Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Palms Healthcare during CMS and state inspections, most recent first.
A resident readmitted with a UTI and an indwelling urinary catheter had no intake and output (I&O) monitoring or documentation, despite physician orders specifying catheter size and balloon volume and MDS findings of moderately impaired cognition and need for assistance with ADLs. During interviews, an RN stated I&O was not obtained because there was no physician order, and the DON reported that I&O is monitored only when a problem is identified. The facility was unable to provide an I&O policy, and this deficient practice resulted in an inability to determine whether the resident was appropriately hydrated and allowed the potential for fluid overload or infection to go unrecognized.
A resident with type 2 DM and moderately impaired cognition had a blood glucose level incorrectly documented by an RN as 551 g/dl instead of the actual 350 g/dl. The RN later acknowledged forgetting to record the correct value and did not correct the entry after the resident was transferred to a GACH. The DON confirmed awareness of the discrepancy and that the clinical record was not updated, contrary to facility policy requiring objective, complete, and accurate documentation to support interdisciplinary communication.
A resident did not receive physician-ordered Refresh Liquigel Ophthalmic Gel 1% for dry eyes at bedtime due to the medication not being available in the medication cart or house supply, and no documentation of pharmacy delivery or follow-up by nursing staff. The pharmacy had not processed the order, as over-the-counter medications require specific requests from the facility, and staff did not ensure the medication was obtained as per facility policy.
The facility did not follow physician orders for pain medication dosing for a resident, continued to administer a discontinued higher dose, and failed to document proper handling of unused medication. Additionally, a controlled substance for another resident was stored in an unlocked refrigerator and not removed or destroyed after discontinuation, contrary to facility policy. Staff interviews revealed confusion and lack of adherence to procedures for controlled substances.
A resident with an open thigh wound requiring daily dressing changes did not have Enhanced Barrier Precautions (EBP) implemented, as the Treatment Nurse did not wear a gown and there was no EBP signage outside the room. Staff interviews revealed a lack of understanding and oversight regarding EBP requirements for residents with wounds, despite facility policy mandating such precautions.
The facility failed to maintain accurate advance directives for two residents, leading to incomplete and invalid documentation. One resident's form was outdated and not discussed with the responsible party, while another's form lacked clear consent details. The facility's policy requires that advance directives be prominently displayed in medical records, but this was not adhered to.
The facility failed to accurately document the use of bedrails in the MDS assessments for two residents, leading to potential inaccuracies in care. Both residents had side rails in use, which were not reflected in their MDS documentation. The MDS Coordinator stated the rails were used for aiding and turning, not as restraints, and thus did not affect the MDS coding, contrary to facility policy and MDS guidance.
The nursing staff failed to update fall risk care plans for two residents, placing them at risk for recurrent falls. One resident, with an amputation and coordination issues, fell on a specific date, but their care plan was not revised. Another resident, with dementia and Alzheimer's, was identified as a high fall risk but had a fall without subsequent care plan updates. The DON confirmed the care plans were not updated, contrary to facility policy.
The facility failed to timely implement dietary recommendations and adequately monitor weight loss in two residents. One resident, with dementia and dysphagia, did not receive an appetite stimulant promptly, and their intake of nutritional supplements was not properly documented. Another resident, with muscle wasting and malnutrition, did not receive recommended nutritional supplements due to a lack of clear documentation and rationale for discontinuation. The facility's policies for weight assessment and intervention were not followed, placing residents at risk for further weight loss.
The facility failed to ensure kitchen staff were trained and competent, leading to two issues: improper knowledge of chlorine sanitizer concentration by DW and DA2, and Cook1 not following recipes, resulting in chunky pureed spaghetti and insufficient meat sauce. DW and DA2 were absent from training, causing confusion about sanitizer ranges, while Cook1 rushed food preparation and did not report shortages.
