Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Foothill Regional Medical Center D/p Snf during CMS and state inspections, most recent first.
A long-term care facility failed to implement proper infection control practices, as evidenced by incomplete infection surveillance, unsanitary conditions, and improper use of PPE. The facility's infection surveillance tool did not record all residents with infections, and staff failed to disinfect stethoscopes and maintain cleanliness. Additionally, staff were not aware of Enhanced Barrier Precautions, leading to improper PPE use during high-contact activities.
The facility failed to develop comprehensive care plans for two residents, one requiring Jejunostomy tube feeding and an abdominal binder, and another dependent on GT feeding. Despite physician's orders, there was no documented care plan for their specific needs, confirmed by staff interviews. The CNO and Director of Quality and Risk acknowledged these deficiencies.
The facility failed to conduct required skin assessments every two hours for two residents with splint devices, as ordered by their physicians. Observations and interviews revealed that the assessments were not documented, and the care plans did not include necessary interventions. Staff cited time constraints as a reason for the oversight.
The facility failed to maintain the required head of bed (HOB) elevation for residents with gastrostomy tubes (GT), as observed in four residents. The facility's policy required the HOB to be elevated at a 30-degree angle or more during enteral feeding and medication administration to prevent aspiration. However, observations revealed that the HOB for these residents was not elevated to the required angle, posing a risk for complications. Staff members acknowledged the errors and the facility's CNO and Director of Quality and Risk were informed of these findings.
A facility failed to obtain informed consent for the use of side rails for a resident with encephalopathy. Despite a physician's order for padded side rails, the necessary informed consent from the resident's representative was not documented. Facility staff confirmed the oversight, acknowledging that the informed consent process had not been completed prior to the use of the side rails.
A facility failed to provide adequate pharmaceutical services, resulting in a 3.85% medication error rate. An LVN did not administer a complete dose of a multivitamin via GT, leaving residue in the cup, contrary to facility policy. Additionally, the LVN signed the electronic MAR for a saliva substitute oral gel before administering it, violating documentation protocols. These actions were confirmed by the CNO and Director of Quality and Risk.
A facility failed to document monitoring of seizure activities and side effects for a resident on multiple anticonvulsant medications, potentially leading to unnecessary medication use and adverse effects. The absence of a physician's order for monitoring was confirmed by both an RN and the CNO.
A facility failed to monitor a resident's behavior for the effectiveness of clonidine, a psychotropic medication used for irritability, and did not obtain informed consent when the medication's administration route, dose, and targeted behavior were changed. The resident had memory problems and impaired cognitive skills, and the facility lacked documentation of behavior monitoring. The Director of Quality and Risk acknowledged the absence of policies for psychotropic medication use.
A facility failed to properly store and label medications, as observed during a survey. An LVN left medications unattended on a cart, and a resident's simethicone bottle lacked an opened date label. The CNO and Director of Quality and Risk acknowledged these issues, highlighting the importance of locking medication carts and labeling opened medications to prevent risks.
The facility failed to maintain kitchen equipment in a sanitary condition and did not properly store food items, leading to potential contamination risks. Observations revealed stained cups, dusty lids, and marred cutting boards, along with expired and unlabeled food items in storage. The CDM verified these deficiencies.
The facility failed to offer and administer the COVID-19 vaccine to three residents, placing them at risk of infection. A resident's immunization record lacked evidence of vaccination, and the DSD/MDS Coordinator admitted the vaccine was not offered. Another resident's record showed consent for vaccination, but the vaccine was not administered due to oversight. The Director of Infection Prevention and CNO acknowledged these findings.
The facility failed to repair the dish machine in a timely manner, resulting in the final rinse temperature not reaching the required 180°F. Despite the CDM's efforts to address the issue through work orders and emails to the Plant Operations Director, the problem persisted, leading to the use of manual dishwashing for sanitization. The deficiency was confirmed through observations, interviews, and document reviews, with no corrective actions documented.
A facility failed to provide a resident or their representative with written notification of the bed hold policy during a transfer to an acute care hospital. Despite the facility's policy requiring such notification, staff interviews revealed that the necessary documentation was not provided, and the Chief Nursing Officer acknowledged the oversight.
The facility failed to complete quarterly MDS assessments for two residents, with the last assessments documented in early September. The MDS Coordinator confirmed the oversight was due to a calendar discrepancy, and the CNO acknowledged the expectation for timely submissions.
A facility failed to accurately code the MDS for a resident who was prescribed aspirin for anticoagulation. The MDS was incorrectly coded to reflect the use of an anticoagulant, despite aspirin not being classified as such. This error was confirmed by the DSD/MDS Coordinator and acknowledged by the CNO.
