Anaheim Point: Medication Tracking Failures - CA
The facility's own policy required licensed nurses to chart the drug, time administered and their initials with each medication administration. But when inspectors reviewed records in March, they found hydrocodone-acetaminophen tablets had been dispensed from the locked narcotic supply without any corresponding documentation that residents actually received them.
Resident 34 had a doctor's order for the powerful pain medication — one tablet every six hours as needed for severe pain rated 7 to 10 on a 10-point scale. The individual narcotic record showed tablets were signed out on February 25 at 6:08 p.m. and March 1 at 8:00 p.m.
But the resident's medication administration records for February and March contained no documentation that either tablet was actually given.
When confronted with the discrepancy, LVN 6 verified the findings. The director of nursing acknowledged the problem and confirmed that licensed nurses must document on medication records when controlled substances are administered to residents.
The medication tracking failure was one of nine violations federal inspectors documented during their March 6 survey of the 140-bed facility on West Ball Road.
Inspectors also discovered expired medical supplies sitting in treatment carts and a resident keeping over-the-counter eye drops at his bedside without a doctor's order. In one treatment cart, they found culture swabs expired since an unspecified date and five packets of wound dressing that had expired. LVN 7 told inspectors the expired culture swab and dressing "could be infective or may be contaminated if used on the residents."
Resident 104 had purchased Walgreens Redness Relief eye drops during a pass outside the facility and kept the sealed container on his nightstand. When asked about the drops, the resident said he bought them when he was out on a pass. LVN 4 acknowledged their presence and said there should be no medications at bedside, promising to ask the resident's physician for an order.
The resident's medical records showed no physician's order for the eye drops.
Kitchen staff violated food safety protocols in multiple ways. The dietary services supervisor failed to wear a hair restraint while working in the kitchen, despite facility policy requiring hair to be covered in all kitchen and food storage areas. Staff also left a canister of brown rice uncovered in the dry storage room, violating guidelines that require tight-fitting lids on opened products.
A cook verified the rice canister should have had a lid to keep the rice clean.
Outside the building, two of six garbage dumpsters sat with lids propped open by overflowing trash, preventing them from closing properly. The administrator acknowledged the problem when shown photographs of the open dumpsters.
Residents suffered from inadequate meal preparation and missing assistive equipment. Resident 88, who was trying to lose weight for knee surgery, ordered a chef salad but received only lettuce with shredded carrots and purple cabbage. The facility's recipe for chef salad called for lettuce, turkey, lean ham, cheese, tomatoes, hard-cooked eggs and salad dressing.
"I was disappointed that I did not receive any protein with my salad," the resident told inspectors.
The dietary supervisor reviewed the recipe card and confirmed the salad was incorrectly made.
Resident 8, who had suffered a stroke and had a contracted left hand, was supposed to receive built-up utensils and a lip plate with all meals according to a January physician's order. Instead, inspectors observed the resident struggling with regular silverware during both lunch and breakfast.
"It was hard to eat and grab the spoon and fork," the resident said, describing weakness in the left hand.
LVN 6 explained that built-up utensils would help the resident maintain better grip and control since stroke had limited hand strength.
The facility's infection control program contained serious gaps. Staff had not implemented required water management testing to prevent Legionella bacteria growth, despite having a written plan calling for quarterly monitoring of disinfectant chemical levels throughout the water system. The infection preventionist told inspectors the testing would begin in March 2025 — the month of the inspection.
In the laundry room, washing machine doors showed large amounts of brown stains and white mineral residue. Pipes behind the machines had similar contamination, and walls showed cracks and gaps between the wall and baseboard. The housekeeping supervisor acknowledged the problems and promised to notify maintenance about the damaged walls.
The antibiotic stewardship program failed to accurately track infections and medication use. The infection preventionist could not provide documentation of McGeer's criteria assessments used to determine whether residents truly had infections requiring antibiotic treatment. When inspectors compared surveillance logs to monthly infection reports, they found discrepancies in the numbers of residents who did not meet infection criteria.
For Resident 54, who received ampicillin for possible exposure to contaminated milk products, the facility's own records contradicted each other. The surveillance log indicated the resident did not meet McGeer's criteria for true infection, but a separate screening evaluation concluded the resident did meet criteria for gastroenteritis.
Medical record keeping problems extended beyond infection tracking. Two residents' POLST forms lacked required documentation about whether they had advance directives. During one record review, an inspector found two other residents' medical records filed in Resident 86's chart.
The facility's hospice coordination failed multiple residents. Resident 79 was supposed to receive visits from a certified hospice aide twice weekly, but sign-in sheets showed the aide visited only once during one week in February and provided no documented visits during three other weeks in February and March.
For Resident 394, hospice consent forms sat blank and unsigned in the medical record. The resident's POLST form was also blank. The facility had no documentation of the required frequency for hospice visits, and records showed no evidence that certified hospice aides had visited the resident during February and March.
The director of nursing, who served as hospice coordinator, acknowledged the missing documentation and blank forms.
Resident 394 also became the center of a bed safety violation. The resident used bilateral upper side rails as enablers, but maintenance staff never conducted the required entrapment assessment to ensure the rails were safely installed. The maintenance director and assistant told inspectors they were never notified about the resident's bed with side rails.
Monthly bed inspection logs and entrapment risk checklists contained no documentation that Resident 394's bed had been inspected, despite facility policy requiring entrapment reviews when beds or mattresses change.
The resident had severe cognitive impairment and depended completely on staff for bed mobility, making entrapment risks particularly dangerous.
All violations were classified as having minimal harm or potential for actual harm, affecting few to some residents. The facility received no immediate jeopardy citations requiring emergency correction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anaheim Point from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ANAHEIM POINT in ANAHEIM, CA was cited for violations during a health inspection on March 6, 2025.
The facility's own policy required licensed nurses to chart the drug, time administered and their initials with each medication administration.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.