Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 La Palma Nursing Center during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity had a POLST and physician order indicating Do Not Attempt Resuscitation (DNR). Facility policy required honoring such directives and using them to guide Basic Life Support and CPR decisions. When the resident became unresponsive and pulseless, a CNA initiated CPR and called for help. An RN and an LVN responded, confirmed the absence of a pulse, and continued CPR without first verifying the resident’s code status in the chart, despite later acknowledging that a DNR order was in place and that CPR should not have been initiated.
A resident in an LTC facility sustained multiple rib fractures after a fall, but the facility failed to investigate or document the incident properly. The facility did not request a physician's fracture progress report or conduct a root cause analysis as per policy. Additionally, after another fall, the facility did not perform required neurological evaluations or document the physician's recommendations, despite the resident being on blood thinners.
The facility failed to develop comprehensive care plans for the use of grab bars for several residents, as identified through observations and medical record reviews. This deficiency affected residents who relied on grab bars for mobility and repositioning, with care plans lacking necessary interventions and assessments. The absence of individualized care plans was acknowledged by the DON and staff.
The facility failed to ensure the safety of residents using bed rails, as assessments for 13 residents lacked documentation of the effectiveness of less restrictive measures before using grab bars. Observations and staff interviews confirmed incomplete assessments, putting residents at risk of entrapment and serious injuries.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as unsanitary cutting boards, wet and dirty utensils, and improperly maintained equipment like blenders and ice machines. These deficiencies were observed during a survey, with the Dietary Director and Maintenance Supervisor acknowledging the potential for cross-contamination and foodborne illnesses.
The facility failed to ensure complete entrapment assessments for residents using grab bars, with missing documentation for several zones. Observations showed residents using grab bars for mobility and transfers, but assessments often lacked documentation for Zones 5 to 7. The Maintenance Supervisor did not document or communicate results to nurses, leading to incomplete assessments, acknowledged by the DON and staff.
A resident with limited English proficiency, who spoke Gujarati, was not provided with effective communication tools in the facility. Staff communicated in English, which the resident did not understand, and relied on guessing or family translation. The facility's translation device was not used, and there was no communication board at the bedside, highlighting a deficiency in promoting dignity and respect.
A facility failed to obtain a physician's signature on the informed consent for a resident's psychotropic medication, trazadone, as required by their policy. The resident, who had the capacity to understand and make decisions, was prescribed trazadone for insomnia. Interviews with an LVN and the DON confirmed the absence of the necessary physician's signature, which is required to ensure the resident is informed about their care and treatment.
A resident was found with medications at her bedside without a proper assessment or physician's order for self-administration, contrary to facility policy. Despite being cognitively intact, her records lacked documentation of an assessment by the Interdisciplinary Team to determine if self-administration was clinically appropriate. Interviews with staff confirmed the oversight, and the resident indicated she had informed the facility about medication discrepancies.
A resident was found with their call light on the floor, out of reach, during a facility tour. The resident, who had intact cognition, was unable to communicate with staff due to this oversight. A CNA confirmed the call light should have been accessible, as per facility policy. The DON was informed and acknowledged the issue.
A facility failed to include a resident's advance directive in her medical record, despite its existence being noted on her POLST form. Staff interviews confirmed the absence of the document, which is crucial for guiding the resident's care and identifying the responsible party.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan, who was diagnosed with anxiety disorder and schizoaffective disorder. The oversight was confirmed by the DON and MDS Coordinator, who admitted to not having a system to alert them to review the determination results, leading to incorrect MDS coding and potential inadequate care.
The facility failed to provide adequate respiratory care for several residents, including incorrect oxygen administration for a resident, undated oxygen tubing for another, and improper storage of nebulizer tubing. Additionally, a resident's oxygen saturation levels were not documented, hindering assessment of their ability to tolerate room air. These deficiencies were confirmed by facility staff.
The facility failed to accurately post Daily Hours Per Patient Day (DHPPD) nurse staffing forms as per AFL 18-27 guidelines. Missing information included the facility's license number, total licensed bed capacity, and the DON's signature. The DON confirmed that the DHPPD was not signed daily, leading to potential inaccuracies in public staffing information.