The facility failed to ensure proper storage of garbage and refuse, as observed in the area around the dumpster and compactor, which was littered with disposable items and a dark liquid with odor. The Plant Operations Director confirmed the need for cleaning, and the findings were acknowledged by the CNO and Director of Quality and Risk.
A resident with chronic respiratory failure fell when a CNA was lowering the siderail to take vital signs. The facility failed to conduct required neurological, skin, and body assessments post-fall, as per their P&P. Interviews with staff revealed inconsistencies in documentation and adherence to fall prevention protocols.
A facility failed to maintain complete and accurate fall risk documentation for a resident with a history of falls and high fall risk. The resident's Morse Fall Scale scores were either left blank or inaccurately recorded, despite staff acknowledging the resident's active nature and tendency to manipulate crib rails. The CNO confirmed the inaccuracies, which were not in line with the facility's policy.
The facility failed to ensure that two residents were free from physical restraints unless needed for medical treatment. The facility did not conduct assessments, obtain informed consent, or secure physician's orders before applying seat belt and chest strap restraints. Additionally, the facility did not implement the least restrictive interventions or monitor and document the use of these restraints.
The facility failed to ensure padded side rails for two residents with seizure disorders, despite physician's orders. Both residents were observed with elevated side rails without padding, which was confirmed by staff during observations and medical record reviews.
The facility failed to assess three residents for the risk of entrapment from elevated side rails, potentially placing them at risk for serious injury. Observations and medical record reviews confirmed that the residents' records lacked necessary assessments, a deficiency verified by facility staff.
A resident was prescribed quetiapine for neuro irritability without proper behavior indication, monitoring of behavior and side effects, or a formulated care plan. The deficiencies were confirmed through medical record reviews and interviews with the RN and DON.
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. An LVN did not administer medications to a resident within the prescribed two-hour window, potentially affecting the resident's health.
The facility failed to ensure proper storage and disposal of medications, as evidenced by an expired nasal spray found on a resident's bedside table and a vitamin D bottle with an unknown substance on it. Both incidents were acknowledged by staff and posed potential risks to resident well-being.
The facility failed to maintain sanitary conditions in the kitchen, with issues including dirty and worn-out utensils, a dirty kitchen hood, improper plumbing for the ice machine, and expired test strips for sanitizing solutions. These deficiencies were verified by the Dietary Services Supervisor and acknowledged by the Director of Food Services.
The facility failed to record all residents with infections on the Infection Surveillance Tool, maintain cleanliness in the laundry room, and remove isolation signage after a precaution order was discontinued. These deficiencies were confirmed through observations, record reviews, and staff interviews.
The facility failed to implement their Antibiotic Stewardship Program by not conducting necessary assessments using McGeer's criteria for three residents prescribed antibiotics and not notifying physicians when criteria were not met for three other residents. This oversight was confirmed by the Director of Infection Control and the Infection Control Coordinator.
A resident did not receive the COVID-19 vaccine despite consent being obtained from their responsible party. The consent form was misplaced, and the physician was not notified, resulting in the vaccination not being administered.
The facility failed to ensure that a resident's POLST was obtained and maintained in the medical record. Despite a physician's order for a Full Code and to obtain a POLST, the document was not present in the resident's medical record. Interviews with RNs confirmed the absence and acknowledged that the POLST should have been included to know the resident's code status and wishes.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge to another SNF. A review of the resident's medical record and interviews with the Ombudsman and RN confirmed the lack of notification.
The facility failed to develop and update comprehensive care plans for four residents, omitting necessary safety measures such as padded side rails and wheelchair restraints, despite physician orders and observed use. This was confirmed by interviews and record reviews with the facility's RNs.
