Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Park Regency Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were not provided with timely, individualized care plans after assessments identified wandering and elopement risks. In both cases, care plans addressing these risks were not initiated until days after the behaviors or risks were documented, as confirmed by RN and DON review.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility after staff failed to complete an elopement risk assessment and did not respond promptly to a door alarm. Staff interviews confirmed lapses in supervision and failure to follow protocols, resulting in the resident being found outside the facility by police.
A resident with a Stage 3 pressure injury did not receive a low air loss (LAL) mattress as required by the facility's care plan and protocol. Staff confirmed the absence of a LAL mattress and lack of a physician's order for one, despite the care plan specifying this intervention for wound management. This deficiency was identified through observation, staff interviews, and medical record review.
The facility failed to provide necessary care for three residents, with care plans not addressing floor mat use and incomplete post-fall neurological assessments. Floor mats were observed but not documented in care plans, and neurological flowsheets lacked required assessments, as confirmed by the DON.
The facility failed to assess and supervise two residents' ability to handle hot liquids, leading to an incident where a resident spilled hot chocolate on herself, causing injury. Despite the facility's policy requiring such assessments, they were not conducted, and the resident was left unsupervised while consuming the hot beverage. This posed a risk of injury to residents consuming hot liquids.
The facility failed to maintain sanitary conditions in the kitchen, with observations of chipped and discolored utensils, unclean equipment with food residue, and improper drying of blenders. The kitchen hood also had dirt residue, posing contamination and fire risks. The DSS confirmed these issues, acknowledging the potential hazards.
The facility failed to conduct complete entrapment assessments for residents using side rails, impacting 15 residents. Observations and interviews revealed that the Bed System Measurement Device Test Results Worksheets lacked documentation for critical zones, posing potential risks. Despite physician orders for side rails, the facility's maintenance staff did not assess all necessary zones, which was confirmed by the Maintenance Director and acknowledged by the administration.
The facility failed to ensure call lights and bed controls were accessible for several residents, including one with a non-functional call light. Observations revealed call lights on the floor or out of reach, and a bed control on the floor. These residents had cognitive impairments or required substantial assistance, highlighting the importance of accessibility.
The facility failed to maintain a clean and homelike environment for several residents. A resident was observed entering a shower room with a soiled towel and unpackaged adult briefs, raising infection control concerns. Another resident's room had scratches, unpainted areas, and stained curtains, leading to dissatisfaction. Additional residents' rooms had similar maintenance issues, indicating a risk for unsanitary conditions and potential impact on residents' quality of life.
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. One resident, diagnosed with psychosis and major depressive disorder, was inaccurately screened as having no mental illness, despite being prescribed Seroquel. Another resident with a depressive disorder was also incorrectly screened, missing a potential Level II evaluation. The MDS Coordinator and DON acknowledged these discrepancies.
A resident with severe cognitive impairment and high fall risk was found without the required floor mattresses on both sides of their bed, as ordered by the physician and outlined in the care plan. This deficiency was observed during a facility tour and confirmed by both an LVN and the DON, highlighting a failure to follow the facility's Fall Prevention Program policy.
The facility failed to maintain proper care and documentation for PICC lines for two residents. Upon admission, required measurements and documentation were not completed, and care plans did not address the PICC lines. Dressings were not changed weekly as per policy, and there was no physician's order for one resident's PICC line care. These failures were confirmed by staff interviews and medical record reviews.
A resident with a history of central cord syndrome and other conditions was not administered the correct dosage of oxycodone for severe pain levels, as per physician's orders. Despite the facility's policy to manage pain according to comprehensive assessments, the resident received a lower dosage than prescribed for pain levels recorded as 8. Interviews with staff confirmed the oversight, highlighting a potential for ineffective pain management.
A facility failed to monitor and document the fluid intake and output for a resident with end-stage renal disease requiring dialysis. Despite a physician's order for a strict fluid restriction, the facility did not record the resident's fluid intake, as confirmed by staff interviews and medical record reviews. This oversight risked the resident's health due to their impaired kidney function.
The facility failed to ensure proper documentation and informed consent for bed rail use, affecting multiple residents. Observations and interviews revealed incomplete consent forms, missing physician orders, and absent care plans, posing potential risks to resident safety.
