident Privacy, Dignity, and Confidentiality stated staff will provide privacy for residents and use curtains to provide full visual privacy and dignity during resident care and other requested times, including clothing and draping to prevent unnecessary exposure of body parts. During the observation, IP 2 verified the findings and stated the curtain should have been pulled to provide privacy and dignity when the resident did not have a shirt covering him. The medical record showed the resident had severely impaired cognitive skills for daily decision making, and care plan and nursing note entries reflected the family member's requests regarding not covering the resident with a blanket and not wearing a gown due to excessive perspiration and tachycardia.
Failure to Care Plan Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 16’s use of Xarelto, an anticoagulant medication ordered for DVT prophylaxis. Facility policy stated that a comprehensive care plan must be developed within 14 days and completed no later than seven days after a comprehensive assessment has been completed, with participation from involved disciplines and ongoing reassessment and updates. Medical record review showed that Resident 16 had a physician’s order dated 12/19/25 to administer Xarelto 10 mg via GT at bedtime for DVT prophylaxis, but the resident’s comprehensive care plans did not include an individualized plan addressing the medication. During a concurrent interview and record review on 3/26/26, RN 3 verified that Resident 16 had an order for anticoagulant medication and confirmed there was no care plan developed for Xarelto. RN 3 stated that the licensed nurse formulates a care plan once there is a new condition of the resident. Later that day, the DON was informed and verified the findings.
Care Plans Not Updated for Aspiration Precautions and Ventilator Cleaning
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised to reflect current care needs and interventions for three sampled residents. The facility’s care planning policy stated that a comprehensive care plan must be developed within 14 days and completed no later than seven days after the comprehensive assessment, with ongoing reassessment and updates at least quarterly and upon change of condition. For Resident 3, who was GT and ventilator dependent, the physician ordered the head of the bed elevated to 35 degrees at all times for aspiration precautions, but the care plan still listed interventions to keep the head of bed greater than 30 degrees for respiratory distress and to elevate it 30 to 45 degrees during and after tube feeding. During observation, Resident 3 was in bed on a ventilator receiving Jevity 1.2 via GT, and the head of the bed was observed at 26 degrees. For Resident 4, who had ventilator-dependent respiratory failure and a GT, the physician ordered the head of the bed elevated to 35 degrees at all times for aspiration precautions, but the care plan continued to include interventions for respiratory distress, altered nutrition with tube feeding, and aspiration risk that directed head-of-bed positioning at 30 to 45 degrees rather than reflecting the physician’s order. During observation, Resident 4 was in bed on a ventilator receiving Jevity 1.2 and water via GT, with the head of the bed observed at 30 degrees. For Resident 15, who had a tracheostomy connected to a ventilator machine and oxygen from a concentrator, the care plan for respiratory distress related to ventilator dependency included ventilator management interventions but did not include cleaning and disinfecting the ventilator machine per the manufacturer’s manual.
Failure to Provide and Document Individualized Activities
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one resident who was bedbound, nonverbal, and dependent on staff for activities of daily living. The resident’s activity assessment showed a need for encouragement to engage in socialization and identified preferred activities such as watching Korean movies. The care plan documented altered activity participation related to a communication deficit, noted that the resident used a Tobii device for communication, and included goals for the resident to engage in independent leisure activities at least once daily and accept activity contact visits twice weekly, with interventions to provide and encourage preferred activities including music, television or movies, and sensory stimulation. During multiple observations, the resident was found lying awake in bed connected to mechanical ventilation, with eyes open and staring at the ceiling; the television was off, no music was heard, and the resident was not observed participating in any activities. Staff interviews confirmed the resident was not engaged in any activity, and one CNA stated the resident enjoyed watching Netflix on the Tobii device but that a family member typically turned it on because she did not know how to operate it. Review of the activity progress notes showed activities were documented on several dates in March 2026, but there was no documentation that activities were provided on multiple other dates, and the Activity Director confirmed there was no documented evidence that activities were offered on those dates or that refusals were documented. The DON was informed and acknowledged the findings.
