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 Lotus Care Center during CMS and state inspections, most recent first.
The facility failed to store food items properly, as observed in the kitchen dry storage room. A container of peanut butter and a bottle of liquid smoke were found with sticky residues, which could attract pests and lead to foodborne illnesses. The Dietary Supervisor acknowledged the issue, and the facility's policy requires maintaining clean food storage areas.
The facility failed to maintain an infection-free environment in the laundry room, where food items were found near clean linens and PPE. Staff admitted to storing food in the laundry room, posing an infection control risk. The DON confirmed the potential for cross-contamination and emphasized proper storage practices. Facility policy indicated that laundry should be handled according to best practices for infection prevention.
A resident with schizophrenia was inaccurately assessed in the MDS, as the diagnosis was not recorded despite being active and the resident receiving Risperidone. Interviews with the MDS Nurse and DON confirmed the error, highlighting a failure to adhere to the facility's policy on comprehensive assessments.
A facility failed to develop a care plan for a resident to address smoking, despite the resident's diagnoses of heart failure, bipolar disorder, and schizophrenia. The resident's cognition was intact, but they lacked the capacity to consent. The absence of a smoking care plan was acknowledged by the RN and DON as a safety risk, and it was noted that the facility's policy requires such a plan to be developed within 48 hours of admission.
A resident on Eliquis, a blood-thinning medication, was observed with bruising on both hands, but the facility failed to complete a change of condition form or notify the doctor. Despite the resident's risk for bruising due to anticoagulation therapy, there was no documentation of monitoring or communication with the physician, contrary to the facility's policy. This oversight could delay necessary care.
The facility did not complete an annual skills checklist for a CNA, as required by policy, which is essential for ensuring competency in resident care. The DSD and DON confirmed the importance of the checklist in maintaining care standards. The facility's policy mandates competency evaluations upon hire and annually.
A facility failed to conduct a monthly Medication Regimen Review (MRR) for a resident with heart failure, bipolar disorder, and schizophrenia, as required by their policies. The Director of Nursing could not provide evidence of the MRR for August 2024, and staff interviews highlighted the risk of adverse drug reactions without the review. The facility's policy mandates MRRs upon admission and monthly.
The facility failed to ensure that three bottles of Enulose on a medication cart were free of sticky residue, posing a risk of cross-contamination. An LVN confirmed the risk of transferring medication to residents, especially if they were allergic, and stated that the facility's policy required the bottles to be wiped off. The DON also confirmed the risk and stated that no contaminated drugs should be available for use.
The facility failed to keep all dumpsters closed, as observed when one out of two dumpsters had its lid off. Interviews with the MS and DON confirmed that dumpsters should be closed to prevent attracting pests and odors. The facility's policy requires all garbage containers to be covered.
A facility failed to maintain proper clinical records for a resident with mental health diagnoses, as several progress notes lacked the name or title of the documenting staff, only showing illegible initials. Interviews with staff confirmed that documentation should include the date, time, signature, name, and title, as per the facility's policy. This deficiency could hinder follow-up or clarification of care provided.
The facility failed to provide the required minimum living space of 80 square feet per resident in multiple occupancy rooms. Observations revealed that several rooms, including Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17, did not meet these requirements. The DON acknowledged that limited space could restrict residents' movement and potentially impact care quality. A waiver request was submitted, but the facility was not in compliance with space requirements.
The facility's phone system failed to receive outside calls, affecting communication with a resident's family. A family member reported that calls were directed to voicemail without response. The surveyor confirmed this by making multiple calls, all unanswered. The DON was unaware of the voicemail setup and acknowledged the potential frustration for residents and families.
A resident with a Stage 4 pressure ulcer was not provided with a low air loss (LAL) mattress as ordered by the physician, despite being at high risk for pressure ulcers. The resident was observed on a regular mattress, and a Licensed Vocational Nurse confirmed the absence of the LAL mattress, acknowledging its importance in preventing further skin breakdown. The facility's policy required adherence to physician orders, which was not followed in this instance.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure proper storage of food items in the kitchen dry storage room, which could lead to the growth of microorganisms causing foodborne illnesses. During an observation, a container of peanut butter was found with a sticky residue and jelly-like substance on its exterior, and a bottle of liquid smoke also had a sticky residue on its outside. The Dietary Supervisor acknowledged the presence of the sticky residue and emphasized the importance of maintaining clean food containers to prevent attracting pests and roaches. A review of the facility's policy and procedure on Food Receiving and Storage, dated December 2008, indicated that food services should maintain clean food storage areas at all times.