The facility failed to ensure informed consent and proper monitoring for residents prescribed psychotropic medications. Several residents were given antipsychotic drugs without signed consent forms, and there was inadequate monitoring for side effects and behavior manifestations. The facility's administration acknowledged these deficiencies.
The facility failed to ensure proper storage, labeling, and disposal of medications. Expired medications were found in Medication Room A and Treatment Cart A, while improper storage practices were observed in Medication Carts A and C. Medications were not stored separately according to their routes of administration, and some lacked proper labeling with open dates. These deficiencies were verified by LVNs and acknowledged by the DON.
The facility failed to ensure safe storage and handling of food brought by family or visitors, as it lacked a designated refrigerator for residents. The policy required food to be consumed within two hours, but did not address storage for later consumption, leading to potential food safety risks.
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies in advance directives, treatment documentation, and informed consents. A resident's POLST was incomplete, while two others had conflicting advance directive information. Another resident's TAR lacked documentation of wound care treatments. Additionally, informed consents for side rails and medications were incomplete or missing physician signatures.
The facility failed to provide information on formulating advance directives and maintain documentation for three residents. One resident was not informed about advance directives despite having the cognitive ability to understand, while another's POLST was incomplete, and a third's advance directive was not documented. The DON and SSD confirmed these deficiencies.
The facility failed to ensure accurate documentation and reconciliation of controlled medications for several residents, leading to discrepancies in the Medication Administration Record (MAR) and Controlled Drug Record. Staff interviews confirmed the lapses, and the Director of Nursing acknowledged the issues.
A resident did not receive a dose of either Keppra or metformin due to a leaking medication cup during administration via enteral tube. The LVN could not identify which medication was not given, and the DON confirmed the error but was unable to determine which medication was missed. The resident, who cannot make medical decisions, was prescribed these medications for seizures and diabetes management.
The facility failed to assess and offer the COVID-19 vaccine to two residents as per its policy. One resident's medical record lacked documentation of vaccination status or an offer of the vaccine. Another resident, who was on antibiotics, had consented to vaccination but was not re-offered the vaccine after completing treatment. These deficiencies were confirmed during a review with the IP.
The facility failed to ensure glucometer quality control tests were accurately documented, with discrepancies found between recorded and observed results for two medication carts. LVNs confirmed that night shift nurses were responsible for these tests, and the DON acknowledged the expectation for nightly completion. This failure had the potential to result in inaccurate glucose readings for residents.
A resident's privacy was compromised during ADL care when a CNA left the door open, exposing the resident to passersby. Additionally, an LVN left a computer monitor displaying the resident's medical information unattended at the nurses' station, violating confidentiality policies.
The facility failed to maintain a pest-free environment as cockroaches were observed in the conference room, posing a potential infection risk. The facility's Pest Control Program requires effective eradication of pests, but observations on multiple occasions confirmed the presence of cockroaches. The QA RN, Social Services Director, and Maintenance Director all acknowledged the infestation and its associated risks.
Failure to Timely Develop Care Plans for Wandering and Elopement Risks
Penalty
Summary
The facility failed to develop and implement timely, individualized care plans for two residents with identified behavioral and safety risks. For one resident with severe cognitive impairment, documentation showed the resident exhibited wandering behavior by attempting to enter other female rooms, as noted on an assessment dated 8/13/25. Despite this, there was no evidence that a care plan addressing this behavior was developed prior to the resident's elopement on 8/17/25. Both the RN and DON confirmed that the care plan should have been initiated as soon as the wandering behavior was observed, but it was not started until after the elopement occurred. For a second resident with moderate cognitive impairment, an assessment identified the resident as being at risk for elopement. However, the medical record did not show that a care plan addressing this risk was developed until several days after the risk was identified. The RN and DON both acknowledged that the care plan should have been created immediately upon identification of the elopement risk. These failures were confirmed through interviews and medical record reviews, and were acknowledged by facility leadership.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to provide necessary care and services to prevent accident hazards for a resident with severe cognitive impairment, resulting in an elopement incident. The resident, who had a documented history of wandering and attempting to enter other residents' rooms, was not assessed for elopement risk following a change in condition. Despite facility policy requiring elopement risk assessments and timely staff response to alarms, there was no documented evidence that the required assessment was completed after the resident exhibited wandering behavior. On the day of the incident, the resident was able to leave the facility in a wheelchair without staff noticing, and the door alarm was not responded to promptly by staff members present. Interviews with staff revealed that the CNA did not hear the door alarm due to being busy, and another staff member, who heard the alarm during a lunch break, did not investigate, assuming someone else would respond. The lapse in supervision and failure to follow established protocols allowed the resident to exit the facility unsupervised. The resident was later found by police outside the facility. Facility leadership acknowledged that the elopement risk assessment should have been completed and that staff should have responded immediately to the door alarm.