POLST Not Fully Reviewed or Reflected in Treatment Orders
Penalty
Summary
The facility failed to ensure Resident 11’s POLST was complete, accurate, and discussed in the IDT meeting when the resident did not have a responsible party. The POLST in the record showed DNR, comfort-focused treatment as the primary goal, and additional orders for no invasive or non-invasive mechanical ventilation, no defibrillation, no chest compressions, and no ACLS drugs. The resident was observed lying in bed and connected to mechanical ventilation via a tracheostomy tube, and the active order set included a physician order for mechanical ventilation with specific ventilator settings and oxygen titration. Review of the IDT/Care Plan Conference documentation showed DNR was selected under the POLST section, but it did not indicate whether the resident’s preferences for comfort-focused treatment or no invasive or non-invasive mechanical ventilation were discussed by the IDT. The MDS/DSD verified the POLST and stated the resident had no responsible party, so the facility IDT team members and representatives from the Council on Aging were making treatment decisions. The DON verified the resident was receiving mechanical ventilation despite the POLST instructions and stated there was no documentation that the POLST preferences were reviewed or discussed with the IDT and Council on Aging representative, and no documented evidence that the physician was contacted to clarify the POLST.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 11 had excessive weight changes, including losses of more than 5 pounds in a week and a 20-pound loss in a month. Resident 11 was admitted to the facility and had documented weights showing repeated significant changes, including 153 lbs. on 1/6/26, 146 lbs. on 1/11/26, 138 lbs. on 1/25/26, and 133 lbs. on 2/1/26, followed by a gain to 142 lbs. on 2/10/26 and a loss to 135.6 lbs. on 2/22/26. The facility’s Weight Variance Monitoring policy stated that excessive weight losses or gains were more than 2 lbs. per week or more than 8 lbs. in one month and that physicians would be notified of all excessive losses or gains. Resident 11’s care plan addressed altered nutrition, risk for weight loss, and intolerance to tube feeding, with interventions to monitor weight and notify the physician of unplanned significant weight changes. A later care plan also addressed the resident’s 20-pound weight loss in 30 days and included notifying the physician of significant weight change. The physician’s progress notes showed the resident had lost about 7 lbs. since admission and that the RD was to evaluate the resident, but the record did not show that the weight changes on 1/25/26, 2/1/26, 2/10/26, and 2/22/26 were relayed to the physician. The facility’s change of condition log documented unplanned weekly weight loss on 1/11/26 and 1/25/26, with a treatment and duration of 72 hours, but the medical record did not show physician notification or that the resident was monitored for 72 hours for those changes.
Missing IV Orders for Fluid and Site Maintenance
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one resident reviewed for IV care. Resident 13 was observed in bed with normal saline infusing at 10 mL/hr through a right hand IV access with a transparent dressing dated 3/22/26. The resident also had a physician’s order dated 3/24/26 to receive cefepime 2 grams IVPB every eight hours at 200 mL/hr for 30 minutes. Review of the medical record did not show documented physician’s orders for the normal saline IV fluid or for peripheral IV access site rotation every 72 hours and as needed. During interview, an RN stated that when an IV antibiotic order is received, the nurse informs pharmacy, starts an IV access, and then begins a normal saline bag via the IV pump before administering the antibiotic. The RN reviewed the record and verified that no physician’s orders were obtained for the normal saline IV fluid or for care and maintenance of the IV access site. The DON was informed and verified these findings.
Medication Administration Errors With Oral and GT Orders
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration when two licensed nurses made errors during medication passes. During an observation for one resident, an LVN prepared multiple medications, including GlycoLax 17 grams, and was observed emptying the powder into a cup, adding chocolate pudding, and mixing it with a tongue depressor before administering it. The resident’s active orders allowed oral medications with a small amount of thickened water and permitted crushed medications with pudding, but the MAR instructions for GlycoLax directed that the powder be stirred in 120 to 240 mL of water, juice, soda, coffee, or tea and then administered. The LVN later verified that she did not mix the GlycoLax with water as directed and instead mixed it with pudding. During another medication administration observation, an LVN prepared and administered several medications via gastrostomy tube for a different resident, including docusate sodium, levetiracetam, calcium carbonate, vitamin C, vitamin D3, Culturelle, and metoprolol. The resident’s active orders also included Pro-Stat Sugar Free 30 mL daily via the GT, scheduled for 0900, but the medication was not administered during the observation. The LVN later reviewed the MAR and verified that Pro-Stat was scheduled for 0900 and had not been given. The DON stated that medications should be administered according to physician orders and within one hour before and after the scheduled time.