Infection Control Breach in Laundry Room
Penalty
Summary
The facility failed to maintain an infection-free environment in the laundry room, as observed during a survey. A bag of dried food items was found on a chair next to a table where clean linens were folded, and clean residents' clothing was stored below. Additionally, a small orange and a jar of sugar packets were discovered in a drawer containing personal protective equipment (PPE). During interviews, the Laundry Aide (LA) admitted that staff stored their food in the laundry room but did not consume it there, instead eating in the break room. The Certified Nurse Assistant (CNA) acknowledged that having food around clean linen and PPE posed an infection control risk and could lead to unpleasant odors. The Director of Nursing (DON) confirmed that storing food items in the laundry area among clean linen and PPE presented a potential infection risk due to cross-contamination. The DON emphasized that PPE should be kept in a clean area and ready for use, and all food items should be stored in the breakroom. A review of the facility's policy and procedure on laundry and bedding, dated October 2018, indicated that soiled laundry and bedding should be handled, transported, and processed according to best practices for infection prevention and control.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to provide accurate information in the Minimum Data Set (MDS) for one of the sampled residents, leading to a potential risk of inappropriate care and services. The resident in question was admitted with diagnoses including schizophrenia, anxiety, and depression, and was receiving Risperidone for schizophrenia. However, during a review of the resident's MDS, it was found that the diagnosis of schizophrenia was not checked off under Psychiatric/Mood Disorder, despite being an active diagnosis. Interviews with the MDS Nurse and the Director of Nursing revealed that the MDS is intended to provide a comprehensive assessment of the resident, including their diagnosis, treatment, and medication. The MDS Nurse acknowledged that the omission of the schizophrenia diagnosis in the MDS was an error. The facility's policy and procedure on comprehensive assessments emphasize the importance of accurate data collection and analysis to ensure appropriate care planning, which was not adhered to in this instance.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 15, to address smoking, which is a deficiency in meeting the resident's needs. Resident 15 was admitted with diagnoses including heart failure, bipolar disorder, and schizophrenia. Despite having intact cognition as per the Minimum Data Set, the resident was noted to lack the capacity to consent. During a review, it was found that no care plan was developed for smoking, which was acknowledged by the Registered Nurse (RN) as a necessary component to ensure safety and appropriate monitoring. The Director of Nursing (DON) confirmed that care plans are essential for identifying potential problems and creating interventions to ensure resident safety and quality of life. A Smoking Safety Evaluation was conducted, indicating it would be used to create a smoking care plan, but this had not been implemented. The facility's policy requires a baseline care plan within 48 hours of admission and specifies that smoking-related concerns should be noted on the care plan, which was not adhered to in this case.
Failure to Report Change of Condition for Resident on Anticoagulant
Penalty
Summary
The facility failed to complete a change of condition and notify the doctor regarding bruising observed on a resident who was receiving Eliquis, a blood-thinning medication. During an observation and interview, the resident was found with dark purplish discoloration on both hands, with the left hand being worse. The resident was unable to recall the cause of the bruising and mentioned that the nurses were aware of it. However, there was no documentation of a change of condition form being completed or the doctor being notified, as confirmed by RN 1. The resident was at risk for bruising due to the anticoagulant medication, and the facility's policy required monitoring for such conditions. The resident's medical history included schizophrenia, bipolar disorder, and chronic ischemic heart disease. The facility's policy and procedure required that any significant change in a resident's condition be reported to the attending physician, especially for those on anticoagulation therapy. Despite the presence of a baseline care plan indicating no initial skin problems, the facility did not adhere to its protocol for monitoring and reporting changes, as evidenced by the lack of documentation and communication with the physician. This oversight had the potential to delay necessary care and services for the resident.
Failure to Complete Annual Skills Checklist for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had an annual skills checklist completed, which is a requirement for maintaining competency in providing care. During an interview and record review with the Director of Staff Development (DSD), it was revealed that CNA 2, hired on December 21, 2022, did not have a completed annual skills checklist as of December 2023. The DSD acknowledged the importance of the checklist in ensuring the CNA's competency and understanding of her job, as well as in ensuring that care is provided accurately. The Director of Nursing (DON) also confirmed that the skills checklist should be completed upon hire and annually to identify areas needing improvement. The facility's policy and procedure, dated May 2019, indicated that competency evaluations are to be conducted upon hire and annually.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for Resident 27, as required by their policies and procedures. Resident 27, who was admitted to the facility with diagnoses including heart failure, bipolar disorder, and schizophrenia, did not receive an MRR for the month of August 2024. This oversight was identified during a review of the facility's MRR binder, where the Director of Nursing (DON) was unable to provide evidence of the completed review. The DON acknowledged the necessity of the MRR to verify medication appropriateness and prevent potential adverse reactions. Interviews with facility staff, including the DON and a Registered Nurse (RN), highlighted the importance of the MRR in ensuring medication safety. The RN emphasized that without the MRR, the resident's safety could be compromised, potentially leading to adverse drug reactions. The facility's policy, dated May 2019, mandates that MRRs be conducted upon admission and at least monthly, underscoring the deficiency in adhering to established protocols for medication management.
