Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Coast Global Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility failed to protect the confidentiality of 27 residents' PHI when a computer displaying sensitive information was left unattended in a hallway. The facility's policy requires that medical records be kept confidential and accessed only by authorized users. Interviews confirmed that computer screens should be locked when not in use.
The facility's assessment failed to involve direct care staff, residents, or their representatives, and lacked plans for staffing resources, recruitment, retention, and contingency for staffing needs. The DON/Interim CNO and Director of Sub-Acute Unit confirmed the assessment was outdated and did not follow CMS's 2024 guidance.
The facility failed to provide written notification of bed hold rights to three residents or their representatives upon transfer to a hospital. Despite the facility's policy requiring such notification, documentation was missing for all three cases. The Social Service Staff acknowledged the oversight, and the Director of the Sub-Acute Unit confirmed the findings.
The facility failed to provide necessary respiratory care and services for several residents, including unlabeled and unchanged respiratory equipment, unclean tracheostomy sites, and improperly set ventilator alarms. These deficiencies were confirmed through observations and staff interviews, with the Director of the Sub-Acute Unit acknowledging the findings.
The facility failed to maintain an accurate infection control surveillance program and did not properly disinfect shared glucometers, leading to potential infection risks. The infection control data from October to December 2024 was incomplete, and specific cases showed that criteria for true infections were not consistently applied. Additionally, a glucometer was not disinfected according to the manufacturer's instructions, as observed during a procedure, potentially exposing residents to blood-borne pathogens. These issues were confirmed by the Infection Preventionist and the Director of the Sub-Acute Unit.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for residents whose conditions did not meet McGeer's criteria. Despite policies requiring monitoring and intervention, many residents were prescribed antibiotics without proper justification. The Infection Preventionist and Director of the Sub-Acute Unit acknowledged issues with form completion and tracking compliance, resulting in continued inappropriate antibiotic use.
A facility failed to maintain a clean environment for a resident, as evidenced by dry, brownish residues on the resident's enteral feeding pump. Despite the facility's policy on infection control, licensed nurses did not clean the device, which was used to infuse Glucerna 1.2. Observations confirmed the oversight, and the Director of the Sub-Acute Unit acknowledged the responsibility of licensed nurses to maintain cleanliness.
A resident was transferred to an acute care unit without written notification to their representative, violating the requirement to inform them of the transfer, reasons, and appeal rights. The Social Service Staff confirmed that only verbal communication was made, and the Director of the Sub-Acute Unit acknowledged the deficiency.
A facility failed to ensure the accuracy of a PASRR Level 1 assessment for a resident, which inaccurately indicated no serious mental illness or psychotropic medication use. The resident's records showed severe cognitive impairment, a psychotic disorder, and antipsychotic medication use. The discrepancy was confirmed by the Director of the Sub-Acute Unit, revealing a failure in the facility's screening and review procedures.
A resident's low air loss mattress was incorrectly set for a higher weight range than appropriate, potentially affecting pressure ulcer care. The resident, weighing 117.5 pounds, was observed on a mattress set for 265-330 pounds. The error was confirmed by an LVN, who noted the resident's inability to communicate discomfort due to cognitive impairment.
Two residents with limited ROM did not receive RNA services as ordered, including passive ROM exercises and splint applications. Documentation showed missed and inconsistent care, with no physician notification of discrepancies. Staffing issues contributed to the failure to provide the required care.
A resident with a seizure disorder was observed without a required helmet while in a wheelchair, contrary to a physician's order. Staff, including a CNA and an LVN, confirmed the absence of the helmet, which was meant to ensure safety during transfers and while the resident was out of bed. The Director of the Sub-Acute Unit verified the findings and emphasized the importance of adhering to safety protocols.
The facility failed to provide proper care for residents with feeding tubes. A resident's head of bed was not elevated to the required angle before medication administration, risking aspiration. Another resident received enteral feeding at an incorrect rate, and the water flush bag was unlabeled. These issues were acknowledged by the facility's director.
The facility failed to ensure accurate medication administration routes for two residents, leading to errors in administering medications via gastrostomy tube (GT) instead of orally as ordered. The errors were confirmed by nursing staff and the pharmacist, who noted limitations in the electronic health record system. The Director of the Sub-Acute Unit acknowledged the findings.