The facility failed to ensure the medical record for a resident was complete and accurate. Physician's orders for a Posey Bed Enclosure and bilateral No-No Posey Sleeves were signed and dated but lacked the required time documentation. The RN Charge Nurse and DON confirmed that orders should be signed, dated, and timed, indicating a failure to adhere to the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection control practices, as evidenced by several deficiencies observed during the survey. The infection surveillance tool used by the facility did not record all residents with infections, only those with positive culture results. This oversight was confirmed by the Director of Infection Prevention, who admitted that the surveillance forms did not include all residents identified with infections according to McGeer's criteria. This failure to comprehensively track infections posed a risk for the transmission of disease-causing microorganisms. Additionally, the facility did not maintain a sanitary environment for its residents. During an initial tour, a resident's water pitcher was found to be dirty, with yellowish powder and stains, which was verified by an LVN. The LVN acknowledged that the water from the pitcher was used during medication administration, indicating a lapse in maintaining cleanliness and infection control. Furthermore, multiple LVNs failed to disinfect their stethoscopes after use on residents and before exiting their rooms, which was acknowledged by the staff and the CNO, highlighting a breach in infection control protocols. The facility also failed to ensure proper use of personal protective equipment (PPE) during resident care. Several staff members, including LVNs and RCPs, did not wear gowns while performing high-contact activities such as medication administration through gastrostomy tubes and suctioning through tracheostomy tubes. The staff's lack of awareness and training on Enhanced Barrier Precautions (EBP) was evident, as they were not familiar with the guidelines requiring gown and glove use during such procedures. This lack of adherence to PPE protocols further increased the risk of infection transmission within the facility.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific care needs. Resident 18, who was on a Jejunostomy tube feeding, had physician's orders for a pureed diet for oral gratification and the use of an abdominal binder to prevent GT dislodgement. However, the facility did not document a care plan to address these nutritional needs or the use of the abdominal binder. Interviews with CNA 3 and RN 2 confirmed the absence of a care plan for Resident 18's oral feeding, tube feeding, and abdominal binder use, despite the presence of physician's orders. Similarly, Resident 7, who was dependent on GT feeding, did not have a documented care plan addressing their enteral feeding needs. The medical record review and interview with RN 1 confirmed that the facility did not initiate a person-centered care plan for Resident 7's tube feeding, relying instead on standard professional practice. The CNO and Director of Quality and Risk acknowledged these findings, indicating a lack of individualized care planning for these residents.
Failure to Conduct Required Skin Assessments for Residents with Splints
Penalty
Summary
The facility failed to provide appropriate care for two residents, Residents 4 and 12, by not conducting required skin assessments every two hours when splint devices were applied, as ordered by their physicians. The facility's policy and procedure for splint application required visual checks of the skin before and after the application of splints, with documentation of these checks. However, observations and interviews revealed that these assessments were not documented, and the care plans for both residents did not include interventions for skin assessments every two hours. Resident 4, who had contractures on both upper and lower extremities, was observed without the prescribed splint devices in place. The medical record review showed physician orders for the application of bilateral splints with skin checks every two hours, but there was no evidence of these checks being documented. Interviews with the RNA and LVN confirmed the lack of documentation and the absence of specific times for skin assessments, citing time constraints as a reason for the oversight. Similarly, Resident 12, also with contractures, was observed without the splint devices. The resident's physician had ordered the application of splints with skin checks every two hours, but the care plan did not include these interventions. Interviews with the RNA and LVN confirmed the absence of documentation for the skin assessments. The CNO was informed of these findings and verified the lack of documentation and care plan interventions for both residents.
Failure to Maintain Proper HOB Elevation for Residents with GT
Penalty
Summary
The facility failed to ensure proper care and services for residents with gastrostomy tubes (GT), as observed in four residents. The facility's policy required the head of the bed (HOB) to be elevated at a 30-degree angle or more during enteral feeding and medication administration to prevent aspiration. However, during observations, it was noted that the HOB for Residents 1, 7, 9, and 12 was not elevated to the required angle, posing a risk for complications related to GT use. Resident 9, who was GT dependent, had their medication administered by LVN 1 with the HOB at a 20-degree angle, contrary to the facility's policy. LVN 1 acknowledged the error upon checking the bed's leveler. Similarly, Resident 12, also GT dependent, had their medication administered by LVN 3 with the HOB between 15 and 30 degrees. LVN 3 admitted to using visual judgment rather than the bed's indicator, which showed the angle was less than 30 degrees. Resident 1, receiving enteral feeding, was observed with the HOB at a 20-degree angle, confirmed by LVN 1, who acknowledged the requirement for a 30-degree angle to prevent aspiration pneumonia. Resident 7, dependent on a tracheostomy and GT, was observed with the HOB at a 15-degree angle during tube feeding. RN 4 confirmed the need for a 30-degree angle to prevent complications and adjusted the HOB accordingly. The facility's CNO and Director of Quality and Risk were informed of these findings and acknowledged the deficiencies.