Failure to Provide LAL Mattress for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure injury for one resident with a Stage 3 pressure injury. Despite the facility's policy and care plan indicating that a low air loss (LAL) mattress should be used for wound management in such cases, the resident was observed using a regular mattress. Multiple staff interviews confirmed that the resident did not have a LAL mattress upon admission and that there was no physician's order for one, even though it was facility protocol for residents with Stage 3 pressure injuries to have this intervention. Medical record review showed the resident was admitted with a Stage 3 pressure injury measuring 3 cm by 2 cm, and the care plan included an intervention for a LAL mattress. However, this intervention was not implemented, as verified by staff and direct observation. The failure to provide the LAL mattress as required by both the care plan and facility policy constituted a deficiency in the provision of necessary care and services for the resident's pressure injury.
Deficiencies in Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure the necessary care and services were provided for three residents, leading to deficiencies in fall prevention and post-fall assessments. For two residents, the care plans did not properly address the use of floor mats, which were observed by their beds but not documented in their care plans. Interviews with the LVN and DON revealed that the floor mats were intended as a nursing intervention for fall risk residents, but the care plans were not updated to reflect this intervention. This oversight occurred despite the residents having experienced unwitnessed falls that required hospital evaluation. Additionally, the facility did not complete post-fall neurological assessments for two residents who had unwitnessed falls. The neurological flowsheets for these residents were missing several assessment items, which were supposed to be documented according to the facility's policy. The DON confirmed that the neurological assessments were incomplete, indicating a failure to adhere to the facility's fall prevention program and documentation requirements.
Failure to Assess and Supervise Residents Handling Hot Liquids
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 1 and 3, were free from accident hazards related to the consumption of hot liquids. The facility's policy required an assessment of residents' ability to handle containers and consume hot liquids, but this was not completed for either resident. Resident 1 experienced an incident where she spilled hot chocolate on herself, resulting in redness and blisters on her left shoulder and upper back. The incident occurred while Resident 1 was lying in bed, not in an upright position, and without adequate supervision. Resident 1 had a history of cognitive loss, forgetfulness, and required partial to moderate assistance with eating due to impairments in both upper extremities. Despite these needs, there was no documented assessment of her ability to handle hot liquids. On the day of the incident, Resident 1 was given hot chocolate by a CNA, who then left to attend to another resident. Resident 1 attempted to drink the hot chocolate but spilled it on herself, causing injury. Interviews with staff confirmed that Resident 1 needed cuing and supervision during meals, and no specific assessment for handling hot liquids was conducted. Similarly, Resident 3's medical records showed no evidence of an assessment for handling hot liquids, as required by the facility's policy. Interviews with the RN confirmed the lack of such assessments for both residents. The facility's failure to conduct these assessments and provide adequate supervision posed a risk of injury to residents consuming hot liquids, as evidenced by the incident involving Resident 1.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a survey. Kitchen utensils were found to be in poor condition, with chipped, discolored, and partially melted surfaces, which did not comply with the USDA Food Code 2022 requirements for utensils to have a smooth, cleanable surface. The Dietary Services Supervisor (DSS) confirmed these findings, acknowledging that such utensils should not be used as they pose a hazard and could contaminate food. Additionally, the facility did not ensure that kitchen utensils were clean and free of food particles or residue. Several stainless steel utensils, including tongs, measuring cups, and serving spoons, were observed with dry and crusted residue. The DSS confirmed that these items should not be used and should be properly cleaned and sanitized to prevent cross-contamination. The facility also failed to adhere to proper drying procedures for kitchen equipment. Heavy-duty blenders used for puree preparation were found to be wet and not air-dried before storage, contrary to the facility's policy and USDA Food Code requirements. Furthermore, the kitchen hood was observed with black dirt residue, indicating inadequate cleaning, which the DSS acknowledged. This lack of maintenance could lead to contamination of food with pathogenic organisms and poses a fire hazard.
