Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamitos West Health & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently implement Enhanced Barrier Precautions (EBP) and proper catheter practices for two residents with indwelling urinary catheters. One resident’s room initially lacked EBP signage and documentation of EBP orders, and although the care plan called for EBP, an LVN later performed catheter care wearing only gloves instead of both gown and gloves as indicated. Another resident’s catheter drainage tubing was observed touching the floor, and despite care plan interventions for EBP and physician orders for Foley care, there was no EBP order or visual indicator (orange dot) by the door to show that EBP had been implemented. These failures were cited as having the potential for cross-contamination and spread of infectious organisms.
A resident with Parkinson’s disease and bilateral ankle contractures was discharged to a board-and-care setting without the facility fully completing the required discharge planning process. Although a physician ordered that the resident could go to a board and care with PT evaluation and HH, and a written Notice of Proposed Transfer/Discharge documented that notice was given to the resident and representative and mailed to the Ombudsman, the medical record lacked documentation that the Ombudsman was actually notified as required. Facility policy called for Ombudsman notification 30 days prior to a facility-initiated discharge, but the DON acknowledged this did not occur, and no discharge care plan was developed for the resident.
A resident with documented decision-making capacity was left unattended outside while waiting for family transportation to a medical appointment. After accompanying the resident outside following lunch, a CNA left the resident alone when the resident repeatedly asked to be left, positioning herself just inside the facility door instead of remaining with the resident. The DON later stated the CNA was expected to stay with the resident until the family arrived, demonstrating a failure to provide adequate supervision to prevent accidents.
A resident receiving carbidopa-levodopa for Parkinson’s disease had two duplicate physician orders with different dates for the same dose and time recorded on the MAR. An LVN confirmed administering the medication and acknowledged that the duplicate orders should have been clarified with the physician but were not. The DON verified the inaccurate, duplicate orders in the medical record, resulting in an inaccurate MAR for the resident’s Parkinson’s medication.
A resident with Parkinson's disease and significant mobility limitations was not repositioned every two hours as ordered by the physician. Staff interviews and observations confirmed that the resident remained on his back for extended periods, with repositioning not performed according to the care plan. Instead, staff adjusted pillows or pulled the resident up in bed, contrary to the specific physician's order.
A resident's medical record was found to be incomplete and inaccurately maintained, with missing documentation by licensed nurses for several physician-ordered treatments and interventions, including oral hygiene, skin care, and use of assistive devices. Despite documentation indicating oral care was provided, both the resident and a CNA confirmed it was not done. The DON verified these deficiencies.
Facility staff did not follow infection control procedures by leaving a used glove on the sink and toilet tank and a soiled towel on the floor in a shower room, instead of disposing of them properly in designated containers, as confirmed by the Account Manager and DON.
Three shower rooms were found to be inadequately cleaned and disinfected, with a resident reporting the appearance of fecal matter in the showers. Observations revealed dark brown residue on shower heads and brown stains on the walls and shower head holders, which were acknowledged by facility management.
Staff did not follow Enhanced Barrier Precautions during wound care for a resident with a chronic wound. An LVN and a CNA performed high-contact care activities without donning gowns, despite posted signage and physician orders requiring both gown and gloves. The staff later acknowledged that gowns should have been worn, and facility leadership confirmed the lapse in infection control practice.
Three residents with significant care needs and fall risks were observed in bed with unlocked bed wheels. Staff, including a CNA and an LVN, confirmed the bed wheels were not locked, despite facility procedures requiring this safety measure. The residents involved had diagnoses such as dementia, hemiplegia, and immobility, and were dependent on staff for mobility and transfers.
A resident who was cognitively intact was observed repeatedly calling a CNA by name and was initially ignored, then addressed with a curt 'what' rather than a respectful response. The resident reported feeling dissatisfied and disrespected by the interaction. Staff interviews confirmed that such a response was not in line with facility policy on resident dignity.
A resident did not receive whole milk with meals as specified on their meal ticket, despite being cognitively intact and having this preference documented. Staff confirmed the omission during both breakfast and lunch, and the DSS verified that all items on the meal ticket should have been served. The issue was acknowledged by facility leadership after being brought to their attention.
A resident refused bowel management medications for three days without the physician being notified, contrary to facility policy. The resident later experienced severe pain and was transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction.
The facility failed to update elopement risk assessments for two residents with dementia, leading to inadequate monitoring and intervention. One resident exhibited increased wandering behavior, prompting the use of a Wander Guard without a reassessment. Another resident, who attempted to elope, was not assessed quarterly as required, missing critical evaluations of their elopement risk.
A facility failed to respect a resident's right to self-determination by not adhering to the requested medication schedule after the resident's return from a hospital stay. Despite previous arrangements to spread out medication administration times, the facility administered medications at an earlier time without documented justification, contrary to the resident and family's request.
A resident with moderate cognitive impairment did not receive timely care for an indwelling urinary catheter, which was inserted due to urinary retention. The facility failed to provide necessary daily catheter care until five days after insertion, despite policy requirements for continual assessment and proper handling. This lapse was confirmed by interviews with the resident, a family member, and an LVN, and acknowledged by the DON, posing a risk for catheter-associated urinary tract infections.
A resident with moderate cognitive impairment was administered docusate sodium despite having loose bowel movements, contrary to physician orders. The medication was given on multiple occasions without proper communication between staff about the resident's bowel condition, leading to unnecessary medication administration.
A resident with moderate cognitive impairment requested a bath, which was not provided on the requested day due to staffing issues. The resident expressed frustration, and facility records confirmed the bath was not documented as given. Interviews with staff and family verified the oversight.
A resident with moderate cognitive impairment experienced mild weakness and a flushed face, but the facility failed to update the care plan to address this change in condition. This oversight was confirmed by interviews with an LVN and an RN, and acknowledged by the DON.
A resident with moderate cognitive impairment received an extra capsule of psyllium on multiple occasions due to a pharmacy error. The physician's order was for one capsule twice a day, but the pharmacy delivered a bubble pack with two capsules, leading to the administration of an extra dose. The DON confirmed the error during a review.
The facility failed to ensure accurate documentation of bladder elimination for three residents with indwelling urinary catheters. CNAs inaccurately recorded these residents as incontinent, despite the presence of catheters, potentially affecting their care needs. The inaccuracies were confirmed by the DON during a review.
The facility failed to notify a physician when a resident had no bowel movements for over three days, despite having a bowel management protocol. Additionally, another resident did not receive dynamic splints as ordered, with multiple instances of non-compliance documented. These deficiencies were confirmed through interviews and record reviews.
A resident in an LTC facility was not provided with the correct toothbrush for oral hygiene, using a denture brush instead. This occurred because a CNA failed to provide the regular toothbrush, which the resident preferred and was supposed to use. Interviews with an LVN and the DON confirmed the intended use of the brushes, highlighting a failure to accommodate the resident's needs.
The facility failed to maintain sanitary conditions in the kitchen, including improper use of hair restraints by staff, inadequate labeling and dating of food items, and unsanitary kitchen equipment. Observations revealed food debris in the microwave, corroded pans, and wet plates and domes. Cutting boards were also heavily marred, and a scoop was improperly stored in a food bin, potentially risking foodborne illnesses among residents.