A facility failed to limit a resident's PRN order for lorazepam to 14 days, as required for psychotropic medications. The absence of physician documentation justifying the extension of this medication was confirmed by staff, including an LVN and the Director of Pharmacy. This oversight could lead to unnecessary medication use, potentially affecting the resident's well-being.
A medication cart in an LTC facility was found unlocked and unattended, containing various medications for multiple residents. The cart's locking mechanism was malfunctioning due to debris obstructing it, allowing unauthorized access to medications. The issue was identified and confirmed by the LVN, Director of Sub-Acute Unit, and Engineering team.
The facility failed to ensure the cook followed the recipe for pureed Swiss steak, potentially affecting a resident's nutritional needs. The cook did not measure the beef broth and used insufficient thickener, contrary to the facility's policy. The RD confirmed the cook should have adhered to the instructions.
The facility failed to follow food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were stored wet, contrary to USDA Food Code requirements. A rack for clean pots and pans was unsanitary, and four cutting boards were heavily marred, hindering proper cleaning. These deficiencies could lead to foodborne illnesses for residents.
A facility failed to maintain accurate and complete documentation for a resident using bilateral soft hand mittens. The Restraint Assessment/Restraint Flowsheet was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Staff interviews confirmed the expectation for accurate documentation, highlighting the potential impact on the resident's care needs.
The facility failed to properly record a resident's personal belongings, as evidenced by incomplete inventory forms and missing items. Interviews confirmed that the inventory process was not consistently followed, leading to difficulties in tracking the resident's belongings.
The facility failed to provide necessary care and services for four residents, including missed showers, improper transfers, and inadequate nail care. Staffing shortages were confirmed by family members and staff, contributing to these deficiencies.
Failure to Protect Residents' PHI
Penalty
Summary
The facility failed to maintain the confidentiality of residents' Protected Health Information (PHI) for 27 residents. During an observation in Hallway 1, a computer was found displaying the names, dates of birth, and ages of all residents currently residing in the facility. This computer was left unattended, and multiple staff members were observed walking past it without securing the information. The facility's policy on confidentiality, revised in August 2023, mandates that medical records are to be kept confidential and accessed only by authorized users on a need-to-know basis. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed that the computer screens should be locked when not in use to prevent unauthorized access to resident information.
Facility Assessment Lacks Comprehensive Planning and Stakeholder Involvement
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during regular operations and emergencies. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, the assessment lacked a detailed plan for staffing resources, particularly for weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Director of Nursing (DON)/Interim Chief Nursing Officer (CNO) and the Director of the Sub-Acute Unit confirmed that the facility assessment was outdated, based on regulations from 2016, and did not incorporate the revised guidance issued by CMS in 2024. They acknowledged the absence of active involvement from key stakeholders and the lack of necessary plans and resources to ensure adequate care for residents, particularly during weekends and unforeseen staffing shortages.
Failure to Provide Bed Hold Notification to Residents' Representatives
Penalty
Summary
The facility failed to notify three residents or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in July 2005, mandates that residents be informed of their right to a bed hold upon admission and when transferred to an acute care facility or during therapeutic leave. However, for Residents 2, 17, and 27, there was no documented evidence that their representatives were provided with a copy of the Bed Hold Notification form when the residents were transferred to the hospital. Resident 27 was transferred to the hospital on January 22, 2025, but the Social Service Staff acknowledged that the bed hold notification was not given or mailed to the resident's responsible party. Similarly, Resident 17 was transferred on January 16, 2025, and the Social Service Staff confirmed that the notification was not provided because the family member did not request it. For Resident 2, although the representative was informed by phone about the bed hold, there was no written documentation provided. The Director of the Sub-Acute Unit acknowledged these findings during interviews conducted on January 23, 2025.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care and services for several residents, as evidenced by multiple observations and interviews. For Resident 18, the Trach-Bar aerosol tubing set-up was not labeled with the date, and there was no documentation that the aerosol set-up was changed weekly as required. Similarly, Resident 26's yanker was not labeled with the opened date, and the T-Bar aerosol set-up was also undated. Resident 28's T-Bar aerosol tubing set-up and sterile water connected to the oxygen flowmeter were not labeled with the opened date, and the yanker was not changed according to the facility's policy. The facility also failed to change the suction canister and tubing as per policy for Residents 2 and 8, and the yankauer tube was not labeled for these residents. Additionally, Resident 8's tracheostomy site was not clean, and the tracheostomy dressing was not changed as required. Resident 6's ventilator machine alarms were not set for high pressure alarms, and there was no documentation that the alarms were checked every shift as per the physician's order. The care plans for respiratory status did not include interventions for monitoring the mechanical ventilator and settings, posing a risk of delayed intervention in emergencies. Furthermore, Resident 27's set-up bag was not changed weekly as required. The facility's policies and procedures for oxygen therapy and changing disposable equipment were not followed, leading to potential negative effects on the residents' medical conditions. Interviews with staff, including licensed nurses and respiratory therapists, confirmed these deficiencies, and the Director of the Sub-Acute Unit acknowledged the findings.