Infection Control Failures During GT Medication and Eye Ointment Administration
Penalty
Summary
The facility failed to implement its infection control program in accordance with its policies during medication administration observations. Resident 8 was on enhanced barrier precautions and had a GT. During a medication pass, LVN 1 prepared and administered baclofen via the GT while reaching across the resident from the right side of the bed to expose the GT from under the resident’s gown. LVN 1 was not observed wearing a gown during the GT medication administration. After the medication was given, LVN 1 was later observed removing gown and gloves and performing hand hygiene before exiting the room, but the stethoscope used to check GT placement was still around her neck and was not disinfected before leaving the room. LVN 1 confirmed she did not don the gown for the GT medication administration and did not disinfect the stethoscope before exiting the room. The facility also failed to follow its eye ointment administration policy during care for Resident 13. RN 2 used the same tissue to wipe both eyes, then removed gloves, performed hand hygiene, and donned a new pair of gloves before administering ophthalmic ointment. RN 2 applied the ointment to the resident’s right eye and then to the left eye without doffing gloves, performing hand hygiene, and donning new gloves between the two eyes. RN 2 stated the gloves should be changed and hand hygiene performed between eyes, and verified she did not change gloves in between the application of the ointment to both eyes. The DON was informed and acknowledged the findings.
Deficiencies in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper labeling and administration procedures for enteral feeding for two residents. For one resident, the enteral feeding formula was not labeled with the time it was started, contrary to the facility's policy and procedure (P&P). This omission was observed on two separate occasions, and the Licensed Vocational Nurse (LVN) responsible was unable to confirm when the feeding formula was initiated. The Director of Nursing (DON) confirmed that the labeling should include the time to ensure the formula does not exceed the 24-hour usage limit. For another resident, the Registered Nurse (RN) did not check the gastric residual volume before administering medications through the gastrostomy tube (GT), as required by the facility's P&P. The RN confirmed this oversight during an interview. The DON stated that checking the gastric residual is a necessary step before medication administration through the GT. These failures posed a risk for complications related to the use of the GT for both residents.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several deficiencies observed during a survey. The cutting boards were found to be heavily marred, discolored, and with deep grooves, making them difficult to clean and sanitize. This condition was acknowledged by the Dietary Director, who stated that the cutting boards should have been replaced. Additionally, kitchen utensils were not air-dried before storage, as required by the facility's policies and the USDA Food Code. Several scoops and utensils were found wet and stored improperly, which was also acknowledged by the Dietary Director. Further observations revealed that many kitchen utensils were in poor condition, with deformations, discolorations, and damages such as cracks and peeling handles. These included mesh strainers, potato mashers, whisks, scoops, basting brushes, and spatulas. The Dietary Director confirmed that these items should have been discarded and not used. Additionally, some utensils were found dirty, with watermarks and crusted food residue, indicating a failure to maintain cleanliness as per the facility's policies and USDA guidelines. The kitchen stove hood was also found to be in an unsanitary condition, with black dirt and grease residue observed. The Food Service Supervisor acknowledged this finding and stated that the janitor was supposed to clean the stove hood every other day. The failure to maintain the sanitary condition of the stove hood could lead to grease and smoke buildup, affecting air circulation. These deficiencies collectively posed a risk of cross-contamination and foodborne illnesses to the residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in Equipment Disinfection and PPE Protocols
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff not disinfecting equipment and not following proper gown and glove protocols. RN 1 and RN 2 both failed to disinfect their stethoscopes after using them on residents and before exiting the residents' rooms. This was confirmed through interviews with the RNs, who acknowledged the oversight and stated that the stethoscopes should have been disinfected to prevent the transmission of organisms between residents. Additionally, CNA 1 did not follow proper gown and glove protocols when moving between residents in the same room. CNA 1 was observed wearing the same gown and gloves while interacting with two different residents' environments, which is against the facility's Enhanced Barrier Precautions. CNA 1 admitted to not changing gloves and gown between residents, acknowledging that they should have been changed to prevent cross-contamination. Furthermore, the facility had issues with the cleanliness of linen cart covers, which were observed to be dirty and stained. The DSD/MDS Coordinator confirmed that the covers should be clean, indicating a lapse in maintaining the cleanliness of equipment used in the facility. These deficiencies were acknowledged by the Director of Nursing and Infection Preventionist during interviews.