Failure to Obtain Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails for one of the residents reviewed, identified as Resident 11. The facility's policy requires informed consent when side rails are used for patient safety. However, during a review of Resident 11's medical records, it was found that there was no documented evidence of informed consent for the use of padded bilateral upper and lower side rails. This oversight was confirmed during interviews with facility staff, including a CNA and an RN, who acknowledged that the informed consent had not been obtained prior to the use of the side rails. Resident 11, who was admitted to the facility with a history of encephalopathy, was observed with elevated padded bilateral upper and lower side rails. A physician's order for these side rails was present in the medical records, but the necessary informed consent from the resident's representative was missing. The RN confirmed that the bed was changed to one with side rails recently, and the informed consent process had not been completed. The CNO and Director of Quality and Risk were informed of these findings and acknowledged the deficiency.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in a medication error rate of 3.85%. During a medication administration observation, a licensed nurse (LVN 4) did not administer the complete dose of a multivitamin to a resident via a gastrostomy tube (GT), as significant residue was left in the medication cup. The facility's policy requires that any noticeable medication residue should be mixed with water and administered to ensure the complete dose is given. This oversight was confirmed by both LVN 4 and the Chief Nursing Officer (CNO), who acknowledged that medications should be administered as ordered by the physician. Additionally, the facility failed to ensure that the electronic Medication Administration Record (MAR) was signed only after the medication was administered. LVN 4 signed the electronic MAR for a saliva substitute oral gel before actually administering it to the resident. The CNO and Director of Quality and Risk confirmed that the electronic MAR should be signed during or immediately after medication administration, not before. These failures in medication administration and documentation could potentially affect the resident's health conditions and pose risks for complications or delays in interventions.
Failure to Monitor Seizure Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not document the monitoring of seizure activities and side effects for a resident who was prescribed multiple anticonvulsant medications, including clobazam, clonazepam, diazepam, lacosamide, lamotrigine, and levetiracetam. This lack of documentation and monitoring could lead to the resident receiving unnecessary medications and experiencing significant adverse effects. During an interview and medical record review, it was confirmed that there was no physician's order for monitoring the seizure activity and side effects of the anticonvulsant medications for the resident. The last recorded seizure activity was noted on 11/8/24, as reported by the resident's mother. Both the RN and the CNO verified the absence of a physician's order for monitoring, highlighting a deficiency in the facility's medication management practices.
Failure to Monitor Psychotropic Medication and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically clonidine, which was used to manage irritability. The facility did not monitor the resident's behavior to assess the effectiveness of the medication. Despite the resident having a history of memory problems and severely impaired cognitive skills, there was no documented evidence that the resident's behavior of irritability was monitored. Interviews with the Director of Pharmacy and a registered nurse confirmed that the behavior should have been monitored, but the medical record lacked documentation of such monitoring. Additionally, the facility did not obtain informed consent from the resident's representative when changes were made to the clonidine medication's route of administration, dose, and targeted behavior. The initial consent was for a clonidine patch for agitation, but the medication was later administered via a gastrostomy tube for irritability without updated consent. The Director of Quality and Risk acknowledged that the facility lacked policies and procedures for the use of psychotropic medications, as they did not have residents with psychiatric issues.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen leaving medications unattended on top of a medication cart. The medications included a green bottle of refresh eye lubricant, packets of polyethylene glycol, and doses of calcium carbonate tablets. The LVN acknowledged that the medications should have been stored inside the locked medication cart when unattended to prevent unauthorized access or administration errors. Additionally, a bottle of simethicone for a resident was found without an opened date label, contrary to the facility's policy requiring multi-dose vials to be labeled with an expiration date once opened. The LVN confirmed the absence of the label and stated that the nurse who first opened the medication should have labeled it. The Chief Nursing Officer (CNO) and Director of Quality and Risk acknowledged these findings, emphasizing the importance of locking medication carts and labeling opened medications to prevent risks such as medication theft and cross-administration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations in the kitchen and storage areas. During an inspection, it was noted that kitchen equipment was not maintained in a sanitary condition. Specifically, seven black cups had white stains, a plastic container lid was dusty, and a white tray with ceramic cups had brown stains and dust. Additionally, cutting boards were heavily marred and discolored, indicating they were not properly cleaned or replaced as needed. These conditions were verified by the Certified Dietary Manager (CDM), who acknowledged the need for re-cleaning and replacement of the items. Furthermore, the facility did not ensure proper storage of food items, which could lead to contamination. Observations in the walk-in refrigerator revealed meat and other food items past their 'good through' dates, such as black beans and pineapples, which were not discarded in a timely manner. There were also unlabeled items, including a piece of cake in multiple containers and a bin of flour, which should have been labeled and dated according to the facility's policy. The CDM confirmed these findings, acknowledging the failure to follow proper labeling and storage procedures.