Incomplete Entrapment Assessments for Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using side rails, impacting 15 residents. The assessments did not include measurements for Zones 1, 6, and 7, which are critical areas for potential entrapment. This oversight was confirmed through observations, interviews, and document reviews, revealing that the Bed System Measurement Device Test Results Worksheets consistently lacked documentation for these zones. Several residents, including those with cognitive impairments and mobility issues, were observed using side rails for assistance with bed mobility and transfers. Despite physician orders and documented needs for side rails, the facility's maintenance staff did not complete comprehensive entrapment assessments. Interviews with staff, including the Maintenance Director, confirmed that only Zones 2, 3, and 4 were assessed, leaving potential risks unaddressed. The deficiency was acknowledged by the facility's administration, including the Director of Nursing and the Administrator. The lack of complete assessments posed a risk of entrapment, which could lead to serious injury or death. The facility's policy required regular inspections and assessments, but these were not fully implemented, as evidenced by the missing documentation for critical zones.
Failure to Ensure Accessibility of Call Lights and Bed Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs of several residents, as observed during a survey. Specifically, the call lights for three residents were not within reach, with one resident's call light found on the floor, another on a floor mat, and a third clipped to the wall above the bed. Additionally, a resident's bed control was found on the floor, out of reach. These residents were noted to have no capacity to make medical decisions or had moderate cognitive impairment, which further emphasizes the importance of having these devices accessible. Another resident's call light button was found to be non-functional, as it was not plugged in correctly. This resident, who required substantial assistance for bed mobility and transfers, reported that the call light had not been working the previous night. The facility's policy requires that call lights be accessible to residents, but this was not adhered to, leading to potential delays in care and impacting the residents' well-being.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Resident 86 was seen entering a shower room that had a soiled towel on the floor and unpackaged clean adult briefs on the floor and shower chair, which was confirmed by RN 2 as an infection control concern. Resident 49's room was found with scratches, unpainted areas on the walls and bathroom door frame, and stained curtains. Resident 49 expressed dissatisfaction with the room's condition, stating he spent most of his time in bed and expected a clean and well-maintained environment. Additionally, Resident 27's room had scratches and unpainted areas on the walls, and she mentioned that painting the walls would make her room more livable. Resident 33's room was observed with scratches and chipped paint on the walls, and although she felt comfortable, she believed her room needed maintenance. These observations indicate a failure to provide a safe, clean, and homelike environment, posing a risk for unsanitary conditions and potentially impacting the residents' quality of life.
Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level 1 PASRR screenings for two residents, leading to potential inappropriate placements without necessary evaluations. Resident 77, diagnosed with unspecified psychosis and major depressive disorder, was prescribed Seroquel, an antipsychotic medication. However, the Level 1 PASRR screening inaccurately indicated no diagnosis of serious mental illness and no psychotropic medication prescriptions, resulting in a negative screening and no Level II evaluation. The MDS Coordinator confirmed the inaccuracies and acknowledged that a Level II evaluation might have been required. Similarly, Resident 53, diagnosed with depressive disorder, had a Level 1 PASRR screening that incorrectly showed no diagnosis of serious mental illness. This screening was completed at an acute care hospital before the resident's readmission to the facility. The MDS Coordinator verified the discrepancy between the PASRR screening and the resident's medical records, which documented the depressive disorder diagnosis. The MDS Coordinator stated that the resident required a PASRR resident review submission to inform the Department of Health Care Services about the diagnosis, potentially necessitating a Level II mental health evaluation. The facility's policy and procedure for coordinating assessments with the PASRR program were reviewed, indicating that all applicants should be screened for serious mental disorders or intellectual disabilities. A negative Level 1 screen permits admission without further PASRR process unless a serious mental disorder arises later, while a positive screen requires a Level II evaluation. The MDS Coordinator and DON acknowledged the findings, highlighting the failure to ensure accurate PASRR screenings and the potential need for Level II evaluations for the residents involved.