The facility failed to follow the standardized recipes and portion sizes for a pureed diet, affecting 16 residents. The pureed spaghetti served was lumpy and required chewing, contrary to dietary requirements. Additionally, residents received incorrect portion sizes of meat sauce and did not receive pureed garlic bread as per the menu. These deficiencies were confirmed by staff interviews and observations.
The facility failed to maintain safe food storage and preparation practices, including the absence of soap at a handwashing sink, improperly labeled and stored food items, and inadequate storage of resident-brought food. These deficiencies could lead to contamination and foodborne illnesses.
The facility failed to implement its antibiotic stewardship program, leading to the administration of antibiotics without meeting McGeer Criteria for four residents. Antibiotics were prescribed for conditions such as Bullous Pemphigoid, UTIs, and bronchitis without proper justification, as the necessary subcriteria were not documented.
A resident with glaucoma and diabetes did not receive timely follow-up with an optometrist or referral to an ophthalmologist, despite recommendations and worsening vision. The facility's staff acknowledged the oversight, and the resident's care plan lacked specific actions for ensuring necessary eye care consultations.
A facility failed to accurately account for a dose of morphine sulfate ER for a resident. An LVN administered the medication but did not sign the Narcotic and Hypnotic Record, leading to a discrepancy between the record and the medication card. The facility's policy requires reconciliation of controlled substances upon administration, including recording the time, quantity remaining, and nurse's signature.
A facility failed to ensure a physician responded to a consultant pharmacist's recommendation for a gradual dose reduction of Depakene for a resident with bipolar disorder. The resident's clinical record lacked documentation of the physician's response, and the resident remained on the same dose since August 2022. The Director of Nursing acknowledged the oversight, noting that the facility's policy for contacting prescribers and documenting responses was not followed, increasing the risk of adverse effects.
A resident with multiple sclerosis was prescribed hydroxyzine for itching but had not used it for months, as her symptoms were managed with Benadryl. Despite a physician's order to discontinue hydroxyzine due to non-use, the facility failed to do so, citing the resident's preference to keep it. The DON confirmed the oversight, noting the risk of side effects from concurrent use of both medications.
A facility failed to perform a gradual dose reduction (GDR) or document a clinical rationale for a resident on Depakene for bipolar disorder. Despite a consultant pharmacist's recommendation, the physician did not respond or adjust the medication dosage, leaving the resident on the same dose since August 2022. The Director of Nursing acknowledged the oversight, which was contrary to the facility's policy on medication tapering and GDR.
A facility failed to assess a resident's mental capacity before having them sign an arbitration agreement. The resident, with cognitive impairments and a history of cerebral infarction, did not recall signing the document, and their family confirmed the resident's inability to sign due to a stroke. The Admissions Assistant acknowledged that a staff member signed on behalf of the resident, contrary to the facility's policy requiring explanation to the resident or their legal representative.
Failure to Monitor Intake and Output for Catheterized Resident
Penalty
Summary
The facility failed to monitor, document, and record intake and output (I&O) for a resident who was readmitted with an indwelling urinary catheter and a diagnosis of urinary tract infection. The resident’s admission face sheet showed an initial admission and subsequent readmission with a UTI diagnosis, and the MDS dated 6/27/2025 documented moderately impaired cognition and a need for partial/moderate assistance with toilet hygiene, bathing, and dressing. The physician’s orders specified a 16 French indwelling urinary catheter with a 10 cc balloon. Despite this, review of the clinical record revealed no I&O documentation for this resident. During an interview and concurrent record review, RN 1 confirmed that the resident was admitted with an indwelling catheter and acknowledged that I&O was not taken because there were no physician orders to do so. In a separate interview, the DON stated that residents’ I&Os are monitored only if a problem is identified. Additionally, when surveyors requested the facility’s policy and procedure on I&O, the facility was unable to provide one. This deficient practice resulted in the inability to determine if the resident was hydrated appropriately and had the potential for fluid overload and/or infection to go unrecognized.