Failure to Administer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was offered and administered to three residents, which placed them at risk of acquiring COVID-19. Resident 1's immunization record did not show evidence of COVID-19 vaccination, and the Director of Staff Development (DSD)/MDS Coordinator admitted that the vaccine was not offered to Resident 1's responsible party. Similarly, Resident 17's immunization record lacked documentation of COVID-19 vaccination from 2023 to 2025, and the DSD/MDS Coordinator confirmed that the vaccine was not offered to Resident 17's responsible party. Resident 6's responsible party had consented to the COVID-19 vaccination, but the immunization record did not show evidence of administration. The DSD/MDS Coordinator acknowledged that the vaccine was not administered due to an oversight. The Director of Infection Prevention and the Chief Nursing Officer (CNO) were informed of these findings and acknowledged the oversight in offering and administering the COVID-19 vaccine to the residents.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure the dish machine was repaired in a timely manner, resulting in the dish machine's final rinse temperature not reaching the required minimum of 180 degrees Fahrenheit as per manufacturer instructions. This deficiency was identified through observations, interviews, and document reviews. The Certified Dietary Manager (CDM) confirmed that the dish machine had not been showing the correct final rinse temperature and had submitted work orders to the engineering department, but the issue remained unresolved. As a result, the facility resorted to using a manual dishwashing method for sanitization. The facility's Dish Machine Temp Log revealed consistent failures in reaching the required final rinse temperature from August 2024 to January 2025, with no corrective actions or managerial reviews documented. Despite the CDM's efforts to address the issue by submitting work orders and following up with the engineering department, the problem persisted. The CDM also sent an email to the Plant Operations Director, highlighting the need for an external company to fix the broken water system, but no response or action was taken. Interviews with the Plant Operations Director confirmed that only two work orders were received, and the issue was temporarily fixed. However, the persistent problem with the dish machine's temperature was not adequately addressed, as evidenced by the lack of follow-up on the CDM's email. The Chief Nursing Officer and Director of Quality and Risk were informed of these findings, acknowledging the deficiency in maintaining the dish machine's proper functioning.
Failure to Notify Resident of Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy, revised in September 2024, mandates that residents be informed of their right to a bed hold upon admission and at the time of transfer or leave. However, during the review of Resident 8's medical records, it was found that the resident was transferred to an acute care hospital without receiving a written notification of the bed hold policy. Interviews with facility staff, including RN 1 and the Pediatric Social Worker, revealed that the bed hold notification was not provided to Resident 8's representative. The Pediatric Social Worker confirmed that although the Notice of Transfer or Discharge form included a seven-day hold notification, it was not given to the resident's representative because the form lacked instructions to do so. The Chief Nursing Officer (CNO) and Director of Quality and Risk acknowledged these findings, indicating a lapse in the facility's adherence to its own policies regarding resident rights during transfers.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed for two residents, Resident 6 and Resident 13. Resident 6 was admitted to the facility, and the last quarterly MDS assessment was completed on September 6, 2024, with no subsequent assessment documented. Similarly, Resident 13's last annual MDS assessment was completed on the same date, with no quarterly assessment following it. During an interview and medical record review, the MDS Coordinator/Director of Staff Development (DSD) confirmed that the assessments were missed due to a discrepancy in the submission date on her calendar. The Chief Nursing Officer (CNO) acknowledged the findings and stated that the expectation was for the MDS Coordinator to complete and submit each MDS assessment on time.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. The deficiency involved Resident 6, who was admitted to the facility and had a physician's order to receive aspirin 40.5 mg chewable tablet via gastrostomy tube (GT) daily, with the indication for use being anticoagulation. However, the MDS was incorrectly coded to reflect the use of an anticoagulant, despite aspirin not being classified as such. This error was confirmed during an interview and medical record review with the Director of Staff Development (DSD)/MDS Coordinator, who acknowledged the mistake. The Chief Nursing Officer (CNO) was also informed and acknowledged the findings, stating the expectation for MDS assessments to be completed and submitted accurately.
Improper Storage of Garbage and Refuse
Penalty
Summary
The facility failed to properly store garbage and refuse in the area of the garbage dumpster and compactor. During an observation and interview with the Plant Operations Director, it was noted that the area around the dumpster and compactor was littered with disposable cups, papers, cardboard boxes, pieces of wood, and a dark liquid with an odor. The Plant Operations Director confirmed these observations and acknowledged that the area should be free of litter and required cleaning. This situation was later communicated to the Chief Nursing Officer (CNO) and the Director of Quality and Risk, who acknowledged the findings.
Failure to Implement Fall Prevention Protocols and Conduct Assessments
Penalty
Summary
The facility failed to provide necessary care and services for a resident who sustained a fall. The facility did not implement its policy and procedure (P&P) for conducting hourly rounding, neurological, skin, and body assessments after the resident's fall. The resident, who had chronic respiratory failure and was ventilator-dependent, fell when a certified nursing assistant (CNA) was lowering the siderail to take vital signs. The resident hit the floor and was later transferred to an acute care hospital emergency department. The facility's P&P required a change of condition report to be filled out and documented in the resident's medical record, including any injuries. However, the medical record review showed that neurological assessments were not conducted to assess the resident's level of consciousness, mentation, behavior, and other critical factors. Additionally, there was no documentation of skin and body assessments for over three hours after the fall. Interviews with facility staff, including a licensed vocational nurse (LVN), a registered nurse (RN), and the chief nursing officer (CNO), revealed inconsistencies in the documentation and lack of adherence to the fall prevention protocol. The CNO confirmed that hourly rounding and assessments were not documented, and there was no documented witness statement from the CNA involved in the incident. The director of quality assurance acknowledged these findings.