Failure to Implement Fall Risk Precautions
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 62, was free from accident hazards as per the physician's orders and the resident's care plan. The deficiency was observed during an initial tour and subsequent observation, where Resident 62 was found lying in a low bed without the required floor mattresses on both sides. This was contrary to the physician's order dated February 3, 2023, and the care plan interventions, which specified the use of floor mattresses as a precautionary measure due to the resident's high fall risk. Resident 62 had a history of severe cognitive impairment, lower extremity impairment, and was at risk for falls due to confusion, psychoactive drug use, psychosis, and dementia with behavioral disturbances. The facility's Fall Prevention Program policy required that residents be assessed for fall risk and receive appropriate interventions. However, the lack of floor mattresses, as confirmed by both an LVN and the DON during interviews, indicated a failure to adhere to the prescribed fall risk precautions, potentially exposing the resident to serious injury.
Deficiency in PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of PICC lines for two residents, Resident 63 and Resident 77. Upon admission, the facility did not complete or document the required measurements of the PICC line's external catheter length and arm circumference for both residents. Additionally, there was no physician's order obtained for the care and maintenance of Resident 77's PICC line, and the facility did not develop a care plan for the use of the PICC line for either resident. These omissions were contrary to the facility's policy and procedures, which require such measurements and documentation to be completed upon admission and weekly thereafter. For Resident 63, the medical record review showed that the PICC line dressing was not changed upon admission as per the physician's order, and the required measurements were not documented until several days later. The resident was receiving IV medications for sepsis and fungal prophylaxis, yet the care plan did not address the PICC line. An interview with RN 1 confirmed that the dressing change and measurements were not completed as required, and the nurse admitted to signing off on tasks that were not performed. Similarly, for Resident 77, the facility failed to document the necessary measurements and did not change the PICC line dressing weekly as required. The resident was receiving IV antibiotics for pneumonia, but the care plan did not include the PICC line. RN 1 confirmed that there was no order for the PICC line dressing change since admission, and the dressing had not been changed weekly. The Director of Nursing verified these findings, acknowledging the lack of documentation and care planning for the PICC lines.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to administer pain medication according to the physician's order for a resident, identified as Resident 87, who was reviewed for pain management. The facility's policy and procedure for pain management, revised on 12/19/22, emphasized managing or preventing pain consistent with the comprehensive assessment and plan of care. However, the medical record review revealed that Resident 87, who had a history of central cord syndrome, wedge compression fracture, multiple rib fractures, and malignant neoplasm of the prostate, was not administered the correct dosage of oxycodone as per the physician's orders. Specifically, on multiple occasions, Resident 87 was given a lower dosage of oxycodone for severe pain levels, which were recorded as 8 on the pain scale, instead of the prescribed higher dosage for such pain levels. Interviews conducted with LVN 7 and the DON confirmed the findings. LVN 7 acknowledged that Resident 87 should have received two tablets of oxycodone 5 mg for the reported pain level of 8, as per the physician's order. The DON stated that licensed nurses were expected to assess the resident's pain and administer medication according to the physician's orders. The failure to administer the correct dosage had the potential for ineffective pain management for Resident 87. The facility's administration, including the Administrator, DON, and Medical Records Assistant, were informed and acknowledged the findings.