Infection Control Deficiencies in Surveillance and Equipment Disinfection
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by deficiencies in maintaining an accurate infection control surveillance program and improper disinfection practices. The infection control surveillance data from October to December 2024 was incomplete and inaccurate, failing to determine whether residents' infections met McGeer's criteria for true infections. Specific cases, such as those of Residents 2, 14, 17, 26, and 27, showed that the section on the form to indicate whether the infection met the criteria for a true infection was not selected, leading to potential mismanagement of infections. Additionally, the facility did not adhere to proper disinfection protocols for shared medical equipment, specifically glucometers. An observation revealed that a glucometer was not cleaned and disinfected according to the manufacturer's instructions after use on a resident. The Licensed Vocational Nurse (LVN) responsible for the procedure did not ensure the glucometer remained wet for the required two minutes with the disinfectant wipe, as per the manufacturer's guidelines, potentially exposing residents to blood-borne pathogens. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed these findings. The IP acknowledged the incomplete surveillance data and the failure to apply McGeer's criteria consistently. The Director of the Sub-Acute Unit was informed of the improper disinfection practices and acknowledged the potential risk of infection transmission due to these lapses in protocol.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, leading to the inappropriate use of antibiotics for residents whose conditions did not meet the McGeer's criteria for true infections. The facility's policy required that culture and sensitivity results be monitored by the pharmacy, with interventions to inform physicians of results and recommendations for antibiotic therapy. However, the facility's Infection Control Surveillance Dashboard revealed that a significant number of residents were prescribed antibiotics for infections that did not meet the McGeer's criteria over a three-month period. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit revealed that the licensed nurses were responsible for completing the Healthcare Associated Infections (HAI) forms, which were then reviewed by the IP to determine if the McGeer's criteria were met. However, the forms were not accurately completed, as selections for the type of infection or criteria for infection were often not made. This led to the continuation of antibiotic treatments without proper justification, as seen in the cases of Resident 27 and Resident 28, who were prescribed antibiotics without meeting the necessary criteria. The Director of the Sub-Acute Unit acknowledged the high prevalence of antibiotic use that did not meet the McGeer's criteria and admitted to incorrectly tracking antibiotic stewardship compliance. Despite discussions in QAPI meetings and awareness by the Medical Director, the facility did not take effective action to address the issue, resulting in continued inappropriate antibiotic use and a failure to adhere to the established antibiotic stewardship program.
Failure to Maintain Clean Enteral Feeding Pump
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident 26, as evidenced by the presence of multiple dry, brownish residues on the resident's enteral feeding pump device. Observations conducted on two consecutive days revealed that the enteral feeding pump was not cleaned, despite being used to infuse Glucerna 1.2 at a rate of 90 ml/hr. Licensed nurses, who were responsible for the cleaning and daily upkeep of the enteral feeding pump, did not notice or address the stains on the device. This oversight was confirmed by both LVN 6 and RN 3 during interviews and concurrent observations. The facility's policy on Environmental Services/Infection Control, reviewed in August 2023, emphasizes the importance of removing soil and dust from surfaces to prevent nosocomial infections. However, the policy was not adhered to in this instance, as the enteral feeding pump remained unclean. The Director of the Sub-Acute Unit acknowledged that the residents' rooms and environment should be clean and comfortable, and confirmed that the licensed nurses were responsible for cleaning the enteral feeding pump. The failure to maintain the cleanliness of the enteral feeding pump device had the potential to negatively impact Resident 26's safety and quality of life.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the transfer and discharge of the resident to an acute care unit. The resident, who lacked the capacity to understand and make decisions, was transferred based on a physician's order, which included a bed hold for seven days. Although the resident's representative was verbally informed and agreed to the transfer, the facility did not provide the required written notice detailing the transfer, the reasons for it, and the resident's rights to appeal the decision. The deficiency was identified during a review of the resident's medical records, which lacked documentation of the written notification. The Social Service Staff, responsible for issuing such notifications, confirmed that the notice was not provided in writing, acknowledging that only verbal communication was made. The Director of the Sub-Acute Unit was informed of these findings, which highlighted the facility's failure to comply with the requirement to notify residents and their representatives in writing about transfers and discharges, including their appeal rights.