Inaccurate Documentation of Blood Glucose Result
Penalty
Summary
The facility failed to ensure accurate documentation of a resident’s blood glucose result in the medical record. Resident 1, who had type 2 DM and moderately impaired cognition, required partial to moderate assistance with several ADLs. A progress note dated 3/17/2026 documented the resident’s blood glucose level as 551 g/dl, far above the stated normal range of 80–100 g/dl. During a subsequent interview, RN 1 acknowledged that this documented value was incorrect and that the resident’s actual blood glucose was 350 g/dl. RN 1 stated she forgot to document the correct blood glucose number and did not correct the entry after the resident was transferred to a GACH, despite recognizing that it was important to document the correct information for accuracy and safety. The DON confirmed being informed by RN 1 that the correct blood glucose level was 350 g/dl, not 551 g/dl, and that RN 1 should have corrected the clinical record. The facility’s charting and documentation policy required that all services and changes in a resident’s condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Provide Ordered Ophthalmic Medication
Penalty
Summary
The facility failed to provide a resident with Refresh Liquigel Ophthalmic Gel 1% as ordered by the physician for dry eyes at bedtime. The resident, who was admitted with diagnoses including paraplegia and required substantial to maximal assistance with activities of daily living, reported not receiving the prescribed eye drops at night. Upon review, it was found that the medication was not present in the medication cart or the facility's house supply closet. Nursing staff confirmed the absence of the medication and indicated there was no record of pharmacy delivery receipts for the eye drops. Further investigation revealed that the pharmacy had not processed the order for the Refresh eye drops until the day of the survey, as the pharmacy does not automatically provide over-the-counter medications unless specifically requested by the facility. There was no documentation that the facility had contacted the pharmacy regarding the missing medication. According to facility policy, nursing staff are responsible for ensuring residents have a sufficient supply of prescribed medications and for communicating with the pharmacy if medications are unavailable. This lapse resulted in the resident not receiving the prescribed treatment for dry eyes.
Failure to Follow Physician Orders and Secure Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not following physician orders and facility policies regarding controlled substances. For one resident with low back pain and difficulty walking, the physician had discontinued Hydrocodone-Acetaminophen 10-325mg and ordered a lower dose of 5-325mg. However, staff continued to dispense and administer the 10-325mg tablets, with no documentation of tablet splitting or proper disposal of unused portions. The resident confirmed receiving the full 10-325mg tablet, and staff interviews revealed uncertainty about the administration process and a lack of adherence to the new order. In another instance, a bottle of Lorazepam Intensol, a controlled substance prescribed for anxiety, was found stored in an unlocked refrigerator in the medication room, contrary to facility policy requiring controlled substances to be kept in a locked container separate from non-controlled medications. Staff interviews indicated a misunderstanding of the storage requirements, with some believing the locked refrigerator was sufficient, while others acknowledged the need for an additional lock on the narcotic container. Additionally, the same bottle of Lorazepam Intensol for the second resident remained in the refrigerator six months after the medication had been discontinued by the physician. Staff failed to remove and properly dispose of the discontinued narcotic, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that discontinued controlled substances should be promptly removed and destroyed to prevent accidental administration.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open left thigh wound requiring daily dressing changes. The Treatment Nurse (TN) did not wear a gown while preparing to perform the dressing change and was unaware that EBP was required for the resident, believing that the absence of an indwelling device meant EBP was unnecessary. There was also no EBP signage posted outside the resident's room to alert staff of the need for these precautions. The resident had a history of a left femur fracture, multiple pelvic fractures, and muscle weakness, and was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care for a ruptured blood blister on the left medial thigh extending to the knee, including cleansing, application of Santyl ointment, and covering with gauze. Observations confirmed that the TN did not don a gown before starting the dressing change, and the lack of signage meant other staff were not alerted to the need for EBP. Interviews with the TN, Infection Preventionist (IP) Nurse, and Director of Nursing (DON) revealed a lack of understanding and oversight regarding the implementation of EBP for residents with open wounds. The facility's policy required EBP for residents with wounds, but both the IP and DON were unaware that the resident's wound was still open and being treated, resulting in the failure to implement appropriate precautions and signage.