Failure to Monitor and Document Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with end-stage renal disease who required dialysis. The resident, who was admitted with a diagnosis necessitating dialysis three times a week, had a physician's order for a strict fluid restriction of 1000 ml per 24 hours. This order specified the distribution of fluid intake across meals and nursing shifts. However, the facility did not monitor or document the resident's fluid intake and output as ordered, which is crucial for managing the resident's condition. Interviews and medical record reviews revealed that the facility staff, including RN 1 and the DON, acknowledged the lack of documentation regarding the resident's fluid intake. The Monitor Record for the resident showed that from late September to early October, there was no recorded evidence of the resident's fluid intake, with only 'X' marks noted in the documentation areas. This oversight had the potential to result in an excess of fluids, posing a risk to the resident's health due to their impaired kidney function.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure the safety of residents through proper documentation and informed consent regarding the use of bed rails. For Resident 83, the Physician's Documentation of Informed Consent was incomplete, lacking a physician's signature and date, despite the resident's diagnosis of Alzheimer's disease and inability to make decisions. Observations confirmed the use of bilateral half side rails without proper consent, and staff interviews acknowledged the oversight. Residents 77 and 80 were also affected by the facility's failure to obtain physician's orders and initiate care plans for the use of side rails. Both residents were observed using the rails for mobility and repositioning, yet their medical records did not reflect the necessary documentation or care plan problems addressing the use of these devices. Interviews with staff confirmed the absence of required orders and care plans, highlighting a systemic issue in the facility's management of side rail use. Additionally, Resident 24's records showed a physician's order for side rail use, but the informed consent documentation was incomplete, missing the physician's signature. Resident 53's case further illustrated the facility's deficiencies, as there was no documentation of informed consent for side rail use upon re-admission. These failures collectively posed a risk of injury to the residents, as acknowledged by the facility's administration and nursing staff.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that five residents were free from unnecessary psychotropic medications, as evidenced by the lack of signed and dated informed consent forms by physicians for the administration of these medications. Residents 13, 23, 77, 83, and 541 were all prescribed antipsychotic medications such as Seroquel and Risperdal without the necessary documentation of informed consent. This oversight was confirmed through interviews with licensed vocational nurses (LVNs) and the Director of Nursing (DON), who acknowledged the absence of physician signatures and dates on the consent forms. In addition to the lack of informed consent, the facility did not adequately monitor residents for adverse side effects associated with the use of psychotropic medications. For instance, Resident 541 was not monitored for orthostatic hypotension or the number of behavioral episodes, and there was no evidence of non-pharmacological interventions being implemented. Similarly, Resident 77's medical records did not show monitoring for orthostatic hypotension or adverse effects related to Seroquel use, despite the care plan indicating such monitoring should occur. Furthermore, the facility's documentation was inconsistent and incomplete regarding the behavior manifestations that warranted the use of psychotropic medications. For example, Resident 541's orders for Seroquel did not match the behavior monitoring orders, leading to discrepancies in the documented reasons for medication use. Additionally, Resident 23's records lacked documentation of behavioral monitoring and non-pharmacological interventions, which were supposed to be part of the care plan. These deficiencies were acknowledged by the facility's administration and nursing staff during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, as observed during a survey. In Medication Room A, expired medications for a nonsampled resident were found in the refrigerator, with expiration dates that had already passed. Additionally, in Treatment Cart A, expired medications such as Bacitracin Zinc ointment, hydrocortisone cream, and triple antibiotic ointment were not removed from the current treatment supply. These expired medications were verified by the respective LVNs, who acknowledged that expired medications should not be administered due to potential adverse effects. Further inspection of Medication Cart A revealed improper storage practices, where orally administered medications were not stored separately from externally used medications and supplies. Items such as nitroglycerin tablets were stored with artificial tears, and stool softeners were stored with topical creams. Additionally, medication bottles and trays were found with sticky residues, and some opened medications lacked proper labeling with open dates. These findings were confirmed by the LVN present during the inspection. In Medication Cart C, similar issues were observed, including the improper storage of medications with different routes of administration. A bottle of shell calcium tablets was stored with suppositories and topical creams, and medications for two residents were found without open dates. The DON was informed of these findings and acknowledged the issues. These deficiencies in medication management had the potential to negatively impact residents' well-being and the effectiveness of the medications.