Inaccurate PASRR Level 1 Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level 1 assessment for a resident, which is a federal requirement to prevent inappropriate placement in nursing homes. The assessment inaccurately indicated that the resident did not have a diagnosed serious mental illness or symptoms of psychosis, and was not prescribed psychotropic medications for serious mental illness. However, the resident's medical records revealed severe cognitive impairment, a psychotic disorder, and the use of antipsychotic medications, including Zyprexa and Seroquel. The discrepancy was identified during a review of the resident's medical records and confirmed through interviews with the Director of the Sub-Acute Unit. The Director acknowledged that the PASRR Level 1 screenings were completed by the discharging facility and reviewed for accuracy by the MDS nurse, DSD, or the Director of Sub-Acute Unit. Despite this process, the assessment for the resident was found to be inaccurate, highlighting a failure in the facility's screening and review procedures.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, identified as Resident 24, was observed on multiple occasions lying on a low air loss mattress set to a comfort level corresponding to a weight range of 265-330 pounds, while the resident's actual weight was 117.5 pounds. This discrepancy was confirmed by LVN 4, who acknowledged that the mattress should have been set to light 2, appropriate for the resident's weight. Resident 24 was admitted to the facility with a physician's order for a Blue-Chip Power Pro Elite Mattress for wound management. The resident was totally dependent on staff for bed mobility and had severely impaired cognitive skills, making it impossible for them to communicate discomfort. The resident had a pressure ulcer of unknown depth on the left buttocks, documented the day before the observations. The Director of the Sub-Acute Unit was informed of these findings, acknowledging the incorrect mattress setting.
Failure to Provide Ordered RNA Services for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered by the physician for two residents with limited range of motion (ROM). Resident 2 was observed without the necessary splints and had missed four days of RNA services, which included passive ROM exercises and knee splint application. The facility's documentation did not provide any explanation for the missed services, and it was noted that staffing issues contributed to the inability to provide the required care. Resident 18 also did not receive RNA services as ordered. The resident's care plan included passive and active ROM exercises and the application of various splints. However, documentation showed inconsistencies in the application of these splints, with some days missing entirely and others exceeding the prescribed duration. There was no evidence that the physician was informed of these discrepancies or that the resident's inability to tolerate the splints was communicated. Interviews with facility staff, including LVNs and the Director of the Sub-Acute Unit, confirmed the findings. The staff acknowledged the challenges in providing RNA services due to insufficient staffing, which resulted in the failure to administer care as ordered by the physician. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the issues.
Failure to Provide Required Helmet for Resident Safety
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 11, was free from accident hazards by not providing a helmet protective device as per the physician's order. On multiple occasions, Resident 11 was observed in a wheelchair without the required helmet, which was ordered for safety when the resident was out of bed. The medical record review confirmed the physician's order dated 10/28/24, which specified the use of a helmet during transfers and while the resident was in a wheelchair. Despite this, the helmet was not available in the resident's personal belongings, and staff members, including a CNA and an LVN, confirmed the absence of the helmet. Interviews with staff members, including a CNA, the Activity Coordinator, and an LVN, revealed a lack of awareness and adherence to the safety precautions outlined in the care plan for Resident 11. The CNA acknowledged the need for two-person assistance with a mechanical lift but did not mention the helmet requirement. The Activity Coordinator, familiar with the resident's participation in activities, also did not observe the resident wearing a helmet. The LVN verified the physician's order for the helmet but admitted that the resident did not have one during transfers or while in the wheelchair. The Director of the Sub-Acute Unit confirmed the findings and expressed an expectation for staff to observe safety protocols at all times.