Failure to Maintain Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that the medical records of two residents, Resident 18 and Resident 83, were up to date concerning advance directives, as per the facility's policy and procedure. Resident 18, who was moderately impaired in cognitive skills and required maximal assistance with self-care, had an advance directive acknowledgment form filled out in 2022. However, the Social Service Director (SSD) was unaware of who completed the form and acknowledged that it was not valid. The SSD stated that the form should have been discussed with Resident 18's responsible party (RP), who would need to fill out the form. Resident 83, who was severely impaired in cognitive skills and dependent on staff for self-care, had an advance directive acknowledgment form dated 9/11/2024. The form indicated that neither the resident nor the RP had executed an advance directive and did not wish to do so at the time. However, the SSD could not confirm which family member provided verbal consent, nor whether the consent was given over the phone or in person, rendering the form incomplete and invalid. The facility's policy, revised in December 2016, requires that residents be provided with information about their right to formulate an advance directive. If a resident is incapacitated, this information should be given to their legal representative. The policy also mandates that the existence of an advance directive be prominently displayed in the medical record. The Director of Nursing (DON) emphasized the importance of having an advance directive to ensure the facility is aware of the resident's or family's wishes regarding end-of-life care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to provide accurate information in the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in care and services. Resident 81 was admitted with multiple diagnoses, including atrial fibrillation, congestive heart failure, and dementia. The MDS for Resident 81 indicated moderate cognitive impairment and maximal assistance needed for self-care and functional abilities, with no use of bedrails. However, an observation revealed that the upper side rails were in use, contrary to the MDS documentation. The MDS Coordinator confirmed the use of side rails for aiding and turning in bed, stating it did not meet the criteria of a restraint, and thus did not affect the MDS coding. Similarly, Resident 83's MDS indicated severe cognitive impairment and dependency on self-care and functional abilities, with no use of bedrails. An observation showed the upper side rails were up, contradicting the MDS. The MDS Coordinator again confirmed the use of side rails for aiding and turning, stating it did not meet the criteria of a restraint. The facility's policy required a change in status assessment when a restraint is used, which was not reflected in the MDS. The MDS 3.0 Section P guidance specifies that if bedrails meet the definition of a physical restraint, their use must be coded as such, which was not done in these cases.
Failure to Update Fall Risk Care Plans
Penalty
Summary
The nursing staff failed to update and revise the fall risk care plans for two residents, which had the potential to place them at risk for recurrent falls. Resident 106 was admitted with an amputation above the knee, lack of coordination, and difficulty walking. Despite a fall on 9/21/2024, the care plan was not updated to reflect this incident. The resident's initial fall risk assessment indicated they were not at risk, but the care plan was not revised after the fall, as confirmed by the Director of Staff Development. Resident 170, diagnosed with dementia, Alzheimer's disease, and hypertension, was identified as a high fall risk with a score of 13 on the fall risk assessment. After a fall on 1/8/2024, the care plan was not updated to reflect this incident. The Director of Nursing verified that the care plans for both residents were not updated following their falls, which is crucial for monitoring the effectiveness of interventions. The facility's policy requires care plans to be updated with any significant changes, but this was not adhered to in these cases.