The facility failed to document the administration of a controlled medication for a resident and did not follow proper procedures for the disposal of non-controlled medications. An LVN admitted to administering clonazepam without proper documentation, and the disposal of non-controlled medications was not signed off by two nurses as required.
The facility failed to ensure accurate monitoring and documentation for three residents using psychotropic medications. One resident's behavior manifestation for divalproex use was not specified, and orthostatic blood pressure readings were inaccurately recorded. Another resident's meal intake related to mirtazapine use showed discrepancies between MAR and CNA documentation. A third resident's orthostatic hypotension was not properly monitored, with identical blood pressure readings for different positions.
A medication error rate of 7.14% was identified in the facility, exceeding the acceptable threshold of 5%. An LVN failed to follow physician's orders by not checking a resident's heart rate before administering antihypertensive medications, metoprolol and diltiazem, which required specific parameters for safe administration. The DON acknowledged the error and confirmed the expectation for compliance with physician's orders.
A resident was administered metoprolol and diltiazem without checking their heart rate, contrary to physician's orders. The LVN admitted to forgetting this step, which was required to ensure the resident's safety due to the risk of an abnormally slow heart rate. The deficiency was acknowledged by the DON.
A facility failed to ensure proper storage, labeling, and disposal of medications, with medications for discharged or deceased residents not removed from supply, expired medications not discarded, and opened inhalation solutions not labeled. Bubble packs were found torn, and medications were left unattended, risking unauthorized access. These deficiencies were confirmed by staff during inspections.
The facility failed to implement its infection prevention and control program, with deficiencies in water management and laundry services. The Legionella Risk Assessment was not completed for the current year, and the facility lacked a water flow chart. In the laundry area, personal items were found on the clean linen folding table, violating infection control practices. The Administrator and MDS Coordinator acknowledged these issues.
The facility failed to maintain essential equipment safely, as a new glucometer was used without required calibration, and a medication refrigerator had significant ice buildup. An LVN confirmed the glucometer was used without quality checks, and an RN verified the refrigerator's condition, both posing potential risks to residents.
A facility failed to document a resident's name on a Grab Bar Use and Entrapment Risk Evaluation, posing a risk for inaccurate care. Interviews with LVN and DON confirmed the oversight, highlighting the importance of including resident names in documentation to ensure proper care.
Failure to Honor DNR Order and POLST During Cardio-Pulmonary Arrest
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented wishes to withhold life-sustaining treatment, including CPR, as specified in a POLST and physician order for Do Not Attempt Resuscitation (DNR). The facility’s policy on Basic Life Support and Cardiopulmonary Resuscitation, revised 10/2017, states that resident wishes expressed in an advance directive or POLST, including DNR orders, are to be honored and that a DNR order indicates the resident should not be resuscitated if respirations and/or cardiac function cease. The resident in question was admitted without capacity to make medical decisions and had a POLST form signed by the legally recognized decision maker indicating DNR, as well as a physician’s order for DNR documented on the Order Summary Report. Despite these orders, when the resident became unresponsive and pulseless, staff initiated and continued CPR. A CNA reported that while accompanying the resident in his room, the resident became unresponsive within approximately five minutes; the CNA checked for a pulse, found none, and immediately began CPR while calling for help. An RN responded to the emergency, assessed the resident, confirmed absence of a pulse, and provided CPR, later acknowledging awareness that the resident had a DNR order and stating she should have verified the code status by checking the Physician Order Summary Report and POLST form. An LVN also participated in providing CPR without verifying the resident’s code status and stated that CPR should not be initiated when a DNR order is in place. The Administrator and DON were informed of and acknowledged these findings.