Incomplete and Inaccurate Fall Risk Documentation
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding the documentation of the resident's Fall Risk Assessment. The resident, who had a history of falls and was considered high risk due to a Morse Fall Scale score of 55, had incomplete and inaccurate documentation on subsequent assessments. On three occasions, the resident's fall risk score was either left blank or inaccurately recorded as a lower risk than previously assessed. Interviews with facility staff revealed that the resident was known to be active and had a tendency to manipulate crib rails, increasing the risk of falls. Despite this, the fall risk assessments on certain dates were not properly documented, potentially impacting the resident's care. The Chief Nursing Officer confirmed the inaccuracies and omissions in the fall risk assessments, acknowledging that the resident's fall risk score was not consistently recorded according to the facility's policy and the resident's condition.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, Resident 8 and Resident 24, were free from the use of physical restraints unless needed for medical treatment. The facility did not conduct an assessment, obtain informed consent, or secure a physician's order before applying seat belt and chest strap restraints to these residents while they were in their wheelchairs. Additionally, the facility did not implement the least restrictive interventions prior to using these restraints and failed to monitor and document their use. These actions compromised the residents' independence and psychosocial well-being. For Resident 8, the medical record review showed no assessment, informed consent, or physician's order for the use of seat belt and chest strap restraints in the wheelchair. Observations and interviews with staff confirmed that Resident 8 was using these restraints without proper documentation or monitoring. Similarly, for Resident 24, the medical record review also lacked an assessment, informed consent, and physician's order for the restraints. Staff interviews verified that Resident 24 was using the restraints without the necessary documentation and monitoring. The Director of Nursing confirmed these findings during an interview and medical record review.
Failure to Ensure Padded Side Rails for Residents with Seizure Disorders
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for two residents, both of whom had a history of seizure disorders and physician's orders for padded side rails. Resident 3 was observed on two separate occasions with bilateral upper and lower side rails elevated without padding, despite a physician's order dated 9/8/23 to apply seizure pads to all four side rails for safety. This was verified by LVN 3 during an observation, interview, and concurrent medical record review on 2/28/24. Similarly, Resident 16 was observed with bilateral upper side rails and one lower side rail elevated without padding, despite a physician's order dated 3/2/23 to use padded side rails while in bed for safety. This was confirmed by RN 4 during an observation, interview, and concurrent medical record review on 2/29/24. Both residents' medical records indicated a history of seizure disorders, necessitating the use of padded side rails to prevent injury.
Failure to Assess Risk of Entrapment from Elevated Side Rails
Penalty
Summary
The facility failed to ensure that three residents (Residents 13, 14, and 24) were assessed for the risk of entrapment from elevated side rails, which could potentially place them at risk for serious injury. Resident 13, who had impaired mobility and cognitive impairment, was observed on multiple occasions with bilateral side rails elevated at the head of the bed. A review of Resident 13's medical record showed no assessment for the risk of entrapment from the elevated side rails, a fact verified by RN 3 during an observation and medical record review. Similarly, Resident 14, who had diagnoses including seizure disorder and spasticity, was observed with bilateral side rails elevated at the head of the bed and one side rail elevated at the foot of the bed. RN 3 confirmed that Resident 14's medical record also lacked an assessment for the risk of entrapment from the elevated side rails. Resident 24, who was severely cognitively impaired and dependent on staff for all ADL care, was observed with all four side rails elevated and padded. A review of Resident 24's medical record and plan of care showed no documented evidence of an assessment for the risk of entrapment or a care plan problem addressing the use of the side rails. This lack of assessment was confirmed by both CNA 5 and RN 2 during interviews and concurrent medical record reviews. The facility's failure to assess these residents for the risk of entrapment from elevated side rails represents a significant deficiency in ensuring resident safety and preventing potential accidents.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the physician's order for quetiapine, a medication used to treat symptoms of schizophrenia or bipolar disorder, did not include a behavior indication for its use, and there was no monitoring of behavior and side effects related to the medication. Additionally, the resident's medical record did not show monthly psychotropic summaries or a formulated plan of care for the use of quetiapine. These failures were observed in the medical record review and confirmed through interviews with the RN and DON. The resident in question was admitted to the facility with severe cognitive impairment and issues with neurostorming and agitation requiring sedation. The resident was prescribed quetiapine 25 mg at bedtime for neuro irritability. However, the physician's order lacked specific behavior manifestations, behavior monitoring, and side effects monitoring. Furthermore, there was no documented evidence of an IDT Care Conference for Behavior and Psychotropic Management, nor was there a care plan addressing the use of quetiapine. These deficiencies were verified by the RN and DON during interviews and medical record reviews.