Failure to Implement Dietary Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to implement the recommendations of the Registered Dietitian (RD) in a timely manner and did not adequately assess, monitor, and evaluate interventions to prevent further weight loss in two residents. Resident 42, who had a history of dementia, dysphagia, and pressure-induced deep tissue damage, experienced significant weight loss. The RD recommended an appetite stimulant, Megestrol Acetate, on August 6, 2024, but the order was not placed until August 29, 2024. Additionally, the facility did not consistently monitor Resident 42's weekly weights or document the intake of nutritional supplements, such as Boost Plus, which were often not consumed in full due to the resident feeling too full during meals. Resident 79, diagnosed with muscle wasting, congestive heart failure, and malnutrition, also experienced significant weight loss. The RD recommended Boost Glucose Control to be administered twice daily on August 13, 2024, but the order was not effectively implemented. The supplement was initially ordered on August 15, 2024, but was discontinued the same day without clear documentation or rationale. The resident continued to lose weight, and the facility did not conduct weekly weight assessments to monitor the effectiveness of interventions, as recommended by the RD. The facility's policies and procedures for weight assessment and intervention, as well as nutritional assessment, were not adequately followed. The multidisciplinary team failed to prevent, monitor, and intervene for undesirable weight loss, as evidenced by the lack of timely implementation of dietary recommendations and insufficient documentation of residents' nutritional intake and weight changes. This oversight placed both residents at risk for continued weight loss and associated health complications.
Deficiencies in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in their duties, leading to two significant issues. Firstly, during an observation in the dishwashing area, it was found that the Dishwasher (DW) and Dietary Aide (DA2) were not knowledgeable about the correct concentration strength of the chlorine sanitizer used in the dish machine. DW incorrectly tested the sanitizer concentration with dirty gloves and misread the acceptable range, while DA2 was also unsure of the correct range. The Dietary Supervisor (DS) confirmed that both DW and DA2 were absent during the in-service training on sanitizers, leading to their confusion between chlorine and quaternary sanitizers. The facility's policy indicated that the acceptable range for chlorine sanitizer should be 50-100 PPM, but DW and DA2 were not aware of this due to their absence from training. Secondly, Cook1 did not follow standardized recipes when preparing a pureed diet, resulting in a chunky texture that was not smooth, and failed to prepare enough zesty meat sauce to meet the residents' needs. Cook1 admitted to rushing and not adding enough liquid to the spaghetti mixture, and also miscalculated the amount of meat needed, leading to a shortage. Cook1 did not notify the Dietary Supervisor when the meat sauce ran out, which could have allowed for alternative arrangements. The facility's recipe for spaghetti with zesty meat sauce required the use of milk for liquid, which was not followed. The cook's job description emphasized the importance of planning food quantities and reporting any issues, which was not adhered to in this instance.
Failure to Follow Pureed Diet Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on a specific date, affecting 16 residents on a pureed diet. The pureed spaghetti served was observed to be dry, lumpy, and contained large pieces of pasta that required chewing, contrary to the requirements of a pureed diet which should be smooth and not require chewing. During an interview and taste test, both the Dietary Supervisor (DS) and the Registered Dietitian (RD) confirmed the inappropriate texture of the pureed spaghetti. Cook1 admitted to not blending the spaghetti long enough and not adding sufficient broth, attributing the error to rushing, which resulted in a texture that could pose a choking risk to residents. Additionally, the facility did not follow the lunch menu and portion sizes as prescribed for residents on a pureed diet. The residents received 1/2 cup of pureed meat sauce instead of the required 2/3 cup, and they did not receive the pureed garlic bread as listed on the menu. Cook1 acknowledged using the wrong scoop size and forgetting to prepare the pureed garlic bread, which could lead to inadequate nutritional intake for the residents. The facility's policy and menu planning guidelines were not followed, as confirmed by a review of the facility's menu and portion guide.