The facility failed to maintain infection control practices, lacking documentation for Legionella risk assessment and testing protocols. CNAs did not follow Enhanced Barrier Precautions for a resident with a Foley catheter, and personal items were improperly stored in the clean laundry area. Visitors did not adhere to contact isolation precautions, and a CNA did not change gowns between assisting two residents.
The facility failed to obtain or provide information on advance directives for several residents, leading to incomplete or missing documentation. Residents with the capacity to make decisions were not offered information on formulating advance directives, and some residents' directives were incomplete or not verified. This deficiency was identified through interviews and medical record reviews.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their individual care needs. A resident with severe cognitive impairment experienced a fall without a care plan being developed. Another resident on antidepressant medication and a third resident on antibiotics for an infected wound also lacked appropriate care plans. These deficiencies were confirmed by staff and acknowledged by the DON and Administrator.
The facility failed to provide adequate respiratory care for multiple residents, as evidenced by undated and unlabeled oxygen equipment, lack of proper storage, and missing care plans. Staff confirmed these deficiencies, indicating a systemic issue in equipment management and documentation.
A facility failed to adjust medication administration for a resident undergoing hemodialysis, resulting in missed doses of colchicine and magnesium on dialysis days. The facility's policy required medication administration within a specific timeframe, but there was no physician's order to hold or reschedule medications, nor was the physician notified of the resident's absence during scheduled medication times. The DON confirmed the lack of documentation and adjustment.
A facility failed to provide necessary medications to a resident due to unavailability, as observed during a medication administration session. An LVN was unable to administer a Calcium Vitamin D tablet and an Acidophilus Probiotic oral tablet, both ordered by the resident's physician. The facility's policy requires contacting the pharmacy if medications are unavailable, but this was not done. The Administrator and DON acknowledged the deficiency.
A facility failed to act on a pharmacy consultant's recommendation to reduce a resident's venlafaxine dosage and did not identify duplicate therapy for acetaminophen. The resident's physician did not respond to the pharmacist's suggestion for a gradual dose reduction, and duplicate orders for acetaminophen were not clarified. These issues were confirmed by the DON and LVN.
A resident's medication regimen was not properly monitored, leading to duplicate therapy for acetaminophen and lack of monitoring for side effects of Keflex and hydrocodone-acetaminophen. An LVN confirmed the oversight, and the facility's Administrator and DON acknowledged the deficiencies.
The facility failed to monitor two residents for side effects and behaviors related to psychotropic medications. One resident was not monitored for sertraline and quetiapine use, while another lacked documentation for extending doxepin use beyond 14 days and was not monitored for side effects. These deficiencies were confirmed by facility staff.
A long-term care facility experienced a medication error rate of 18.52% during a medication pass observation. Errors included incorrect mixing of a laxative, failure to instruct a resident to rinse after using an inhaler, administering the wrong B complex supplement, not administering vitamin B6 due to expiration, and giving the wrong potassium supplement. These errors involved three LVNs and three residents, highlighting a failure to adhere to prescribed medication orders and facility policies.
The facility failed to ensure proper storage, labeling, and disposal of medications, leading to several deficiencies. A resident's eye solution was left unattended, and medication rooms had temperature control issues. Medication carts contained unlabeled and expired medications, and oral medications were stored with externally used ones. These lapses were confirmed by staff, indicating a failure to adhere to proper protocols.
The facility did not follow prescribed pureed recipes for 12 residents, potentially affecting their nutritional intake. Observations and interviews revealed deviations from the recipes for chicken ala king, steamed broccoli, and brown rice, including the use of milk, butter, and rice hot cereal instead of specified ingredients. The Dietary Services Supervisor confirmed these discrepancies, indicating a failure to meet the nutritional needs of residents on a pureed diet.
The facility did not follow its policy on the use and storage of food brought by family and visitors. Staff interviews revealed that the facility lacked a refrigerator for storing outside food, leading to instructions for immediate consumption and no storage of unconsumed food. This failure had the potential to cause foodborne illnesses among residents.
A facility failed to ensure a resident receiving hospice services attained their highest well-being by not communicating with the hospice agency about missing aide visits. The resident had orders for hospice aide visits twice weekly, but several visits were missed without coordination or follow-up. Interviews with staff confirmed the lack of communication and coordination, and the designated hospice coordinator did not have a clinical background or meet the resident.
The facility failed to monitor antibiotic use for two residents who did not meet McGeer's criteria for infection. Antibiotics were prescribed without symptoms, and there was no documentation of physician notification. The IP and DON confirmed these findings.
A facility failed to ensure a resident received the influenza vaccine and did not properly document the refusal process. The resident's representative was not provided with information about the risks and benefits of the vaccine, and the necessary consent or declination form was incomplete. The facility's IP confirmed the lack of follow-up, and the DON acknowledged the deficiency.
The facility failed to maintain essential kitchen equipment, including a dish machine and digital thermometers, in safe operating condition. The dish machine was not sanitizing properly, and digital thermometers were not calibrated, potentially risking foodborne illnesses for residents.
The facility failed to accommodate residents' needs by not ensuring call lights and controls were within reach. A resident waited 30 minutes for toilet assistance, resulting in wetting her diaper. Other residents had call lights, bed controls, and remotes out of reach, impacting their ability to request help or perform daily activities. Staff confirmed these deficiencies, acknowledging the need for accessibility.
A resident was served cooked carrots despite having a documented dislike for them, as observed during a dining session. The resident, who is cognitively intact, expressed dissatisfaction, and both the LVN and DSS confirmed the oversight. The facility's diet spreadsheet included carrots, and the resident's medical records specified a diet excluding cooked carrots, highlighting a failure to adhere to dietary instructions.
A facility failed to ensure accurate medical record documentation for a resident, leading to conflicting information about the resident's decision-making capacity. The H&P examination showed both that the resident had and did not have the capacity to make decisions, while a surrogate decision-maker was listed. Despite this, the resident signed a consent form for treatment. The DON confirmed the findings and acknowledged the need for physician clarification.
The facility failed to dispose of trash in a sanitary manner, with three out of four dumpsters not properly covered, risking pest infestation. The green food waste dumpster was overflowing, preventing the lid from closing, and an untied garbage bag was open with food waste dripping to the ground, attracting flies. The blue recycling dumpster was fully open, and one gray trash dumpster had a lid not fully closed. These issues were confirmed by the Maintenance Director.