Failure to Investigate and Document Resident's Fractures and Falls
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to prevent accident hazards, specifically in the case of a resident who sustained a subacute closed fracture of multiple ribs. The facility did not thoroughly investigate or document the resident's rib fractures, nor did they request the physician to complete a fracture progress report. Additionally, the facility did not conduct a root cause analysis by the interdisciplinary team (IDT) as per the facility's policy and procedures (P&P) when the fractures were identified after a fall incident. The facility's P&P required immediate notification and assessment by a licensed nurse following a fall, with an incident report and investigation to be reviewed by the Director of Nurses and the IDT. However, the facility did not follow these procedures for the resident's fall on 10/16/24, which resulted in multiple rib fractures. The resident's medical record did not show documentation of the fractures prior to the fall, and there was no evidence of an investigation into the cause of the fractures or a request for a physician's fracture progress report. Furthermore, after another fall incident on 10/25/24, the facility failed to conduct and document neurological evaluations and the physician's recommendations. The resident, who was on a blood thinner medication, was found lying on the floor with a bump to the head, but the facility did not complete the required change in condition evaluation or follow up with the physician. The Director of Nursing confirmed that the staff did not notify her or complete the necessary evaluations and documentation after the fall.
Failure to Develop Comprehensive Care Plans for Grab Bar Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for the use of grab bars for 13 out of 16 sampled residents. This deficiency was identified through observations, interviews, and medical record reviews, which revealed that the care plans did not reflect the individual care needs of the residents. The absence of these care plans meant that the residents were not provided with appropriate, consistent, and individualized care regarding the use of grab bars. For instance, Resident 32 was observed using bilateral grab bars for bed mobility, turning, and repositioning, as per a physician's order. However, the care plan did not include interventions for the use of grab bars, such as assessing for entrapment risks or considering less restrictive alternatives. Similarly, Resident 35's care plan lacked documentation for the use of grab bars, despite a physician's order and the resident's reliance on them for mobility and repositioning. The deficiency was further highlighted by the lack of care plans for other residents, such as Resident 40, who had no capacity to make decisions, and Resident 45, who used grab bars for transfers. The Director of Nursing (DON) and other staff members acknowledged the absence of individualized care plans for these residents, confirming the facility's failure to ensure comprehensive care planning for the use of grab bars.
Deficiency in Bed Rail Safety Assessments
Penalty
Summary
The facility failed to ensure the safety of residents using bed rails, as evidenced by the lack of complete and accurate assessments for 13 out of 16 residents reviewed. The facility's policy required an assessment of a resident's risk for entrapment before the installation of side rails or bed rails, but this was not consistently followed. The assessments did not document whether the least restrictive measures were effective or ineffective before resorting to the use of grab bars. This oversight put residents at risk of entrapment and serious injuries. Several residents, including those with cognitive impairments and those who could make decisions, were observed with elevated grab bars without proper documentation of the effectiveness of less restrictive measures. For instance, Resident 32, who was alert and responsive, had grab bars installed without evidence of prior assessment of alternative measures. Similarly, Resident 40, who lacked decision-making capacity, had grab bars installed without the completion of the least restrictive measures section in the assessment. Interviews with facility staff, including CNAs, LVNs, and the DON, confirmed the lack of documentation and assessment of the effectiveness of less restrictive measures. The DON acknowledged that proper assessments were not completed, and least restrictive approaches were not tried before the use of grab bars. The MDS Coordinator also verified that sections of the assessments were left incomplete, and the least restrictive measures were not reevaluated during quarterly reviews.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a survey. The cutting boards were found to be in poor condition, with deep grooves, discoloration, and fuzziness, making them difficult to clean and sanitize. This was acknowledged by the Dietary Director, who stated that new cutting boards had been ordered. Additionally, scoops used for food portioning were stored wet with visible water and dry, crusted food residue, which was verified by the Dietary Director. Further observations revealed that various kitchen utensils were not in good repair or cleanable condition. Stainless spatulas, a can opener, a peeler, a lemon squeezer, and a rolling pin were found to be chipped, deformed, dirty, and stained. The Dietary Assistant Director confirmed these findings and stated that these items should not be used to prevent food contamination. Additional utensils, such as a stainless slotted scooper, rubber spatulas, and a stainless strainer, were also found to be in poor condition, with melted handles and brownish stains. The facility also failed to ensure that equipment such as blenders, measuring containers, and drinking cups were air-dried before storage, as they were found wet with visible water. The kitchen hood was observed with a black, greasy residue, and the microwave used for reheating residents' food had dry, crusted food residue. The ice machine, used by residents and staff, was found with a light yellowish/pinkish stain, indicating a lack of proper cleaning and maintenance. These findings were verified by the Dietary Director and Maintenance Supervisor, who acknowledged the potential for cross-contamination and foodborne illnesses.