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Firstly, there was no soap available at the handwashing sink in the kitchen, which was noted when a cook attempted to wash their hands. The cook and the dietary supervisor acknowledged the absence of soap, which is crucial for infection control and preventing foodborne illnesses. The facility's policy emphasizes the importance of having soap readily available for handwashing. Additionally, the facility did not properly label and store food items. Observations revealed a plastic bag of thawed raw sliced beef and logs of ground beef without thaw dates, as well as an open container of cottage cheese and a container of juice without open dates. A house shake was stored in a milk gallon, which posed a risk of contamination. The dietary supervisor admitted to not knowing when the beef was thawed and acknowledged the importance of labeling food with thaw and use-by dates to ensure safety. Furthermore, food brought in by residents from outside the facility was improperly stored. In the resident refrigerator, leftover food and TV dinners were found without use-by dates, and the TV dinners were not stored frozen as per manufacturer instructions. The dietary supervisor confirmed that the food was not labeled according to policy and should be discarded. The facility's policy requires perishable foods to be labeled with the resident's name, item, and use-by date, and stored in a refrigerator with tightly fitting lids.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy for four out of five sampled residents, leading to the administration of antibiotics without meeting the McGeer Criteria. Resident 39 was admitted with conditions including Parkinsonism, Bullous Pemphigoid, and Type II Diabetes Mellitus. Despite being prescribed Doxycycline for Bullous Pemphigoid, the McGeer's Criteria documentation did not meet the necessary subcriteria for antibiotic use. Additionally, Resident 39 was given Amikacin Sulfate for a urinary tract infection without meeting the required subcriteria. Resident 96, who was readmitted with a urinary tract infection and ESBL resistance, was prescribed Cephalexin. However, the McGeer's Criteria form lacked the necessary subcriteria to justify the antibiotic's use. Similarly, Resident 37, admitted with hemiplegia and other conditions, was prescribed Bactrim for folliculitis, but the McGeer's Criteria documentation only met two of the required four subcriteria. Resident 42, readmitted with pneumonia and a urinary tract infection, was given Ceftriaxone for bronchitis. The McGeer's Criteria form did not indicate any subcriteria to justify the antibiotic's administration. The Infection Preventionist Nurse acknowledged the lack of documentation and follow-up to determine the effectiveness of the antibiotics, which is crucial to ensure residents are not on unnecessary antibiotics.
Failure to Ensure Timely Eye Care Follow-Up
Penalty
Summary
The facility failed to ensure timely follow-up with an optometrist and referral to an ophthalmologist for a resident diagnosed with glaucoma and other eye conditions. The resident, who was admitted with a history of end-stage renal disease, diabetes, left eye blindness, and glaucoma, was seen by an optometrist in March, who recommended a follow-up visit in six months. However, the facility did not arrange this follow-up appointment, nor did they refer the resident to an ophthalmologist, despite the resident's concerns about worsening vision in the right eye. The resident's medical records indicated a need for regular eye care due to his conditions, including glaucoma and diabetes, which can lead to complications such as diabetic retinopathy. Despite this, the facility's interdisciplinary team meetings and care plan did not address the necessary follow-up with eye care specialists. The resident's care plan included interventions for medication administration and monitoring for eye problems, but it lacked specific actions for ensuring timely optometry and ophthalmology consultations. Interviews with facility staff, including the Social Service Director, Registered Nurse Supervisor, and Director of Nursing, revealed an acknowledgment of the oversight in arranging the necessary follow-up care. The facility's policies and procedures required the coordination of ancillary services, including eye care, but these were not effectively implemented for the resident, leading to a deficiency in maintaining the resident's vision care needs.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of a controlled medication, specifically morphine sulfate ER, for Resident 10. During an observation and interview with a Licensed Vocational Nurse (LVN 1) at the West Station Cart 1, a discrepancy was noted between the Narcotic and Hypnotic Record and the medication card. The record indicated two doses were left, but the medication card contained only one dose. LVN 1 admitted to administering the missing dose earlier in the morning but failed to sign the Narcotic and Hypnotic Record at that time. The facility's policy on controlled substances, revised in April 2019, requires that controlled substances be reconciled upon administration. The nurse administering the medication is responsible for recording the time of administration, the quantity of medication remaining, and their signature. LVN 1 acknowledged that failing to sign the log could result in the resident receiving a controlled substance more often than prescribed, potentially leading to medical complications.