Sticky Residue on Medication Bottles Poses Contamination Risk
Penalty
Summary
The facility failed to ensure that three bottles of Enulose, a medication used for a brain disorder caused by liver disease, were free of sticky residue on Medication Cart 1. This was observed during a survey on 10/15/24 at 12:30 p.m. The sticky residue on the bottles posed a risk of cross-contamination, as confirmed by an LVN during a concurrent observation and interview. The LVN acknowledged the risk of transferring the medication to residents, especially if they were allergic, and stated that the facility's policy required the bottles to be wiped off. The Director of Nursing also confirmed that sticky bottles were a risk for cross-contamination and that the facility's policy indicated no contaminated drugs should be available for use.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that all dumpsters were kept closed, which is a violation of their policy and procedure for food-related garbage and refuse disposal. During an observation on October 15, 2024, at 9:15 a.m., it was noted that one out of two dumpsters had its lid off. This observation was corroborated by interviews with the Maintenance Supervisor (MS) and the Director of Nursing (DON) on October 17, 2024. Both the MS and the DON acknowledged that dumpsters should be closed at all times to prevent attracting flies, rodents, and insects, as well as to avoid harboring odors. The facility's policy, dated October 2017, clearly states that all garbage containers must be kept covered.
Deficient Documentation Practices in Resident's Medical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of the sampled residents, identified as Resident 24. The deficiency was identified during a review of Resident 24's medical records, which revealed that several entries in the Licensed Nurses Progress Notes lacked the name or title of the staff member who wrote them, containing only illegible initials. This issue was noted in multiple entries dated 9/10/2024. Resident 24 had been admitted with diagnoses including schizophrenia, bipolar disorder, and depression, and was assessed to have moderately impaired cognition. Interviews with the facility's staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the standard for documentation, whether handwritten or electronic, should include the date, time, signature, name, and title of the documenting staff member. The facility's policy on Charting and Documentation, dated 7/2017, also required these elements. The absence of clear identification in the notes made it difficult to determine who documented the care, which could impede follow-up or clarification if needed.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that each resident had the required minimum living space of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. During an observation, it was noted that several rooms, including Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17, did not meet these requirements. For instance, Room 1, which housed two residents, only provided 62.6 square feet per resident, and Room 11, with four residents, offered just 72.4 square feet per resident. This deficiency was confirmed through interviews and a review of the Client Accommodations Analysis, which detailed the room measurements and capacities. The Director of Nursing acknowledged during an interview that the limited space could restrict residents' movement and potentially impact the quality of care provided by the staff. The facility had submitted a waiver request letter, indicating that certain rooms did not meet the required space per resident but claimed that this would not adversely affect the residents' health, safety, and welfare. However, the observations and measurements indicated that the facility was not in compliance with the space requirements, potentially affecting the residents' ability to move freely and store personal items, as well as the staff's ability to provide adequate care.
Facility Phone System Failure
Penalty
Summary
The facility failed to ensure that its telephone system was functioning properly, preventing outside calls from being received. This issue was identified when a family member of a resident, who had been admitted with a Stage 4 pressure ulcer and muscle weakness, reported that her calls to the facility were consistently directed to voicemail without any return calls. The family member had been attempting to contact the facility daily since the resident's admission, leaving several voicemails without receiving any response. The surveyor confirmed the issue by making multiple calls to the facility's phone number, all of which were directed to voicemail without any return calls from the facility staff. During an interview, the Director of Nursing (DON) stated she was unaware of the voicemail setup and did not have access to it. The DON acknowledged that the inability to answer calls or return them could lead to frustration and worry for residents and their families.
Failure to Provide Ordered LAL Mattress for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide a low air loss (LAL) mattress for a resident with a Stage 4 pressure ulcer, as ordered by the physician. The resident, who was admitted with a diagnosis of a Stage 4 pressure ulcer on the sacral region and muscle weakness, was identified as being at high risk for developing pressure ulcers. The physician's order, dated 9/19/2024, specified the use of a LAL mattress every shift, which was also reflected in the resident's care plan. However, during an observation on 9/25/2024, the resident was found lying on a regular mattress, contrary to the physician's order. The resident confirmed that they were supposed to receive an air loss mattress seven days prior due to their pressure ulcer but had not received it. An interview with a Licensed Vocational Nurse (LVN) revealed that the LAL mattress was not provided as per the physician's order, and the LVN acknowledged the importance of the LAL mattress in preventing the worsening of the current pressure ulcer and future skin breakdown. The facility's policy and procedure on physician orders indicated that care and services should be provided in accordance with the physician's order, which was not adhered to in this case.
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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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| Inglewood Health Care Center | 1.7 mi | — | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.