Failure to Implement Enhanced Barrier Precautions and Proper Catheter Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control practices, including Enhanced Barrier Precautions (EBP), for residents with indwelling urinary catheters. CMS QSO-24-08-NH and the facility’s own IPCP policy require EBP, including gown and glove use during high-contact resident care activities such as catheter care, and clear signage to indicate required PPE. Surveyors observed that, although an isolation cart with gowns and gloves was present near one resident’s room, there was initially no EBP signage posted outside the room, and the resident’s medical record did not contain a physician’s order or documentation showing the resident had been placed on EBP related to the indwelling urinary catheter. For Resident 2, who had an indwelling urinary catheter with physician orders for Foley catheter management and a care plan intervention specifying the use of EBP, the facility did not have a corresponding physician’s order or documentation that EBP had been implemented at the time of the initial review. During observations, a CNA confirmed the presence of the catheter and that CNAs were responsible for catheter care, but had not yet provided hygiene care. Later, after EBP signage and an orange dot indicator were present at the door, an LVN acknowledged that these indicators signaled the need for gown and glove use for high-contact care such as catheter care. However, when the LVN performed catheter care for Resident 2, the LVN wore only gloves and did not don a gown, contrary to the facility’s EBP expectations and signage. For Resident 3, surveyors observed an indwelling urinary catheter with drainage tubing touching the floor, and a CNA confirmed this observation. The CNA stated that treatment nurses were responsible for catheter care. Resident 3’s physician orders included Foley catheter care every shift and catheter management instructions, and the care plan also identified the use of EBP as an intervention for the indwelling catheter. Despite this, the medical record did not contain a physician’s order or documentation that EBP had been implemented for Resident 3, and there was no orange dot indicator by the resident’s name on the door to signify EBP status. The QIC/IP later verified that EBP should be in place for residents with medical devices such as indwelling urinary catheters and confirmed that EBP orders and indicators for these residents had not been in place at the time of the initial observations. The report states these failures had the potential for cross-contamination and spread of infectious organisms in the facility.
Failure to Complete Required Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to complete the discharge planning process for one of three sampled residents by not providing required notifications and not developing a discharge care plan. Facility policy titled “Admission, Transfer and Discharge” (revised 4/2025) requires that residents not be transferred or discharged unless specific criteria are met and that written notice of transfer or discharge, including reasons and appeal rights, be provided to the resident and representative, with a copy sent to the State Long-Term Care Ombudsman at least 30 days in advance except in limited circumstances. The policy also requires that, when a transfer or discharge is necessary because the resident’s needs cannot be met, the physician document the basis for transfer and the specific needs and services involved. Resident 1, who had Parkinson’s disease and contractures of both ankles, was admitted to the facility on an unspecified date and later had a physician order dated 1/30/26 stating it was acceptable for the resident to go to a board and care if acceptable to the family and resident, and that the resident may go with PT evaluation and home health. A Notice of Proposed Transfer/Discharge for this resident, dated 2/2/26, documented that the notice was provided to the resident and the resident representative on that date, that the notice was mailed to the Long-Term Care Ombudsman on that date, and that the reason for discharge was that the resident’s health had improved sufficiently so that facility services were no longer required. The notice also indicated that notice was given as soon as practicable. However, review of Resident 1’s medical record did not show documented evidence that the Ombudsman was notified of the resident’s discharge as required by facility policy, and the DON confirmed during interview that the notice of transfer/discharge should have been provided to the Ombudsman 30 days in advance. Additionally, review of Resident 1’s care plans showed no care plan developed for a discharge plan, and the DON verified that a discharge plan care plan was not developed for this resident. These inactions constituted a failure to ensure the discharge planning process was thoroughly completed for Resident 1.
Resident Left Unattended Outside While Awaiting Transportation
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and that adequate supervision was provided when a resident was left unattended outside while waiting for transportation to a medical appointment. The resident, who had decision-making capacity per a history and physical dated 10/18/25, was scheduled to be picked up by family for a doctor's appointment. On the day of the incident, after the resident’s lunch, CNA 4 accompanied the resident outside the facility to wait for the family. During this time, the resident repeatedly told CNA 4 to leave him. CNA 4 reported that she left the resident alone outside to give him space, remaining just inside the door rather than staying with him. The DON later confirmed that CNA 4 was expected to remain with the resident until the family arrived, indicating that the resident had been left unattended in violation of supervision expectations. This sequence of events, as identified through complaint intake, medical record review, and staff interviews, formed the basis of the deficiency for failure to provide necessary care and services to ensure adequate supervision and prevent accidents for one of four sampled residents.
Duplicate Parkinson’s Medication Orders Not Clarified on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident receiving carbidopa-levodopa for Parkinson’s disease. The facility’s policy on Medication Administration requires that all current drugs and dosage schedules be accurately recorded on the MAR and that licensed or otherwise authorized staff prepare, administer, and record medications. For this resident, the Order Summary Report showed a physician’s order dated 1/14/26 for carbidopa-levodopa 25-100 mg, two tablets by mouth daily. However, review of the January 2026 MAR revealed two active physician orders for the same medication and dose, one dated 11/25/25 and another dated 1/14/26, both scheduled for administration at 0900. During an interview and concurrent record review, an LVN confirmed that she administered carbidopa-levodopa 25-100 mg, two tablets at 0900, and verified that there were duplicate orders with different dates on the MAR. She stated that she should have clarified these duplicate orders with the resident’s physician but had not done so. In a separate interview and concurrent record review, the DON also verified the presence of the duplicate orders and the inaccuracy in the medical record. The report states that this failure had the potential for the resident’s care needs not being met because the medical information was inaccurate.
Failure to Follow Physician's Repositioning Order for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained or maintained their highest practical physical well-being. Specifically, the facility did not follow a physician's order to reposition the resident every two hours on the left side and every two hours on the right side while in bed. The resident, who had diagnoses including Parkinson's disease, right ankle contracture, and mobility abnormalities, was dependent or required substantial assistance for bed mobility and transfers. Observations on multiple occasions showed the resident lying on his back with the head of the bed elevated, and interviews with CNAs revealed that repositioning was not performed as ordered. Instead, staff reported only pulling the resident up in bed or adjusting pillows under his arms, rather than turning his body as specified in the physician's order. The facility's policies required that all physician orders be specific and complete, and that staff provide interventions according to individualized care plans and professional standards. Despite these policies, staff interviews indicated that repositioning was done only when the resident requested it or according to his preference to remain on his back, rather than following the prescribed schedule. The DON acknowledged that the order should have been discontinued if it was not being followed, but at the time of the survey, the order remained in place and was not being implemented as written.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as evidenced by missing documentation on the Treatment Administration Record (TAR) for multiple physician-ordered treatments and interventions. Specifically, there were no entries from licensed nurses for several ordered tasks, including application of fluocinonide cream, transferring the resident to a wheelchair, floating the heels, oral hygiene after meals, use of a foot brace, monitoring an ingrown toenail, and use of a PRAFO device. When questioned, a licensed nurse confirmed that the documentation was missing and could not verify whether the tasks had been completed as ordered. Additionally, there was inaccurate documentation regarding the provision of oral hygiene. The resident reported not receiving oral care, and a CNA confirmed during an interview that oral care supplies had not been set up and that she had not provided oral care, despite having documented that it was done. The DON verified these findings, indicating that the resident's clinical record did not provide a concise and accurate account of the care and treatments provided, as required by facility policy.