Failure to Address Pharmacist's Recommendation for Medication Review
Penalty
Summary
The facility failed to ensure that a physician responded to a consultant pharmacist's recommendation for a gradual dose reduction (GDR) of Depakene solution for a resident diagnosed with bipolar disorder. The consultant pharmacist had recommended on 8/3/24 that the physician consider reducing the dose or provide a clinical rationale for not doing so. However, there was no documentation in the resident's clinical record indicating that the physician responded to this recommendation. The resident had been on the same dose of Depakene since August 2022, and the facility did not document any contraindications for a dosage reduction. During an interview, the Director of Nursing (DON) acknowledged that the facility failed to ensure the physician responded to the pharmacist's request. The DON stated that the GDR request involved two medications, but only one was addressed, and there was no specific response regarding Depakene. The facility's policy required a licensed nurse to contact prescribers and document their responses, with follow-up if no response was received within 10 business days. However, this procedure was not followed, increasing the risk of adverse effects for the resident.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to discontinue the medication hydroxyzine for a resident, despite a physician's order to do so due to non-use. The resident, who was admitted with multiple sclerosis and had the capacity to make decisions, was prescribed hydroxyzine for itching but had not used it between August and October 2024. Instead, the resident's itching was effectively managed with Benadryl, another medication for itching and allergies. A consultant pharmacist recommended discontinuing hydroxyzine, and the physician agreed, provided it was not being used. However, the facility documented that the resident declined to have it discontinued, stating she still used it. The Director of Nursing acknowledged that the facility failed to follow the physician's order to discontinue hydroxyzine, as the Medication Administration Report showed no doses had been administered since August 2024. The facility's policy requires that medication regimens include only necessary medications, and the physician should identify when medications should be tapered or discontinued. The failure to discontinue hydroxyzine, despite its non-use and the effective management of symptoms with Benadryl, was a deficiency in adhering to the facility's medication therapy policy.
Failure to Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) or document a clinical rationale for not doing so for a resident prescribed Depakene solution for bipolar disorder. The resident, who was admitted with a diagnosis of bipolar disorder, had been on the same dose of Depakene since August 2022. A consultant pharmacist recommended a dose reduction or a documented rationale for not reducing the dose, but there was no response from the physician to this request, nor was there any documentation indicating a change in the medication dosage. During an interview, the Director of Nursing (DON) acknowledged the facility's failure to ensure the physician responded to the pharmacist's request for a GDR. The DON confirmed that the GDR request involved two medications, but only one was addressed, leaving the Depakene dose unchanged. The facility's policy on tapering medication and GDR, which requires periodic review of medication necessity and appropriate tapering, was not followed in this case, increasing the risk of adverse effects for the resident.
Failure to Assess Resident's Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to assess the mental capacity of a resident before having them sign a legally binding arbitration agreement. The resident, who was admitted with diagnoses including cerebral infarction, bipolar disorder, anxiety disorder, and dementia, was found to have moderately impaired cognitive skills according to their Minimum Data Set (MDS). Despite this, the resident's admission record showed that they had signed the arbitration agreement, which was meant to resolve disputes within the facility rather than in court. Interviews and record reviews revealed that the resident did not recall being informed about the arbitration agreement and did not recognize their signature on the document. The resident's family also confirmed that the resident was unable to sign for themselves due to a stroke. The Admissions Assistant admitted uncertainty about the resident's capacity to sign and stated that a facility staff member had signed the document, indicating it was the resident's signature. The facility's arbitration agreement required that it be explained to the resident or their legal representative in a manner they could understand, 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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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marlora Post Acute Rehab Hosp | 0.1 mi | — | 29 | 1 |
| Coral Cove Post Acute | 0.5 mi | — | 6 | 0 |
| Ocean Ridge Post Acute | 0.5 mi | — | 23 | 0 |
| Shoreline Healthcare Center | 0.6 mi | — | 3 | 0 |
| Bel Vista Healthcare Center | 0.6 mi | — | 3 | 0 |
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