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer pneumococcal vaccines to two residents, despite having obtained consent for the vaccinations. Resident 4 was admitted and readmitted to the facility, and consent for the pneumococcal vaccine was obtained on July 8, 2024. However, there was no documented evidence that the vaccine was administered to Resident 4, nor was there any explanation provided for the failure to administer the vaccine after consent was obtained. Similarly, Resident 19 was admitted to the facility, and consent for the pneumococcal vaccine was obtained on September 30, 2024. Like Resident 4, there was no documented evidence that the vaccine was administered to Resident 19, and no explanation was provided for this oversight. During an interview and medical record review, Infection Preventionists (IPs) 1 and 2 confirmed that the vaccines were offered and consents obtained, but acknowledged that the vaccines were not administered to the residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for several residents, as observed during a survey. Specific deficiencies included brownish stains on the walls of a resident's room, stained curtains in multiple residents' rooms, and feeding formula spills and residue on the floor and medical equipment. These observations were confirmed by interviews with the DSD/MDS Coordinator, who acknowledged that the staff should have cleaned the affected areas promptly. The failure to maintain cleanliness was attributed to a lack of immediate action by the nursing staff and a communication gap with the Environmental Services (EVS) staff. The report highlights that the EVS staff were not informed about the need to clean certain areas, such as the wall in a resident's room, which was stained with enteral feeding formula. Interviews with the LVN and EVS Aide revealed that the responsibility for notifying EVS staff about cleaning needs was not consistently fulfilled. The Director of Nursing (DON) also acknowledged that the residents' rooms and equipment should be cleaned of stains and wiped down, and that all stains should be reported by staff when first observed. This lack of communication and prompt action led to the observed deficiencies in maintaining a clean and homelike environment for the residents.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during a survey. Two tubes of Zinc Oxide paste, a medicated cream used to treat or prevent skin irritation, were found on a resident's bedside table. This was contrary to the facility's policy and procedure, which mandates that all medications be stored in lockable areas accessible only to authorized personnel. During an interview and medical record review, the DSD/MDS Coordinator confirmed that the Zinc Oxide paste should have been secured in the treatment cart, verifying the improper storage of the medication.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential care issues. For Resident 12, the facility did not document a weekly wound assessment for a sacral pressure injury on a specific date, despite the facility's policy requiring such documentation. Additionally, the wound treatments administered did not align with the Wound Consultant Physician's orders, and there was no documentation of any clarifications made to these orders. The Director of Nursing (DON) confirmed these discrepancies, noting that the nurse should have documented the wound assessment and any order clarifications. Resident 19's medical records also lacked proper documentation. Upon readmission, the facility failed to document the skin assessment for measuring pressure sores and non-pressure sores, as required by the facility's policy. The Skin Body Check Sheet for Resident 19 showed superficial erythema on the buttocks and mid-spine, but there were no measurements recorded. The Licensed Vocational Nurse (LVN) involved was unable to provide the necessary documentation and confirmed that the assessments were not completed as required. These documentation failures indicate that the facility did not adhere to its own policies and procedures regarding medical record-keeping and wound care management. The lack of accurate documentation for both residents could potentially lead to unmet care needs, as their medical information was not accurately recorded.
Delayed Response to Abuse Allegation
Penalty
Summary
The facility failed to take immediate action to prevent further potential abuse after an allegation of verbal and physical abuse was reported by a resident. The facility's policy and procedure for abuse recognition and reporting required immediate protective measures, such as removing the alleged perpetrator from the resident's care assignment. However, after the resident reported the abuse by a CNA, the CNA was not removed from the assignment until seven hours later, following a call from the Director of Nursing. Interviews with the RN and the Clinical Educator/Acting DON confirmed that the CNA should have been immediately removed from the assignment when the allegations were made.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. An allegation of abuse involving a Certified Nursing Assistant (CNA) and a resident was not reported timely to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The facility's policy requires that all incidents of alleged or suspected abuse be reported to the Department of Health Services within 24 hours. However, the report of suspected abuse was submitted five days after the allegation was made. The incident involved a resident who was cognitively intact and had sustained a scratch on the left temple area. The resident's family accused the CNA of causing the injury. The CNA reported the injury to a Licensed Vocational Nurse (LVN) and stated that the charge nurse overheard the accusation. Despite this, the Director of Nursing (DON), who is the Abuse Coordinator, stated that no allegations of abuse involving the resident were reported to her on the day of the incident. This delay in reporting posed the risk of potential abuse going unreported and uninvestigated.
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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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Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anaheim Crest Nursing Center | 0 mi | ★★★★★ | 30 | 0 |
| Beach Creek Post-acute | 0.6 mi | ★★★★★ | 28 | 0 |
| Anaheim Healthcare Center, Llc | 0.6 mi | ★★★★★ | 3 | 0 |
| Anaheim Terrace Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Park Anaheim Healthcare Center | 0.8 mi | ★★★★★ | 28 | 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.