Failure to Follow Infection Control Practices in Shower Room
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by its Infection Prevention and Control Program. During an observation in a shower room, a used glove was found on the sink and on top of the toilet tank, and the Account Manager confirmed that the glove should have been properly disposed of. In a separate observation in the same shower room, a soiled towel with visible stains was found on the floor, and the Account Manager acknowledged that the towel should have been placed in the dirty linen barrel. The Director of Nursing (DON) was informed of these findings and stated that the cleaning process for shower rooms should ensure they are free of used gloves and washcloths.
Failure to Clean and Disinfect Shower Rooms
Penalty
Summary
The facility failed to ensure that three shower rooms were properly cleaned and disinfected, specifically neglecting to clean the shower heads. During an interview, a resident reported that the showers appeared to have fecal matter present. Observations confirmed the presence of dark brown residue on the lower half of the shower heads and brown stains on the walls and shower head holders in the shower stalls. The Account Manager acknowledged that the shower heads had a constant leak and required replacement, and both the Administrator and DON confirmed the discoloration and residue observed during the inspection. Medical record review indicated that the resident who reported the issue had been admitted to the facility prior to the observation, but no additional medical history or condition at the time of the deficiency was provided.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices as outlined in their own policies and procedures for a resident requiring Enhanced Barrier Precautions (EBP) during wound care. During an observed wound care treatment, an LVN and a CNA did not don gowns as required, despite an EBP sign posted outside the resident's room and a physician's order specifying the use of gown and gloves for direct care. The LVN prepared wound care supplies and the CNA assisted in turning the resident, both wearing gloves but not gowns. The LVN proceeded with the wound care treatment without a gown, stating that a gown was not necessary if the wound was not draining. However, the facility's policy and the EBP sign indicated that gowns and gloves were required for high-contact care activities, including wound care, regardless of wound drainage status. The resident involved was non-verbal, lacked decision-making capacity, and had a chronic wound in the sacrococcyx area. Medical records confirmed the need for EBP, and staff interviews later acknowledged that proper PPE, including gowns, should have been used during the wound care procedure. The Infection Preventionist and Director of Nursing both confirmed that the observed practice did not align with facility policy and recognized the potential for infection transmission when proper PPE is not utilized.
Failure to Lock Bed Wheels for Dependent Residents
Penalty
Summary
The facility failed to maintain a safe environment for three nonsampled residents by not ensuring that bed wheels were locked while the residents were in bed. Observations confirmed that Residents A, B, and C were each found lying in beds with unlocked wheels. Staff members, including a CNA and an LVN, verified during interviews that the bed wheels were indeed unlocked at the time of observation. Medical record reviews for these residents indicated that all three had significant care needs, including dependence on staff for bed mobility, transfers, and activities of daily living, as well as documented risks for falls. Resident A had a diagnosis of unspecified dementia with psychotic disturbance and was care planned for self-care deficits and fall risk. Resident B had diagnoses including obesity, difficulty walking, hemiplegia, and hemiparesis, and used a trapeze bar for mobility; this resident also had a recent assisted fall and was care planned for fall risk and substantial assistance with mobility. Resident C had dementia, bowel incontinence related to immobility, and was dependent on staff for transfers and hygiene, with a care plan noting fall risk. Staff interviews confirmed that the facility's process for resident safety included locking bed wheels, but this was not followed for these residents.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency was identified when a cognitively intact resident, as indicated by a BIMS score of 15, was not treated with dignity and respect by a CNA. The resident was observed sitting in his wheelchair at his doorway, repeatedly calling the CNA by name. The CNA initially ignored the resident and, when she did respond, replied with a curt 'what' rather than addressing the resident respectfully. The resident expressed dissatisfaction with the interaction, stating he had been waiting for 30 minutes and felt as though he was working for the CNA. Interviews with other staff, including another CNA, an RN, and the DON, confirmed that responding to residents with 'what' is not considered respectful or acceptable according to facility policy. The facility's policy on promoting and maintaining resident dignity requires staff to speak respectfully to residents. The incident was acknowledged by facility leadership after being brought to their attention.
Failure to Follow Resident Food Preferences
Penalty
Summary
The facility failed to follow a resident's documented food preferences as outlined in their policies and procedures. During a meal observation, it was noted that a cognitively intact resident did not receive whole milk with their lunch, despite it being listed on their meal ticket. A CNA confirmed that the whole milk was missing and stated that she also had to retrieve whole milk for the resident at breakfast. The Dietary Services Supervisor (DSS) verified that all items on the meal ticket, including whole milk, should have been served. The Administrator and Director of Nursing (DON) were made aware of these findings and acknowledged the issue. The deficiency was identified through observation, interviews, and review of facility documentation, which showed that the resident's nutritional preferences were not consistently honored as required by facility policy.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition, specifically regarding the refusal of bowel management medications over a three-day period. The resident, who had been refusing stool softeners and other bowel management medications from January 1 to January 3, did not have a bowel movement during this time. Despite the facility's policy requiring notification of a physician when there is a change in a resident's condition, there was no documented evidence that the physician was informed of the resident's medication refusal. On January 4, the resident finally had a bowel movement, but later complained of severe pain and requested to go to the hospital. The resident was subsequently transferred to the hospital, where a CT scan revealed diverticulitis with an abscess and an associated ileus or possible small bowel obstruction. The Director of Nursing acknowledged that the physician should have been notified of the resident's refusal to take bowel management medications.
Failure to Update Elopement Risk Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services to prevent elopement for two residents. Resident 2, who was admitted with dementia and a low risk for elopement, exhibited increased wandering behaviors shortly after admission. Despite these changes, the facility did not update Resident 2's elopement risk assessment when a Wander Guard was placed on the resident's wrist. The Director of Nursing (DON) confirmed that a new elopement risk evaluation should have been completed following the change in Resident 2's behavior. Resident 4, also diagnosed with dementia, was not assessed for elopement risk quarterly as required by the facility's policy. Although Resident 4 had an elopement attempt and was seen outside the facility, the elopement risk assessments were not completed at the necessary intervals. The DON verified that the assessments were only completed upon admission and after an elopement attempt, missing several required quarterly assessments. This oversight failed to capture changes in Resident 4's elopement risk and the need for interventions.
Failure to Honor Resident's Medication Schedule Request
Penalty
Summary
The facility failed to respect a resident's right to self-determination by not administering medications according to the resident and family member's request. Resident 1, who was initially admitted to the facility, had their medication administration times altered without documented justification after returning from a hospital stay. The facility's policy on resident rights emphasizes supporting residents' choices, including medication schedules. However, upon Resident 1's return from the hospital, the administration times for cholecalciferol and cyanocobalamin were changed from 1300 hours to 0900 hours, contrary to the previously agreed schedule. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) revealed that the medication schedule was initially adjusted to spread out administration times per the resident and family's request. However, upon readmission, the facility failed to resume the agreed-upon schedule. Family Member 1 attempted to discuss the medication schedule with the facility before Resident 1's readmission but was unable to do so. Consequently, the medications were administered at 0900 hours, including additional medications, without adhering to the previously established schedule, leading to a failure in honoring the resident's rights.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a potential risk of catheter-associated urinary tract infections. The resident, who had moderate cognitive impairment, had an indwelling urinary catheter inserted due to urinary retention. However, the facility did not provide the necessary daily catheter care until five days after the insertion. This lapse in care was confirmed through interviews with the resident, a family member, and a Licensed Vocational Nurse (LVN), who acknowledged that catheter care was not ordered or rendered until several days after the catheter was inserted. The facility's policy and procedure for urinary catheters required continual assessment and proper handling of catheters, including keeping the urine collection bag below the bladder level and ensuring the catheter tubing was unobstructed. Despite these guidelines, the resident's catheter site was not checked or cleaned, and a bruise was observed by a family member during a urologist appointment. The Director of Nursing (DON) confirmed that catheter care should have been ordered upon insertion and that nurses were expected to assess the catheter site for signs of infection. The failure to adhere to these standards posed a risk for the resident to develop catheter-associated urinary tract infections.