Deficiencies in Feeding Tube Care and Administration
Penalty
Summary
The facility failed to provide appropriate care for residents with feeding tubes, as evidenced by two specific incidents involving Resident 12 and Resident 18. For Resident 12, the facility did not ensure that the head of the bed (HOB) was elevated to the required 30 to 45 degrees before administering medication via a gastrostomy tube (GT). During an observation, a licensed vocational nurse (LVN) elevated the HOB to less than 30 degrees, contrary to the physician's order, which could potentially lead to aspiration. The LVN admitted to estimating the angle due to the absence of a measuring device on the bed. In the case of Resident 18, the facility failed to administer enteral feeding according to the physician's orders. The resident was supposed to receive Vital 1.5 at 55 ml per hour, but the feeding pump was set to infuse Pivot 1.5 at 60 ml per hour. Additionally, the water flush bag was not labeled with the resident's name or the ordered rate, which is against the facility's policy. The LVN responsible for the administration acknowledged the discrepancies and admitted to not verifying the physician's order before starting the feeding. Both incidents were acknowledged by the Director of the Sub-Acute Unit, who confirmed that the facility's policies were not followed. The director stated that licensed nurses are expected to review physician orders and ensure correct administration rates, and that all feeding and flush bags should be properly labeled with the resident's details and the ordered rate.
Medication Administration Route Errors for Two Residents
Penalty
Summary
The facility failed to ensure accurate physician's orders for two residents, leading to the administration of medications via the incorrect route. For Resident 23, medications were ordered to be administered orally, but were given via gastrostomy tube (GT) by LVN 6. The medical record review revealed discrepancies in the physician's orders, which specified oral administration for medications such as ferrous sulfate, lactobacillus acidophilus, and Phenobarbital. LVN 6 acknowledged the error and indicated that the charge nurse should have verified the route with the physician. RN 4 confirmed the findings and noted limitations in the electronic health record system, which sometimes lacked an option for GT route, requiring manual entry in the comment section. Similarly, Resident 2's medications were also administered via GT despite the physician's order specifying oral administration. LVN 8 confirmed the error and stated that the RN should have contacted the physician to correct the order. The pharmacist verified the oral orders and acknowledged the limitations of the electronic health record system, which sometimes did not provide an option for GT route. The Director of the Sub-Acute Unit was informed and acknowledged the findings.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not limit the PRN order for lorazepam, an antianxiety medication, to 14 days as required. The resident had an order for lorazepam 1 mg intramuscularly every four hours as needed for seizures, but there was no documentation from the physician or prescribing practitioner justifying the extension of this medication beyond the 14-day limit. This lack of documentation and oversight could potentially lead to the unnecessary use of psychotropic medication, which might negatively impact the resident's mental, physical, and psychosocial well-being. Interviews with facility staff, including an LVN and the Director of Pharmacy, confirmed the absence of necessary documentation for the continued use of lorazepam beyond the 14-day period. The LVN verified that the resident last received the PRN lorazepam on a specific date, but there was no physician documentation providing a rationale for its continued use. The Director of Pharmacy acknowledged the requirement for such documentation and confirmed its absence in the resident's medical record. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the deficiency.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of its medication carts, specifically Medication Cart B, was properly locked and secured when unattended. During an observation, the cart was found unlocked and unattended in a hallway near the activity room. The cart contained various medications, including Valsartan, insulin pens, and other medications for multiple residents. The cart's drawers, except for the one with a lock, could be easily opened, allowing potential unauthorized access to the medications. Upon further investigation, it was discovered that the locking mechanism on the right column of drawers was not functioning properly. The LVN responsible for the cart confirmed that it should have been locked, but the drawers could still be opened after the locks were engaged. The Director of the Sub-Acute Unit and the Engineering team confirmed the malfunction and identified debris, including oral swab sticks, obstructing the locking mechanism. After removing the debris and resetting the drawers, the cart was confirmed to be fully locked.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that the cook followed the recipe when preparing pureed Swiss steak, which could potentially affect the nutritional needs of residents. During an observation, the cook, identified as [NAME] 1, was seen preparing the pureed Swiss steak for a resident. The cook measured 4 oz of Swiss steak but did not measure the beef broth before blending it with the steak. Additionally, only one teaspoon of thickener was added, contrary to the facility's policy which required two to three tablespoons per pound of solid food. The facility's policy on pureed diets, dated June 2023, clearly outlined the procedure for preparing pureed meals, including specific measurements for broth and thickener. The Registered Dietitian (RD) confirmed that the cook should have adhered to these instructions. The failure to follow the recipe as per the facility's policy could lead to the residents' nutritional needs not being met, as the consistency and nutritional content of the meal might not align with dietary requirements.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were found stored while still wet, contrary to the USDA Food Code 2022, Section 4-901.11, which requires equipment and utensils to be air-dried before storage to prevent microorganism growth. The Clinical Dietician confirmed these observations, acknowledging that the items should have been air-dried before being stored in the clean dish storage area and the kitchen, respectively. Additionally, a rack used for storing clean pots and pans was found to be in an unsanitary condition, with white water residue and dry dust on four of its bottom shelves. This was verified by the Clinical Dietician, who stated that the rack should have been cleaned. Furthermore, four cutting boards were heavily marred and discolored, which could hinder proper cleaning and sanitization, as per FDA Food Code 2022, Section 4-501.12. The Clinical Dietician confirmed that these cutting boards needed replacement. These deficiencies had the potential to result in foodborne illnesses for the residents receiving kitchen services.