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below 5%, with an observed error rate of 8%. During a medication administration observation, a licensed nurse (LVN 3) did not administer medications to Resident 3 as scheduled. Specifically, Resident 3 had a physician's order for ocular lubricant ophthalmic solution and chlorhexidine mouthwash to be administered at 0800 hours. However, these medications were not given within the prescribed two-hour window, as they were administered at 1119 and 1121 hours, respectively. The facility's policy and procedure (P&P) titled Medication Orders and Management, revised in September 2021, stipulates that medications should be administered within one hour before or after the prescribed time. LVN 3 verified that the medications were not administered within this timeframe. This failure to adhere to the scheduled medication times had the potential to negatively affect Resident 3's health.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and disposal of medications, as evidenced by two specific incidents. In the first incident, Resident 16's expired medication, Flonase nasal spray, was found on the resident's bedside table. The medication had an open date of 1/14 and an expiration date of 2/14. During an initial tour, a CNA acknowledged the presence of the expired medication but admitted to not informing the licensed nurses. An RN later confirmed that the medication should not have been left on the bedside table and should have been stored in the medication cart and disposed of after expiration. In the second incident, Resident 1's vitamin D liquid bottle was found with an unknown substance accumulated on the outside. The bottle was stored inside Medication Cart A. An LVN verified the findings and acknowledged that the build-up of the unknown substance on the bottle posed a potential infection control concern. Both incidents highlight the facility's failure to adhere to its own policies and procedures regarding medication storage and labeling, potentially impacting resident well-being.
Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure the sanitary requirements were met in the kitchen, leading to multiple deficiencies. Observations revealed that the cutting boards were heavily marred, discolored, and had deep grooves, making them difficult to clean and sanitize. Additionally, several kitchen utensils, including rubber spatulas, butter brushes, ladles, and strainers, were found to be cracked, chipped, discolored, and worn out, posing a safety hazard and potential for cross-contamination. The utensils were also observed to be dirty, with food particles and residue, indicating improper cleaning practices. The kitchen hood over the stove was found to be covered in brownish, yellowish dirt residue, which could potentially drip onto food, causing contamination. The microwave used to warm up residents' food was also observed to be dirty with dry, crusted debris inside and on the door. Furthermore, the plumbing for the ice machine lacked an air gap, creating a risk of backflow and cross-contamination. The test strips used to measure the pH of the chemical sanitizing solution for washing raw fruits and vegetables were expired, and the pH value of the solution was found to be above the acceptable range, compromising the effectiveness of the sanitization process. These deficiencies were identified during an initial kitchen tour and verified by the Dietary Services Supervisor (DSS). The DSS acknowledged the findings and stated that the issues should have been addressed to prevent potential foodborne illnesses in the medically vulnerable resident population. The Director of Food Services also confirmed the findings and emphasized the importance of maintaining proper pH levels for the chemical sanitizing solution to ensure the safe consumption of fruits and vegetables.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices were implemented, leading to several deficiencies. Firstly, the facility did not record all residents with infections on the Infection Surveillance Tool. Only residents with positive culture results were listed, while those with symptoms or on antibiotics without positive cultures were excluded. This was confirmed through interviews with the Administrator, DON, and Director of Infection Control, who acknowledged that the surveillance forms did not include all residents with identified infections, contrary to the facility's policy and procedures (P&P). This oversight was verified during a record review and interviews conducted on multiple occasions with the facility's staff. Additionally, the facility failed to maintain cleanliness in the laundry room. During an observation, the laundry soap bucket was found directly on the floor, covered in dirt and dust, with a rust-colored sludge film on the lid. The Director of Plant Operations (DPO) confirmed the findings and acknowledged the need for cleaning and proper storage of the soap bucket. This failure to maintain a sanitary environment in the laundry room was observed and verified during a tour of the facility. Lastly, the facility did not remove isolation signage after the neutropenic precaution order for a resident was discontinued. An RN was observed entering the resident's room without the required gown and gloves, despite a contact isolation sign on the door. The RN confirmed that the resident was no longer on contact isolation, and the DON later verified that the isolation signage should have been removed. This discrepancy was confirmed through a review of the resident's medical records and interviews with the facility's staff.