Failure to Withhold Medication Despite Loose Bowel Movements
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered docusate sodium, a stool softener, despite having loose bowel movements or diarrhea, which was against the physician's order to hold the medication under such conditions. The resident had a history of fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. The physician's order clearly stated to administer the medication twice daily unless the resident experienced loose bowel movements. The medication administration records showed that the resident received the medication on multiple occasions when they had loose stools, as documented in the bowel elimination records. An LVN confirmed administering the medication without being informed of the resident's bowel condition, and the DON verified the discrepancy between the medication administration and the resident's bowel movement records. This oversight in communication and adherence to physician orders led to the administration of unnecessary medication to the resident.
Failure to Accommodate Resident's Bathing Request
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who requested a bath on a specific date. The resident, who had a moderate cognitive impairment with a BIMS score of 12, expressed frustration when his request for a bath was not fulfilled. The resident had returned from the hospital the day before and refused a scheduled shower, opting instead to request a bath the following day. However, the bath was not provided until the day after the request, as the CNA assigned to the resident was working a double shift and needed to take a break. Interviews with the resident, family member, and facility staff, including the DSD and LVN, confirmed that the bath was not documented as given on the requested date. The DSD and DON verified that the facility's records did not show a bath being provided on the requested date, and the LVN could not recall if the bath was given or who was responsible for it. This oversight led to the resident feeling frustrated, which could negatively impact their physical and emotional well-being.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a change in condition for one of the sampled residents. On 11/11/24, the resident exhibited mild weakness and a flushed face, but the care plan did not reflect this change in condition. The resident's medical history included fluctuating capacity to understand and make decisions, with a BIMS score indicating moderate cognitive impairment. Despite these observations, the care plan was not updated to address the resident's new symptoms, as confirmed by interviews with LVN 2 and RN 1. The Director of Nursing was informed and acknowledged the findings.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident, specifically regarding the administration of psyllium, a soluble fiber used as a bulk-forming laxative. The physician's order required the administration of one capsule by mouth twice a day. However, due to a pharmacy error, the resident received an extra capsule on multiple occasions. This discrepancy was noted in the resident's progress notes, which indicated that the pharmacy delivered a wrong medication bubble pack containing two psyllium capsules. The resident, who had a fluctuating capacity to understand and make decisions and a BIMS score indicating moderate cognitive impairment, received an extra capsule of psyllium on four separate days. The Director of Nursing (DON) confirmed this error during an interview and medical record review. The failure to administer the medication as ordered by the physician had the potential to negatively affect the resident's well-being.
Inaccurate Documentation of Bladder Elimination for Residents with Catheters
Penalty
Summary
The facility failed to ensure the accuracy of medical records for three residents who had indwelling urinary catheters. The Certified Nursing Assistants (CNAs) inaccurately documented these residents as incontinent in the Task-Bladder Elimination records, despite the presence of the catheters. This discrepancy was identified through interviews, medical record reviews, and facility policy and procedure reviews. The inaccurate documentation had the potential to impact the residents' care needs due to the incorrect medical information. Resident 1, who had fluctuating capacity to understand and make decisions, was documented as incontinent on two occasions while having an indwelling urinary catheter. Resident 2, who had the capacity to understand and make decisions, was documented as incontinent on multiple occasions over a span of several weeks, despite having a catheter. Similarly, Resident 3, who also had an indwelling urinary catheter, was inaccurately documented as incontinent on numerous occasions. The Director of Nursing (DON) confirmed the inaccuracies in the documentation during an interview and concurrent medical record review.
Failure to Notify Physician and Apply Splints as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For Resident 1, the facility did not notify the physician when the resident had no bowel movements for more than three days, despite having a bowel management protocol in place. The resident was on a bowel management medication regimen, but the lack of bowel movement from 9/29/24 to 10/3/24 was not communicated to the physician, which was against the facility's policy. This oversight was confirmed by both the LVN and the DON during interviews. For Resident 2, the facility did not adhere to the physician's orders regarding the application of dynamic splints. The resident, who had diagnoses including Parkinson's Disease and contractures, was ordered to have dynamic splints applied three times a day. However, the splint tracking log and progress notes revealed multiple instances where the splints were not applied as ordered. Interviews with the PT and LVN confirmed that the splints were crucial for the resident's functional improvement, yet there was no documentation of refusals or education provided to the resident about the benefits of the splints. These failures in following physician orders and facility protocols had the potential to negatively impact the residents' well-being. The facility's policies on constipation management and the use of assistive devices were not followed, leading to a lack of necessary care for the residents involved.