Incomplete Entrapment Assessments for Residents Using Grab Bars
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using grab bars, which could potentially lead to entrapment, serious injury, or death. The assessments were incomplete for 13 out of 16 sampled residents, with missing documentation for several entrapment zones. The facility's policy required assessments to be conducted prior to the installation of siderails or bedrails, but the assessments were not fully completed, leaving several zones unchecked. Observations and interviews revealed that residents were using grab bars for assistance with bed mobility, turning, repositioning, and transfers. However, the Grab Bar Use and Entrapment Risk Evaluations often lacked documentation for Zones 5 to 7, and in some cases, Zones 1 to 4 were also incomplete. The Maintenance Supervisor, who was responsible for measuring the entrapment zones, did not document or communicate the results to the licensed nurses, leading to incomplete assessments. The Director of Nursing (DON) and other staff members acknowledged the deficiencies in the entrapment assessments. The Maintenance Supervisor admitted to only recently starting to document the measurements and assessments, and there was a lack of communication between the maintenance and nursing staff regarding the entrapment zone measurements. This lack of documentation and communication contributed to the incomplete assessments, potentially putting residents at risk.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide effective communication for a resident with limited English proficiency, specifically Resident 28, who spoke and understood only the Gujarati language. Despite having a care plan in place that included the use of translation tools and communication aids, these were not effectively utilized. Observations revealed that staff members, including CNAs, communicated with Resident 28 in English, which the resident did not understand. The staff often guessed the resident's needs based on routine rather than using available translation resources. There was no communication board at the resident's bedside, and the translation device available in the facility was not used or demonstrated to support the Gujarati language. Interviews with staff, including the DON and DSD, confirmed the lack of training on the translation device and the absence of a communication board for Resident 28. The DON acknowledged that the staff typically relied on the resident's family for translation, indicating a gap in the facility's ability to independently meet the communication needs of residents with language barriers. The Administrator and MDS Coordinator were informed of these findings, acknowledging the deficiency in providing necessary care that promotes dignity and respect for Resident 28.
Failure to Obtain Physician-Signed Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the informed consent for psychotropic medication was signed by the physician for one of the residents, identified as Resident 366. The facility's policy and procedure require that the attending physician, PA, or NP obtain informed consent from the resident or their responsible party before prescribing or increasing an order for psychotherapeutic medication. This policy also mandates that the facility verify informed consent has been obtained prior to administering such medication. However, a review of Resident 366's medical records revealed that the informed consent for the use of trazadone, prescribed for insomnia, lacked the physician's signature. Interviews conducted with LVN 4 and the DON confirmed the absence of the physician's signature on the informed consent form for Resident 366's trazadone medication. LVN 4 acknowledged that the physician's signature was necessary to indicate that the medication had been reviewed with the resident and approved. The DON also confirmed that the informed consent needed to be signed by the physician to allow the facility to administer the medication as ordered. This oversight posed a risk of the resident not being fully informed about their care and treatment regarding the use of psychotropic medication.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if it was safe for Resident 316 to self-administer medications, as required by their policy. During an initial tour, Resident 316 was observed with several medications at her bedside, including Synthroid, Equate Gas Relief, Tylenol, and Neuriva Brain Health Plus. Despite being cognitively intact and having the capacity to understand and make decisions, there was no physician's order or care plan addressing her self-administration of medications. The facility's policy requires an assessment by the Interdisciplinary Team to determine if self-administration is clinically appropriate, but this was not documented in Resident 316's records. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed the presence of medications at Resident 316's bedside and the lack of a reassessment for her ability to self-administer medications. The resident herself stated that she informed the facility about the discrepancy in medication supply strength and that the licensed nurses were aware of her self-administration. However, her self-administration assessment indicated she preferred the licensed nurse to administer her medications. The Administrator and MDS Coordinator acknowledged these findings, highlighting a lapse in following the facility's policy for medication self-administration assessments.