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship Program as required by their policies and procedures. Specifically, the facility did not conduct assessments using the McGeer's criteria for three residents who were prescribed antibiotics. These residents were prescribed various antibiotics, but there was no documented evidence that the necessary assessments were conducted to determine if the antibiotics were truly needed. This failure was confirmed by the Director of Infection Control during an interview and medical record review. Additionally, the facility did not notify physicians when the McGeer's criteria were not met for three other residents who were prescribed antibiotics. The McGeer's Criteria for Surveillance Checklists for these residents showed that the criteria for true infection were not met, yet the residents were still prescribed antibiotics. The Infection Control Coordinator confirmed that the physicians were not notified about the residents' symptoms not meeting the criteria, which could have led to the discontinuation of unnecessary antibiotics. The report highlights that the facility's failure to adhere to their Antibiotic Stewardship Program and McGeer's criteria potentially led to the inappropriate use of antibiotics. This oversight could have significant implications for the residents' health, including increased risk of adverse drug events and antibiotic resistance. The facility's policies clearly state that all antimicrobial use should be monitored, and the necessary assessments and notifications were not carried out as required.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure the COVID-19 vaccination was administered to Resident 9 after receiving consent from the resident's responsible party. Medical record review showed that the consent form was signed on 1/6/23, but the vaccination was never administered. The Infection Control Coordinator confirmed that the charge nurse who obtained the signature placed the consent form in the medical records basket instead of giving it to the charge nurse responsible for notifying the physician. As a result, the physician was not informed, and the vaccination was not given to Resident 9.
Failure to Maintain POLST in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that Resident 22's Physician Orders for Life-Sustaining Treatment (POLST) was obtained and maintained in the medical record. The facility's policy, revised in August 2023, mandates that all departments honor the POLST to communicate an individual's wishes about life-sustaining and resuscitative measures. Resident 22 was admitted to the facility and had a physician's order dated October 19, 2022, for a Full Code and to obtain a POLST. However, a review of Resident 22's medical record on February 26, 2024, revealed that the POLST was not present. Interviews with RN 1 and RN 2 confirmed the absence of the POLST in the medical record, with RN 2 acknowledging that the POLST should have been included to know the resident's code status and wishes in case of an emergency. Without the POLST, the resident was considered full code by default.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of Resident 25's discharge to another skilled nursing facility (SNF). This deficiency was identified during a closed medical record review initiated on 2/29/24, which revealed that Resident 25 was discharged on 12/19/23 without documented evidence of notification to the Ombudsman. Interviews with the facility's assigned Ombudsman and RN 3 confirmed that no discharge notifications had been provided to the Ombudsman office for this year or the previous year. The Ombudsman verified that she had not received any discharge notifications for Resident 25 or any other residents during this period.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive care plans for four residents, leading to deficiencies in individualized care. For Residents 3 and 16, the care plans did not include the use of padded side rails for safety and injury protection, despite physician orders and the residents' history of seizure disorders. This omission was confirmed during interviews and record reviews with the facility's registered nurses, who acknowledged that the care plans should have included these safety measures. Similarly, the care plans for Residents 8 and 24 were not revised to reflect the use of seat belt and chest strap restraints in their wheelchairs, even though these restraints were observed in use. The registered nurses responsible for updating the care plans verified that the interventions for the use of these restraints were missing from the residents' plans of care. These failures indicate a lack of adherence to the facility's policy and procedures for developing and updating comprehensive care plans based on individual resident needs.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the medical record for one of twelve sampled residents (Resident 19) was complete and accurate. This deficiency was identified through an interview, medical record review, and facility policy and procedure (P&P) review. Specifically, the medical record for Resident 19, who was admitted to the facility on an unspecified date, contained physician's orders for a Posey Bed Enclosure and bilateral No-No Posey Sleeves that were signed and dated but lacked the required time documentation. These orders were dated 1/30/24 and 2/5/24. During an interview on 2/28/24, the RN Charge Nurse and Director of Nursing (DON) confirmed that physician's orders should be signed, dated, and timed, indicating a failure to adhere to the facility's P&P titled Physician Order - End of Month Recaps, revised 9/23, which aims to ensure the accuracy of renewal orders for medications and treatments.
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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 Tustin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehab Center Of Tustin | 1.2 mi | — | 2 | 0 |
| The Hills Post Acute | 2.3 mi | — | 0 | 0 |
| French Park Care Center | 2.4 mi | — | 10 | 0 |
| South Coast Post Acute | 3.1 mi | — | 2 | 0 |
| Plaza Healthcare Center | 3.2 mi | — | 4 | 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.