Failure to Provide Correct Oral Hygiene Tools
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 2's oral hygiene needs, as observed during a survey. Resident 2, who was admitted and readmitted to the facility on unspecified dates, was found using an incorrect dental tool for brushing their teeth. During an observation and interview, it was noted that Resident 2 used a short handle brush with bristles on both sides, typically used for cleaning dentures, instead of a regular toothbrush. This occurred because CNA 2 did not provide the regular toothbrush, which Resident 2 preferred and was supposed to use for brushing their teeth. Further interviews with LVN 4 and the DON confirmed that the short handle brush was intended for denture cleaning, while the regular toothbrush was meant for Resident 2's teeth. LVN 4 acknowledged Resident 2's preference for the regular toothbrush, and the DON verified the intended use of both brushes. This oversight in providing the correct toothbrush potentially impacted Resident 2's well-being, as the facility's policy requires accommodations to meet individual needs and preferences.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as observed during a survey. Dietary and non-dietary staff were found not wearing hair restraints, which is a violation of the Food Code of 2022. This was confirmed during observations and interviews with staff members, including a Dining Assistant and the Dietary Services Supervisor (DSS). The DSS acknowledged that kitchen staff should wear hair restraints for any exposed hair, beard, and body hairs. Additionally, the facility did not ensure proper labeling and dating of food items in the kitchen. During an initial tour, several food containers were found without labels or dates, including an opened container of Montreal chicken seasoning and clear containers of red and brown powders. This was verified by a cook present during the observation. Furthermore, kitchen equipment and utensils were not maintained in a sanitary condition. The microwave had food debris and rust, and a corroded pan was found among other pots and pans. Plates ready for use were also observed with food debris. The facility also failed to maintain sanitary conditions for cutting boards and air-drying of utensils. Cutting boards were heavily marred and discolored, making them difficult to clean and sanitize. Plates and insulated domes were observed wet, indicating they were not air-dried properly. Lastly, a scoop was improperly stored inside a bin containing oatmeal, contrary to the facility's policy on food storage. These deficiencies had the potential to cause foodborne illnesses among the residents consuming food prepared in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. The facility did not have documentation of a Legionella risk assessment, control measures, or testing protocols, which are essential to prevent the growth and spread of Legionella and other opportunistic pathogens in the water system. The Maintenance Supervisor confirmed the absence of these critical documents and acknowledged the lack of records for using chlorine tablets in decorative water fountains. Additionally, CNAs 11 and 12 did not adhere to Enhanced Barrier Precautions (EBP) when providing care to Resident 34, who had a Foley catheter and was under EBP. They failed to wear gowns and perform hand hygiene before donning gloves, which are necessary steps to prevent the transmission of multidrug-resistant organisms. The Director of Nursing (DON) confirmed that repositioning a resident is considered high-contact care, requiring full PPE, including gowns. The facility also failed to ensure that employee personal items were not stored in the clean laundry area, as observed with personal items placed on a table where linens were being folded. Furthermore, visitors in Resident 109's room did not follow contact isolation precautions, as they were not wearing PPE despite the resident being on contact isolation for ESBL in urine. Lastly, CNA 14 did not change gowns between assisting two residents, which is a breach of standard precautions to prevent cross-contamination.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to ensure that copies of advance directives were obtained or that information on how to formulate an advance directive was provided for eight of the 24 sampled residents. This deficiency was identified through interviews, medical record reviews, and facility policy and procedure reviews. The facility's policy requires informing and providing information to all new residents upon admission regarding their rights to accept or refuse medical treatment and to formulate an advance directive. However, the facility did not adhere to this policy for several residents. For Resident 34, there was no documented evidence that the resident was offered information on how to formulate an advance directive, despite having the capacity to understand and make decisions. Similarly, Resident 81's medical record showed no attempt to obtain a copy of the resident's advance directive, even though the resident had one. Resident 566, who had cognitive and psychiatric impairments, also lacked documentation of an attempt to obtain an advance directive. Other residents, such as Resident 59, had incomplete advance directives that were not verified for completeness before being uploaded into the electronic health record. Resident 75 was not provided with written information regarding advance directives, and Resident 89's POA was for financial authority rather than healthcare, with no attempt made to obtain an advance directive for healthcare. Additionally, Residents 109 and 414 had no documented evidence of attempts to obtain their advance directives, despite having the capacity to understand and make decisions.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which resulted in deficiencies in addressing their individual care needs. Resident 20, who had severe cognitive impairment, experienced a fall on 9/15/24, but no care plan was developed to address this incident. During an observation and interview, it was confirmed by LVN 1 and RN 1 that there was no care plan in place for the fall, despite the presence of bilateral floor mats in the resident's room. Similarly, Resident 42, who lacked the capacity to make decisions, was prescribed sertraline for depression, but the facility did not create a care plan to manage the use of this antidepressant medication. This was verified by LVN 3 and acknowledged by the DON. Additionally, Resident 81, who had intact cognition, was prescribed Keflex for an infected wound, yet no care plan was developed to address the use of this antibiotic. LVN 13 confirmed the absence of a care plan, and both the Administrator and DON acknowledged these findings.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by the lack of proper labeling, dating, and storage of respiratory equipment. For Resident 814, the oxygen nasal cannula tubing, humidifier, and Yankauer were not dated or labeled, and were not stored in a set-up bag when not in use. Additionally, there was no care plan developed for the resident's oxygen use and monitoring, nor was there a physician's order for oral suction at the bedside. This oversight was confirmed by LVN 3 and RN 1, who acknowledged the absence of necessary documentation and care plans. Similarly, Resident 76's oxygen tubing, humidifier, and storage bags for the nebulizer and suction devices were not dated or labeled, and there was no set-up bag for the oxygen tubing. LVN 17 verified these findings and stated that the respiratory devices and storage bags should be dated, labeled, and changed weekly. Resident 564 also had a storage bag for the nebulizer that was not dated or labeled, as confirmed by LVN 2, who emphasized the importance of changing respiratory supplies weekly for infection control. Other residents, including Residents 10, 42, 87, 75, 89, 414, 417, and 418, were found to have similar deficiencies in the management of their respiratory equipment. The nasal cannulas, humidifiers, and set-up bags were either undated, unlabeled, or not changed weekly as required. These findings were verified by various staff members, including LVNs and the Central Supply Clerk, who confirmed the facility's policy for changing and labeling respiratory equipment. The DON acknowledged these deficiencies, highlighting a systemic issue in the facility's respiratory care practices.
Failure to Adjust Medication Administration for Dialysis Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident requiring hemodialysis, specifically in the administration of medications. Resident 108, who was admitted to the facility and had physician's orders for hemodialysis on specific days, did not have their medications adjusted or rescheduled on dialysis days. The medications, including colchicine and magnesium, were not administered or rescheduled on multiple occasions when the resident was absent from the facility for dialysis. The facility's policy and procedure for medication administration required medications to be administered within 60 minutes of the scheduled time unless specified otherwise by the prescriber. However, there was no physician's order to hold or reschedule the medications on dialysis days, and the facility did not document any notification to the physician about the resident's absence during medication times. The Director of Nursing confirmed the lack of documentation and the failure to adjust medication times for the resident on dialysis days.
Failure to Provide Required Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of a resident, as observed during a medication administration session. A Licensed Vocational Nurse (LVN) was unable to administer a Calcium Vitamin D tablet to a resident because it was not available and had not been replaced. The facility's policy and procedure for medication administration, revised in November 2021, requires that if a medication with a current, active order cannot be located, the pharmacy should be contacted. However, this procedure was not followed, leading to a failure in medication administration. Further investigation revealed that the resident also did not receive an Acidophilus Probiotic oral tablet, which was ordered by the resident's physician. The LVN acknowledged that both the Calcium Vitamin D and Acidophilus Probiotic tablets were unavailable during the medication administration. The LVN admitted that he should have informed the physician about the unavailability of the medications. The facility's Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Failure to Act on Pharmacy Recommendations and Identify Duplicate Therapy
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendations were acted upon for a resident reviewed for unnecessary medications. Specifically, the consultant pharmacist recommended a gradual dose reduction of venlafaxine, an antidepressant, for a resident who had been on the same dose since September 2023. However, the physician did not respond to this recommendation, and the resident's dosage was not adjusted. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the physician did not act on the pharmacist's suggestion. Additionally, the facility did not ensure that the consultant pharmacist identified a duplicate therapy issue involving acetaminophen. The resident had two separate orders for acetaminophen, one as a generic and the other as the brand name Tylenol, both for mild pain. This duplication was not addressed, and the orders were not clarified with the resident's physician. The Licensed Vocational Nurse (LVN) confirmed the duplication and stated that it should have been clarified. The Administrator and DON were informed of these findings and acknowledged the issues.