Deficiency in Safe Storage of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure the safe use and storage of food brought in by family members or visitors, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy and procedure (P&P) stated that residents have the right to receive food from outside sources, but it must be handled safely. The P&P required that all food items brought in must be approved by nursing staff to ensure they align with the resident's diet order, consumed within two hours, and any leftovers discarded. However, the facility did not have a designated refrigerator for residents, which was acknowledged by the Director of Social Services (DSS), Registered Dietitian (RD), and Director of Nursing (DON) during interviews. The DSS, RD, and DON confirmed that the facility lacked a refrigerator for residents and that food brought from outside was intended for immediate consumption within two hours. The DON further stated that they discouraged families from bringing perishable food due to concerns about mold and insects. The facility's P&P did not address the storage of food if a resident or their responsible party preferred to eat it later or beyond the two-hour window. This oversight in the facility's policy and lack of proper storage facilities contributed to the deficiency identified by the surveyors.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to discrepancies and omissions in critical documentation. For Resident 541, the Physician Orders for Life-Sustaining Treatment (POLST) was incomplete, lacking advance directive information. Similarly, Residents 291 and 49 had conflicting information regarding their advance directives, with discrepancies between their POLST forms and Advance Directive Acknowledgment forms. These inconsistencies were verified by the Social Services Director (SSD) during interviews and record reviews. Resident 87's Treatment Administration Record (TAR) for October 2024 was found to be inaccurate. Although physician orders were in place for wound care treatments on the resident's heels, there was no documentation of these treatments being administered from October 3 to October 7, 2024. Licensed Vocational Nurse (LVN) 4 confirmed that the treatments were given but not signed off in the TAR, and there was no documentation in the progress notes to explain the omission. Additional deficiencies were noted in the informed consent documentation for Residents 12, 13, and 62. Resident 12's consent for side rail use was incomplete, lacking confirmation from the resident or responsible party. Resident 13's consent for bilateral half side rails was missing the physician's signature and date. For Resident 62, informed consents for multiple medications were not signed by the physician, despite verification that consent was obtained from the responsible party. These findings were acknowledged by the Director of Nursing (DON) and other staff members during interviews.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure that information on how to formulate an advance directive was provided to Resident 33, who had the cognitive capacity to understand and make decisions. Despite having an Advance Directive Acknowledgment form indicating that Resident 33 had executed an advance directive, the resident stated she did not have one and was not provided with information on how to formulate it. The facility's records showed conflicting information between the POLST and the Advance Directive Acknowledgment form, and the Director of Nursing (DON) confirmed that there was no advance directive in the medical record. For Resident 87, the facility did not maintain a copy of the advance directive in the medical record, despite the resident having executed one. The POLST form was incomplete, lacking information and signatures in Section D. The Social Services Department (SSD) acknowledged that there was no documentation showing follow-up to obtain a copy of the advance directive from the resident's representative, who had promised to fax it to the facility. Resident 23's medical record also lacked a copy of the advance directive, and the POLST form did not document whether the resident had an advance directive. The SSD confirmed that there was no follow-up to verify the presence of an advance directive, and RN 1 verified that the advance health care directive was not maintained in the medical record. These deficiencies indicate a failure to uphold residents' rights to have their treatment preferences documented and respected.
Controlled Medication Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate reconciliation and documentation of controlled medications for several residents. Specifically, the administration of hydrocodone/apap for Residents 54, 741, and 742 was not accurately documented in the Medication Administration Record (MAR), despite being signed out in the Controlled Drug Record. Additionally, Resident 48's hydrocodone/apap administration was not documented in the Controlled Drug Record, leading to discrepancies in the medication count. The facility's policies and procedures for medication administration and controlled substance accountability were not followed. The Controlled Substance Shift Count Log for Medication Cart C was also incomplete, with missing signatures from licensed nurses for specific shifts. These lapses in documentation and accountability posed a risk for medication diversion. Interviews with staff, including LVN 7, LVN 5, and RN 3, confirmed the discrepancies and acknowledged the failure to document medication administration as required. The Director of Nursing (DON) was informed of these findings and acknowledged the issues identified during the survey.
Medication Administration Error Due to Leaking Medication Cup
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 76, was free from significant medication errors. During a medication administration observation, it was noted that a liquid medication intended for Resident 76 leaked from the medication cup into the medication tray, resulting in the medication not being administered. The Licensed Vocational Nurse (LVN) involved was unable to identify which medication had leaked, as both Keppra, an anticonvulsant, and metformin, an antidiabetic medication, were prepared in unlabeled cups. This incident occurred despite the facility's policy and procedure for medication administration via enteral tube, which requires each medication to be administered separately and not combined. Resident 76, who lacks the capacity to make medical decisions, was prescribed Keppra to manage seizures and metformin for diabetes mellitus. The Director of Nursing (DON) confirmed the medication cup leakage and acknowledged that one of the medications was not administered, although it was unclear which one. The DON communicated with the physician's assistant (PA) on call, who ordered an additional dose of Keppra and instructed monitoring of the resident's blood glucose levels. However, the DON did not initially seek laboratory tests to assess the resident's condition following the medication error.