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of a nonsampled resident, identified as Resident 60. During an initial tour of the facility, Resident 60 was observed lying in bed with the call light on the floor, out of reach. This observation was confirmed by CNA 4, who acknowledged that the call light should have been within the resident's reach. Resident 60's medical records indicated that their cognition was intact, suggesting they were capable of using the call light if it had been accessible. The facility's policy and procedure for call lights, dated January 2017, required staff to ensure call lights were within easy reach of residents when they were in bed or seated. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Include Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive was included in her medical record, which could potentially lead to her healthcare decisions not being honored. The facility's policy and procedure on advance directives, revised in April 2017, requires that residents or their responsible parties provide a copy of the advance directive for inclusion in the clinical record. However, during a medical record review initiated on August 27, 2024, it was found that Resident 43, who was admitted earlier in the year, did not have a copy of her advance directive in her medical record. Interviews with facility staff confirmed the absence of the advance directive in the resident's medical record. The Health Information Director and LVN 9 both verified that although the resident's POLST form indicated the existence of an advance directive, no copy was found in the record. The Social Services Director also acknowledged the absence of the document, emphasizing its importance in guiding the resident's care and identifying the appointed responsible party. This oversight in documentation could potentially impact the resident's medical care and treatment decisions.
Failure to Implement PASARR Recommendations for Resident Care
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination into the care plan for a resident diagnosed with anxiety disorder and schizoaffective disorder. The PASARR Level II Evaluation, conducted by the Department of Health Care Services, recommended special services for the resident due to their medical and mental health conditions. However, a review of the resident's medical records and care plan revealed that these recommendations were not followed up or documented, indicating a lack of coordination in the resident's care planning process. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the oversight. The MDS Coordinator admitted to not having a system in place to alert her to review the Level II determination results, leading to an incorrect coding in the resident's annual MDS. The DON acknowledged the absence of documentation and the potential risk of the resident not receiving adequate care and services as recommended by the PASARR Level II determination.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, leading to deficiencies in oxygen administration and equipment management. Resident 55 was observed receiving three liters per minute of oxygen via nasal cannula, contrary to the physician's order of one to two liters per minute. This adjustment was made by the night shift nurse without documentation of the resident's difficulty breathing or physician notification. LVN 3 confirmed these findings, indicating a lack of adherence to the prescribed oxygen therapy. Resident 15's oxygen tubing was not dated, and the humidifier was dated 8/11/24, despite the facility's policy of changing and dating the tubing and humidifier every Sunday. LVN 3 was unable to confirm when the oxygen tubing was last changed, highlighting a lapse in the facility's protocol for equipment maintenance. Additionally, Resident 34's nebulizer tubing was found touching the floor, and the oxygen tubing was not stored in a plastic bag when not in use, as verified by LVN 5 and the MDS Coordinator. Resident 59's medical records lacked documentation of oxygen saturation levels on room air, which was necessary to assess the resident's ability to tolerate room air without supplemental oxygen. The MAR showed check marks instead of actual oxygen saturation levels for several shifts, and both LVN 5 and the DON acknowledged this oversight. This deficiency in documentation prevented the facility from determining the resident's potential for weaning off oxygen, as required by the care plan.
Inaccurate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Hours Per Patient Day (DHPPD) nurse staffing forms were accurately posted in accordance with the All Facility Letter (AFL) 18-27 guidelines. The review of the facility's documents titled Daily Staff from specific dates showed missing information such as the facility's license number, total licensed bed capacity, names of the administrator and the Director of Nursing (DON) or designee, designated census periods, actual nursing hours worked, actual DHPPD hours, and the DON or designee's signature to verify the accuracy of the information. The Payroll Director confirmed that the DON did not sign the DHPPD form daily but only twice a month, which was not in compliance with the AFL 18-27 requirements. Interviews with the Director of Staff Development (DSD), Payroll Director, and the DON confirmed the findings. The DSD acknowledged that the Daily Staff document was incomplete and only posted projected nursing hours without including actual nursing hours. The DON admitted that the facility's Daily Staff document did not accurately reflect the information as per AFL 18-27 guidelines and acknowledged that the DHPPD should be signed daily to ensure accurate staffing coordination based on the census. The failure to post accurate staffing information had the potential to result in inaccurate information being provided to the public.