Failure to Monitor Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, leading to several deficiencies. The resident was prescribed duplicate therapy for acetaminophen, with two separate orders for Tylenol and acetaminophen, both intended for mild pain relief. This duplication was acknowledged by an LVN during an interview, who stated that the orders should have been clarified with the resident's physician. Additionally, the resident was not monitored for side effects of Keflex, an antibiotic prescribed for an infected wound, nor for the side effects of hydrocodone-acetaminophen, a controlled pain medication. The LVN confirmed the lack of monitoring for potential side effects such as headache, dizziness, nausea, vomiting, constipation, and drowsiness. The medical record review and interviews revealed that the facility's policies and procedures were not followed, as there was no adequate monitoring for the side effects of the medications administered to the resident. The resident, who had intact cognition, was receiving Keflex for a skin tear and hydrocodone-acetaminophen for moderate to severe pain. Despite the absence of observed side effects or allergic reactions, the lack of monitoring for these medications was a significant oversight. The facility's Administrator and DON were informed of these findings and acknowledged the deficiencies.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 566, the facility did not monitor side effects and behaviors related to the use of sertraline, an antidepressant, and quetiapine, an antipsychotic. Despite the resident's cognitive and psychiatric impairments, there was no documented evidence of monitoring for these medications. During an interview, RN 3 confirmed the lack of monitoring and emphasized the importance of tracking side effects to adjust medication dosages appropriately. For Resident 75, the facility did not document the physician's rationale for extending the use of doxepin, an antidepressant, beyond the 14-day period. Additionally, there was no evidence of monitoring for behavior manifestations and side effects related to doxepin from the evening shift on 9/4/24 to 9/27/24. LVN 13 was unable to provide documentation of monitoring, and the DON confirmed that the licensed staff failed to continue monitoring after the physician extended the order. These deficiencies were acknowledged by the facility's Administrator and DON, who verified the findings during interviews. The lack of monitoring and documentation for psychotropic medications had the potential to negatively impact the residents' well-being, as stated in the facility's policy and procedure for the use of psychotropic drugs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a cumulative error rate of 18.52% during a medication pass observation. This was observed across three licensed nurses who administered medications to three nonsampled residents. The errors included incorrect mixing of a laxative, failure to instruct a resident to rinse their mouth after using an inhaler, administering the wrong type of B complex supplement, failing to administer a prescribed vitamin due to expiration, and administering the wrong potassium supplement. One of the errors involved LVN 8, who added 90 ml of water to a laxative powder for a resident, contrary to the instructions on the medication container, which specified mixing with four or eight ounces of beverage. Another error by LVN 9 involved not instructing a resident to rinse their mouth after using an inhaler, as required by the physician's order. Additionally, LVN 9 administered a B complex supplement that did not contain biotin, as was ordered by the physician. Further errors were observed with LVN 3, who did not administer vitamin B6 to a resident because the medication had expired. LVN 3 also administered potassium chloride instead of the prescribed potassium citrate. These actions were contrary to the facility's policies and procedures, which emphasize the importance of administering medications as prescribed and ensuring familiarity with the medications being administered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, which was observed through various deficiencies. Resident 51's Artificial Tears ophthalmic solution was left unattended on the bedside table by LVN 8, who acknowledged the oversight. This lapse in procedure could lead to unauthorized access to medications. Additionally, Medication Room A had multiple instances of out-of-range room temperatures above 77 degrees Fahrenheit, which were not reported to the Maintenance Director as required. RN 3 and the DON confirmed these findings, indicating a failure to maintain proper environmental controls for medication storage. Medication Room B lacked a temperature log, which RN 3 and the DON acknowledged. This absence of documentation suggests a failure to monitor and ensure appropriate storage conditions for medications. Furthermore, Medication Cart F contained topical prescription medications that were not labeled with a specific resident's name, as verified by LVN 11. This lack of labeling could lead to medication errors and unauthorized use. Medication Cart C had oral medications stored with externally used medications, and Resident 1's Refresh lubricant eye solution lacked an open date label. LVN 3 confirmed these findings, indicating a failure to adhere to proper medication storage protocols. Additionally, Medication Cart B contained an expired bottle of Humulin R and had oral medications stored with suppositories, as verified by LVN 9. These deficiencies highlight the facility's failure to ensure the safe and effective administration of medications, as outlined in their policies and procedures.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to the prescribed pureed recipes for 12 residents who were on a pureed diet, potentially compromising their nutritional needs. The deficiency was identified through observations, interviews, and document reviews, revealing that the pureed recipes for chicken ala king, steamed broccoli, and brown rice were not followed as specified. The facility's policy and procedure for pureed foods outlined specific instructions for preparing these meals, including the use of food thickeners and specific liquids to achieve the desired consistency. However, during the preparation, deviations from these instructions were observed, such as the addition of milk and butter to the pureed chicken ala king and steamed broccoli, and the use of rice hot cereal instead of brown rice for the pureed brown rice. Interviews with the dietary staff and the Dietary Services Supervisor (DSS) confirmed these discrepancies. The DSS verified that the recipes did not include the use of milk or butter for the chicken ala king and broccoli, nor the substitution of rice hot cereal for brown rice. Additionally, the preparation of the pureed brown rice involved the use of hot water instead of the specified 2% milk. These deviations from the established recipes indicate a failure to provide meals that meet the nutritional requirements of residents on a pureed diet, as outlined in the facility's policies.
Failure to Follow Policy on Outside Food Storage
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use and storage of food brought to residents by family and visitors. The policy, which was reviewed on 8/10/23, allows residents to have food brought in by family or visitors, provided it is handled safely. This includes labeling food not in original containers with a use-by date, refrigerating labeled items, and consuming food within four days. However, interviews with staff, including RNs, LVNs, the DON, and the DSS, revealed that the facility did not have a refrigerator designated for storing food from outside sources. Consequently, visitors were instructed to consume the food immediately, and any unconsumed food was not allowed to be stored at the facility. The staff interviews indicated a lack of awareness and implementation of the facility's policy on safe food handling of outside food. Staff members, including RN 3, LVN 13, and LVN 14, confirmed that visitors were encouraged not to bring excess food and were informed that the facility could not store unconsumed food. The DON and DSS also verified that visitors were not allowed to leave any unconsumed food due to the absence of a refrigerator for such items. This failure to follow the established policy and procedures had the potential to cause foodborne illnesses among the medically vulnerable resident population.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident receiving hospice services attained and maintained their highest practicable well-being. Specifically, the facility did not communicate with the hospice agency regarding missing hospice aide visitations for a resident, which could potentially delay hospice care. The facility's policies and procedures, as well as their contract with the hospice provider, outlined the responsibilities for coordinating care and maintaining communication with hospice representatives, but these were not followed. The medical record review revealed that the resident was admitted to hospice services with orders for hospice aide visits twice per week. However, documentation showed that several scheduled hospice aide visits were missed over multiple weeks, and there was no evidence that the facility coordinated with the hospice agency to address these missing visits. Interviews with facility staff, including a registered nurse, the social services department, the director of nursing, and the infection preventionist, confirmed the lack of communication and coordination regarding the missed hospice aide visits. The designated hospice coordinator, who was responsible for coordinating care with the hospice agency, did not have a clinical background and had not met the resident. The facility conducted weekly interdisciplinary team meetings, but the missing hospice aide visits were not discussed. The infection preventionist, who was also a designated hospice coordinator, acknowledged that they would need to contact the hospice agency if visits were missing but admitted that no follow-up had been conducted regarding the missed visits for the resident.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics for two residents, as their conditions did not meet the McGeer's criteria for infection. Resident 40 was prescribed Keflex despite having no urinary symptoms and not meeting the criteria for infection. The medical records lacked documentation of physician notification regarding the inappropriate use of antibiotics. Similarly, Resident 64 was prescribed cefpodoxime without meeting the infection criteria, and there was no evidence of physician notification in the medical records. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed these findings. The IP acknowledged that the facility's antibiotic stewardship program required physician notification if a resident did not meet the infection criteria, but was unable to provide documentation of such notifications for Residents 40 and 64. The DON was informed of these findings and acknowledged the deficiency.