Failure to Assess and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 23 and 80, were assessed for their COVID-19 vaccination status or offered the COVID-19 vaccine, as per the facility's policy. The policy, revised on June 9, 2023, mandates that residents and staff be educated and offered the COVID-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. However, a review of Resident 23's medical record showed no documentation of the resident's COVID-19 vaccination status or any offer of the vaccine. For Resident 80, the medical record indicated that informed consent for the COVID-19 vaccination was obtained on July 1, 2024, but the resident was on antibiotics and chose to wait until the treatment was completed. The facility's records did not show any evidence that Resident 80 was re-offered or received the COVID-19 vaccine after completing the antibiotic treatment. These findings were verified during an interview and medical record review with the Infection Preventionist (IP) on October 9, 2024.
Failure to Maintain Accurate Glucometer Quality Control
Penalty
Summary
The facility failed to maintain essential equipment, specifically glucometers, in safe operating condition. During a review of the Assure Platinum Glucose Monitoring System's Quality Control Records for two medication carts, it was found that the quality control test results documented in the logs did not match the results observed on the glucometer devices. For Medication Cart A, discrepancies were noted on 10/8/24 and 10/9/24, where the normal and high control results were recorded as 88 mg/dL and 230 mg/dL, and 87 mg/dL and 226 mg/dL, respectively, but these results were not observed on the device. Similarly, for Medication Cart C, discrepancies were found for multiple dates, including 10/2/24 through 10/9/24, with recorded results not matching those on the glucometer. Licensed Vocational Nurses (LVNs) 7 and 5 verified these findings, acknowledging that the 11-7 shift licensed nurses were responsible for performing and documenting the glucometer quality control tests every night shift. The Director of Nursing (DON) confirmed that the facility's expectation was for these tests to be completed every night shift. However, the failure to ensure accurate documentation and observation of glucometer quality control results had the potential to lead to inaccurate glucose readings for residents requiring glucose checks.
Privacy and Confidentiality Breach
Penalty
Summary
The facility failed to ensure the privacy of a resident during activities of daily living (ADL) care. During an observation, it was noted that a certified nursing assistant (CNA) was providing ADL care to a resident in Room A with the door wide open. The resident was seated on a shower chair and covered with a blanket from the neck to the waist, leaving the legs and buttocks exposed to anyone passing by in the hallway. Interviews with the quality assurance registered nurse (QA RN), the CNA, and the director of nursing (DON) confirmed that the privacy curtain and door should have been closed to protect the resident's privacy. Additionally, the facility failed to maintain the confidentiality of the resident's medical information. An observation at the nurses' station revealed that a licensed vocational nurse (LVN) left a computer monitor on, displaying the resident's personal medical information. The LVN walked away from the station twice, leaving the information exposed. Upon returning, the LVN acknowledged the oversight. These actions were in direct violation of the facility's policies and procedures regarding patient privacy and confidentiality.
Cockroach Infestation in Conference Room
Penalty
Summary
The facility failed to ensure the environment was free of pests, specifically cockroaches, which were observed in the conference room. The facility's Pest Control Program, revised on 12/19/22, mandates maintaining an effective pest control program to eradicate and contain common household pests and rodents. On 9/13/24, during an observation and interview with the QA RN, a cockroach was seen crawling towards a trash bin in the conference room, and the QA RN confirmed the potential risk of infection spread due to the presence of cockroaches. Later the same day, another cockroach was observed in the conference room during an interview with the Social Services Director, who acknowledged its presence. The Maintenance Director also confirmed the presence of cockroaches in the conference room and recognized the risk of spreading infection.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Habra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bonita Hills Post Acute | 0 mi | — | 4 | 0 |
| Whittier Hills Health Care Ctr | 1.3 mi | — | 35 | 0 |
| St Elizabeth Healthcare Center | 2.7 mi | — | 25 | 0 |
| Imperial Healthcare Center | 2.9 mi | — | 1 | 0 |
| The Pavilion At Sunny Hills | 3 mi | — | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.