Deficiencies in Medication Administration and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the administration and documentation of controlled medications for a resident. During an inspection, it was found that a bubble pack of clonazepam, a controlled medication for anxiety, was not properly documented in the controlled drug record and Medication Administration Record (MAR) after administration. A Licensed Vocational Nurse (LVN) admitted to administering the medication but failed to document the removal and administration of the clonazepam on the required records. This oversight was confirmed by the Director of Nursing (DON) during a review. Additionally, the facility did not adhere to its policy for the disposal of non-controlled medications. The policy requires two licensed nurses to sign off on the disposal of such medications. However, a review of the Medication Disposition Record/Pass Log revealed that non-controlled medications were disposed of with only one nurse's signature. This discrepancy was verified by a Registered Nurse (RN) during an interview and document review.
Inaccurate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as evidenced by the lack of specific behavior manifestations and inaccurate monitoring of vital signs and meal intake. For one resident, the facility did not identify a specific behavior manifestation related to the use of divalproex, an antipsychotic medication. Additionally, the resident's orthostatic blood pressure was not accurately monitored, with identical readings recorded for both sitting and lying positions, contrary to physician orders. Furthermore, discrepancies were found between the meal intake documented by licensed nurses in the MAR and the documentation by CNAs in the POC Legend Report. Another resident's meal intake monitoring related to the use of mirtazapine, an antidepressant, also showed inconsistencies between the MAR and the POC Legend Report. The facility's failure to accurately document meal intake and behavior episodes related to poor appetite was evident, as the psychotherapeutic drug summary sheet did not match the actual meal intake records. Interviews with staff revealed conflicting accounts of the resident's meal consumption, further highlighting the lack of coordination in monitoring. For a third resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician. The blood pressure readings for both sitting and lying positions were identical, indicating a failure to properly assess the resident's condition. Interviews with the DON and LVN confirmed that the staff did not follow the correct procedure for monitoring orthostatic hypotension, as the blood pressure readings should have differed between positions.
Medication Administration Error Due to Non-compliance with Physician's Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.14%. This deficiency was identified during a medication administration observation involving a licensed vocational nurse (LVN 5) and Resident 16. LVN 5 did not adhere to the physician's orders for administering antihypertensive medications, specifically metoprolol and diltiazem. The orders required checking both the systolic blood pressure (SBP) and heart rate before administration, with instructions to hold the medication if the SBP was less than 110 mmHg or the heart rate was less than 60 beats per minute. However, LVN 5 only checked the resident's blood pressure and failed to measure the heart rate before administering the medications. Resident 16 had specific physician's orders for the administration of diltiazem and metoprolol due to hypertension, with parameters set to ensure safe administration. Despite these orders, LVN 5 proceeded to administer the medications without verifying the heart rate, which was a critical step in the process. The Director of Nursing (DON) acknowledged the findings and confirmed that the medications should be administered as per the physician's orders, emphasizing the expectation for licensed nurses to follow the specified parameters.