Failure to Ensure Informed Consent for Influenza Vaccination
Penalty
Summary
The facility failed to ensure that a resident received the influenza vaccine and did not adequately document the refusal process. Specifically, the facility did not provide the resident's representative with the necessary information about the risks and benefits of the influenza vaccination when the vaccine was refused. The facility's policy requires that individuals or their legal representatives sign a consent or declination form, which should be filed in the individual's medical record. However, for the resident in question, the documentation was incomplete, lacking the signature of the resident's representative, the time of contact, and confirmation that the risks and benefits were discussed. The medical record review revealed that the resident's representative was contacted multiple times regarding the flu vaccine, but there was no evidence that the representative was informed about the risks and benefits of the vaccination. The facility's Infection Preventionist (IP) confirmed these findings and acknowledged the lack of follow-up with the resident's representative. Additionally, the Director of Nursing (DON) was informed and acknowledged the deficiency, which highlights a failure in the facility's process to ensure informed decision-making regarding vaccinations.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the dish machine and digital thermometers. During an observation and interview, it was found that the dish machine was not functioning properly as the chlorine test strip only read 10 ppm, which is below the required level for proper sanitization. Dining Assistant 3 admitted to not documenting the chlorine test results due to a missing log and did not report the inadequate chlorine level. The facility's documentation showed that the temperature and chlorine levels were not recorded for certain periods, confirming the dish machine was not working as intended. Additionally, the facility did not ensure that digital thermometers used in the kitchen were calibrated. Interviews with staff revealed a misunderstanding regarding the necessity of calibrating digital thermometers, as they believed calibration was unnecessary for digital devices. However, the facility's policy and the manufacturer's manual both indicated that regular calibration is required to ensure accurate temperature readings. The DSS acknowledged the need for calibration of the digital thermometers. These deficiencies in maintaining kitchen equipment could potentially lead to foodborne illnesses among the residents, as 116 out of 121 residents received food prepared in the facility's kitchen. The lack of proper documentation and failure to adhere to established procedures for equipment maintenance and calibration were significant factors contributing to these deficiencies.
Failure to Ensure Accessibility of Call Lights and Controls
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents, as observed during a survey. One resident, who was cognitively intact and capable of making decisions, reported waiting for 30 minutes for assistance to use the toilet, resulting in her wetting her diaper. This incident occurred despite the resident's preference to use the toilet, highlighting a delay in staff response to call lights, which is against the facility's policy. Multiple residents were found with their call lights out of reach, preventing them from requesting assistance when needed. For instance, one resident was observed with the call light on the floor, another with it clipped to a curtain, and another with it inside a bedside drawer. These observations were confirmed by staff members, who acknowledged that the call lights should be within reach and accessible to residents at all times. Additional deficiencies included a resident unable to reach the bed control to adjust the bed position, another unable to reach the headlight cord, and a resident unable to reach the TV remote control. These inactions by the facility staff potentially impacted the residents' ability to perform daily activities and maintain their psychosocial well-being. The Director of Nursing acknowledged these findings, confirming the facility's failure to ensure that necessary controls and devices were within reach of the residents.
Failure to Follow Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, specifically for Resident 418, who was served cooked carrots despite having a documented dislike for them. During a dining observation, Resident 418, who is cognitively intact, expressed dissatisfaction with being served carrots, which he had previously indicated he did not like. The facility's diet spreadsheet for the specified menu cycle included baby carrots for lunch, and this was confirmed by both the LVN and the DSS during interviews. A review of Resident 418's meal ticket and medical records showed a physician's order specifying a regular renal focus diet with no cooked carrots, among other restrictions. Despite these documented preferences and orders, the resident was still served the disliked food item, indicating a lapse in following dietary instructions.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident, identified as Resident 564. Upon review of the resident's medical records, it was found that there was a discrepancy in the documentation regarding the resident's decision-making capacity. The History and Physical (H&P) examination dated 9/12/24 indicated conflicting information about the resident's ability to understand and make decisions, stating both that the resident did and did not have the capacity. Additionally, a surrogate decision-maker was listed. Despite this, the Consent For Treatment form, also dated 9/12/24, was signed by the resident, indicating consent to be admitted and treated at the facility. There was no documented evidence that the physician had been consulted to clarify the resident's decision-making capacity. During an interview and concurrent medical record review with the Director of Nursing (DON) on 9/27/24, the DON confirmed the findings and acknowledged that the physician should have been consulted to clarify the resident's decision-making capabilities. The DON stated that the physician would need to reevaluate the resident to address this issue.
Improper Trash Disposal and Pest Risk
Penalty
Summary
The facility failed to ensure that trash was disposed of in a sanitary manner, as observed during a survey. Three out of four dumpsters were not properly covered, which had the potential to harbor pests. Specifically, the green food waste dumpster was overflowing with trash, preventing the lid from closing, and an untied black garbage bag was open with food waste dripping to the ground, attracting flies. The blue recycling dumpster was fully open, and one gray trash dumpster had a lid that was not fully closed. These observations were verified by the Maintenance Director. The facility's policy and procedure for garbage and trash disposal, dated 2023, required that all food waste be placed in sealed, leak-proof, non-absorbent containers and disposed of as necessary to prevent nuisance or unsightliness. It also required that garbage and trash cans be inspected daily to ensure no debris was on the ground or surrounding area and that lids were closed. Additionally, the trash collection area was to be kept clean to prevent it from becoming a feeding ground for vermin and rodents.
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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 Los Alamitos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seal Beach Health And Rehabilitation Center | 3 mi | — | 2 | 0 |
| Park Anaheim Healthcare Center | 3.6 mi | — | 28 | 0 |
| Anaheim Point | 3.6 mi | — | 0 | 0 |
| Anaheim Terrace Care Center | 3.9 mi | — | 2 | 0 |
| Healthcare Center Of Orange County | 4.2 mi | — | 10 | 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 August 2026) and official state health department websites.