Incomplete Restraint Documentation for Resident
Penalty
Summary
The facility failed to ensure the medical record for one resident was accurate and complete, specifically regarding the Restraint Assessment/Restraint Flowsheet for a resident using bilateral soft hand mittens. The resident was observed with these mittens to prevent pulling out medical tubing, with a physician's order to release them every two hours for 15 minutes to check circulation and skin condition. However, the flowsheet documentation was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Interviews with staff, including an LVN and the Director of the Sub-Acute Unit, confirmed the expectation that the Restraint Assessment/Restraint Flowsheet should be completed accurately for each shift. The LVN verified the incomplete documentation, and the Director emphasized the importance of accurate and complete nursing documentation to reflect the care provided. The failure to document the restraint assessments accurately had the potential to impact the resident's care needs due to the inaccuracy of their medical information.
Failure to Properly Record Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure the proper recording of a resident's personal belongings, as evidenced by incomplete Resident Inventory of Personal Effects forms for one of the sampled residents. The facility's policy and procedure (P&P) titled 'Handling of Personal Effects' requires that all residents' personal belongings be recorded and signed by both staff and the responsible party upon admission and whenever new items are brought in or removed. However, the review of Resident 1's inventory forms showed multiple instances where either the staff or responsible party's signatures were missing, indicating a lack of proper documentation and accountability for the resident's belongings. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the inventory forms were not consistently filled out as required. Additionally, a family member of Resident 1 reported that several personal items, including blankets and clothes, had gone missing since the resident's admission. The family member acknowledged awareness of the procedure but noted that it was not being consistently followed by the staff, making it difficult to track the missing items. The DON confirmed that some of the missing items had been replaced but acknowledged the deficiencies in the inventory process.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that four sampled residents maintained good grooming, personal hygiene, and proper transfers. Resident 1 did not receive scheduled showers and was not transferred out of bed as planned. The medical record review showed that Resident 1, who had a major stroke and was nonverbal, was supposed to receive showers twice a week and be transferred to a wheelchair three times a week. However, the CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Interviews with family members and staff confirmed dissatisfaction with staffing levels, which led to these deficiencies. Resident 2, who was in a vegetative state and dependent on staff for all activities of daily living, also did not receive scheduled showers. The CNA flowsheet and nurses' progress notes for April 2024 showed missed showers on multiple dates. Additionally, Resident 2 was observed with long fingernails, including a jagged-edged right thumb fingernail with black matter underneath. Interviews with staff revealed that nail care was not consistently provided, and the DON confirmed ongoing staffing challenges. Resident 3, who was rarely able to express ideas or understand others, did not receive scheduled showers and was not transferred to a wheelchair as planned. The CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Family members and staff interviews highlighted the facility's staffing shortages, which contributed to these deficiencies. Similarly, Resident 5 was observed with long fingernails, and interviews with staff confirmed that nail care was not consistently provided. The DON acknowledged the staffing issues and the impact on resident care.
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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 Santa Ana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plaza Healthcare Center | 0.6 mi | — | 4 | 0 |
| South Coast Post Acute | 0.7 mi | — | 2 | 0 |
| Fountain Valley Post Acute | 2.3 mi | — | 32 | 0 |
| French Park Care Center | 3.5 mi | — | 10 | 0 |
| Newport Subacute Healthcare Center | 3.5 mi | — | 7 | 0 |
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