Failure to Monitor Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antihypertensive medications. During a medication administration observation, it was noted that a Licensed Vocational Nurse (LVN) did not check the resident's heart rate before administering metoprolol and diltiazem. According to the physician's orders, these medications should be withheld if the systolic blood pressure (SBP) is less than 110 mmHg or the heart rate is less than 60 beats per minute, and both the blood pressure and heart rate should be checked prior to administration. The resident involved had specific physician's orders requiring the monitoring of vital signs before medication administration due to the potential risk of an abnormally slow heart rate. The LVN admitted to forgetting to check the resident's heart rate before administering the medications. This oversight was acknowledged by the Director of Nursing (DON) after being informed of the findings. The failure to adhere to the physician's orders and facility policy and procedures (P&P) regarding medication administration led to this deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, which was observed during an inspection of Medication Room A and Medication Cart A. Medications for residents who were discharged, transferred, or deceased were not removed from the current medication supply. Specifically, medications for Residents 22, 53, and 63 were found in the medication room despite their discharge or death. Additionally, expired medications were not removed from Medication Cart B, and opened inhalation solution medications for Residents 5, 15, and 40 were not labeled with an opened date. The facility also failed to maintain the integrity of medication packaging. Bubble packs containing medication tablets for Residents 2, 16, 37, and 45 were found with tears, compromising the tamper-evident packaging. Furthermore, orally administered medications were not stored separately from externally used medications, and medications were left unattended, posing a risk of unauthorized access. Resident 55's inhalation solution medication and Resident 37's insulin pen were left unattended on top of the medication cart and bedside table, respectively. These deficiencies were verified by the nursing staff during the inspection and interviews. The facility's policies and procedures for medication storage were not adhered to, as evidenced by the presence of outdated and improperly stored medications. The lack of proper medication management had the potential to negatively impact the residents' well-being and the effectiveness of the medications.
Infection Control Deficiencies in Water Management and Laundry Services
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by deficiencies in its water management and laundry services. The facility did not complete the Legionella Risk Assessment for the current year, which is crucial for identifying potential Legionella outbreaks. Additionally, the facility lacked a water flow chart to document how water circulates through the building and identify areas where water may stagnate. This oversight was confirmed during an interview with the Administrator, who acknowledged that the assessment and documentation were incomplete. In the laundry services area, the facility did not adhere to infection control practices. During an inspection, personal items belonging to the laundry staff, such as a water bottle, opened soda can, radio, purses, cookies, and a Styrofoam container, were found on the clean linen folding table. The Maintenance Supervisor confirmed that these items should not have been on the table, as it is designated as a clean area. The Administrator and MDS Coordinator were informed of these findings and acknowledged the breach in infection control practices.
Deficiencies in Equipment Maintenance and Calibration
Penalty
Summary
The facility failed to ensure that essential equipment was maintained in safe operating condition, specifically regarding the use of a new glucometer and the maintenance of a medication refrigerator. An inspection revealed that a new Assure Platinum glucometer, with serial number 1040-4324393, was used for residents' blood glucose monitoring without performing the required calibration or quality control checks. LVN 3 confirmed that the glucometer was brand new and acknowledged that no documentation was available to show that these checks were performed, despite the facility's protocol requiring such checks before using a new meter or test strips. Additionally, an inspection of the refrigerator used for medications in Medication Room A showed a significant ice buildup in the freezer compartment. This condition was verified by RN 1 and acknowledged by the DON. The ice buildup had the potential to affect the refrigerator's functionality and the potency of the medications stored inside, posing a risk to the residents who rely on these medications.
Failure to Document Resident's Name on Facility Document
Penalty
Summary
The facility failed to document the resident's name on a critical facility document for one of the sampled residents, identified as Resident 366. This oversight was discovered during a review of the Grab Bar Use and Entrapment Risk Evaluation dated 8/10/24, which lacked the resident's name. The absence of the resident's name on this document posed a risk for Resident 366 not receiving accurate and necessary care. The facility's policy and procedure (P&P) titled Facility Assessment emphasized the importance of personalized care and accurate resident assessments, yet this standard was not met in this instance. Interviews conducted with facility staff, including LVN 4 and the Director of Nursing (DON), confirmed the deficiency. LVN 4 acknowledged that the Grab Bar Use and Entrapment Risk Evaluation document was incomplete without the resident's name, which is essential for ensuring proper care and treatment. The DON also confirmed that facility documentation should include the resident's name and the date of completion, acknowledging the findings of the surveyors. This lapse in documentation accuracy was identified through a combination of interviews, medical record reviews, and facility policy reviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Leisure Court Nursing Center | 0 mi | — | 3 | 0 |
| Sun Mar Nursing Center | 1.6 mi | — | 1 | 0 |
| Harbor Villa Care Center | 1.7 mi | — | 24 | 0 |
| Parkview Healthcare Center | 1.8 mi | — | 0 | 0 |
| St. Catherine Healthcare | 1.8 mi | — | 22 | 0 |
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