Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bakersfield Post Acute during CMS and state inspections, most recent first.
A facility failed to ensure call lights were answered in a timely manner for four residents. Interviews showed one resident waited a long time for a call light response, another said staff took too long to answer, a third waited over an hour for a pain pill because the call light was not answered promptly, and a fourth also reported delayed response. Records showed the residents were cognitively intact or alert and oriented, and each required substantial assistance or was dependent with ADLs; the facility policy stated call lights should be answered as soon as possible.
Failure to notify the physician and resident representative of an abuse allegation and changes in condition occurred for multiple residents. A cognitively intact resident reported being struck by a roommate and sustaining a bruise, but the DON confirmed the allegation was not reported to the facility until days later and no physician or RP notification was made until then. In addition, a resident with moderate cognitive impairment and a resident with severe cognitive impairment had documented wounds, swelling, skin tear, and weight loss, but the QA nurse stated only the residents were notified and no RP notification was made.
Falls Prevention and Safe Transfer Failures: The facility failed to implement ordered fall precautions for one resident, failed to carry out the Falling Star program for another resident, and had CNA confusion about room fall-risk identifiers. The facility also failed to safely perform a Hoyer lift transfer for a resident who was completely dependent for care, and failed to evaluate or train staff on a resident’s personal shower chair before allowing its use. During the shower, the chair flipped over and the resident hit his head and face, causing a nosebleed and severe pain.
Incomplete dialysis communication and post-dialysis assessments: The facility failed to ensure HCOA forms were fully completed for three residents receiving HD. Records showed missing dialysis center entries, blank post-dialysis sections, and absent LPN signatures/dates for residents with ESRD and diabetes, while staff stated the forms should have been completed and residents assessed after dialysis.
Insufficient CNA staffing and missed shower documentation: CNA staffing assignments showed resident-to-CNA ratios above the Facility Assessment plan, with CNAs reporting they sometimes cared for up to 15-18 residents when short staffed. Staff stated call lights took longer to answer and showers were sometimes missed, and the DSD said the prior DSD had not scheduled enough CNAs to meet resident needs. Review of shower sheets showed no shower documentation on multiple dates, despite policy requiring detailed bath/shower documentation.
The facility failed to document competency and skills performance for three sampled CNAs. Personnel files showed each CNA’s last competency had been completed the prior year, and the DSD confirmed the next required competency was due but had not been completed. The facility’s competency policy did not state how often competencies should be completed.
Missing Annual CNA Performance Evaluations: The facility failed to complete performance evaluations for five sampled CNAs. During record review with the DSD, no evaluation was found in any of the five personnel files, and the DSD confirmed none had been completed. The facility policy stated evaluations are to be completed after the 90-day probationary period and at least annually thereafter.
Infection control practices were not followed when clean resident laundry was stored in the laundry supervisor’s office with chemicals and other items instead of a separate designated space, and a portable AC in the laundry room had thick gray debris in its vent grills. The facility also failed to follow EBP for a resident with a chronic arterial ulcer when two CNAs entered the room for high-contact care, including brief, clothing, and linen changes, without gowns as required by the resident’s care plan and facility policy.
Call Lights Not Accessible or Working in Resident Rooms and Shower Areas: A resident with intact cognition had a call light placed out of reach at the bedside, another resident’s call light did not work when he tried to request water, and multiple shower room call systems were found inaccessible because strings were missing or the devices were placed outside the stalls. The facility policy required residents to have a means to call staff from the bed, bathing areas, and from the floor.
Unsafe Storage of Laundry Supplies Near Washing Machine: Multiple cardboard boxes containing commercial detergents, bleach, and soap solutions were observed stored behind the washing machine in the laundry room, about one to two inches from the back of the unit. The HLS stated the boxes should not have been there, and the HLM stated there was no policy for safely storing supplies.
Staff failed to treat three cognitively intact residents with dignity when CNAs spoke languages other than the residents' primary language while providing care. The residents, whose primary language was English, stated they felt disrespected, isolated, and believed staff may have been talking about them. CNAs also acknowledged that speaking another language in front of residents could be taken the wrong way, and the facility policy required residents to be treated with kindness, respect, and dignity and for English to be spoken in resident areas.
Delayed investigation of a resident abuse allegation occurred when a resident reported that his roommate had hit him, but the allegation was not reported to facility staff until several days later and the investigation did not begin until 6 days after it was reported. The facility’s P&P required all abuse allegations to be thoroughly investigated and a follow-up investigation report within 5 business days.
Delayed Reporting of Resident Abuse Allegation: A cognitively intact resident reported that his roommate struck him and caused bruising to his right forearm, and CNA observed a fresh mark the same day. CNA said the resident reported the altercation to him, but the allegation was not escalated to the nurse or reported to the state, LTC Ombudsman, or law enforcement until several days later. The DON stated abuse allegations with injuries should be reported within 2 hours.
The facility failed to accurately complete PASRR screening for a resident with bipolar disorder, psychosis, dementia, and adjustment disorder. The resident’s Level I PASRR was marked positive, but no Level II PASRR was completed, and a later Level I screen incorrectly marked that the resident did not have a serious diagnosed mental disorder despite the resident receiving divalproex for mental illness.
Failure to implement fall-related care plans for two residents. One resident’s call light was placed on a nightstand about three feet from the bed, and staff stated it could not be reached; the resident also did not have the ordered fall mats at bedside. Another resident’s fall-prevention plan included the Falling Star program, but the DSD stated there was no Falling Star identifier on the room name plate.
A resident with an order for daily Trelegy Ellipta inhalation did not receive the medication because no inhaler was available at the time of administration. RN prepared the medications but stated there was no Trelegy inhaler to give, and the pharmacy reorder had been placed after the supply was already needed. The facility policy stated medications should be reordered 3 to 4 days in advance to ensure an adequate supply is on hand.
Failure to provide ordered q2h repositioning was identified for a resident with a stage 4 coccyx pressure injury. The resident was dependent for rolling and sit-to-lying, had an OSR order for repositioning with a wedge, but the care plan did not include turn-and-reposition interventions. DSR documentation showed multiple extended periods without T&R, and staff stated the resident could not reposition independently.
Inaccurate nutritional assessment for a resident receiving tube feeding. The resident had a feeding tube and was observed receiving Jevity 1.5, while the RD’s note documented Jevity 1.2. The MAR and OSR also showed Jevity 1.5 was being given, and the RD stated she was not aware the formula had been changed. An LVN stated the MD approved the switch because Jevity 1.2 was unavailable, and there was no documentation notifying the RD of the change.
Missing physician progress notes for a resident were identified during record review. The MDS nurse and MRD could not locate PPN for the last three months, and the facility’s policy required the attending MD to write, sign, and date PPN at each visit and complete required resident visits on schedule.
The facility failed to follow its MedBank P&P for controlled drugs. The DON stated there was no process in place to count narcotics in MedBank and that narcotics were not being counted daily, despite the policy requiring the DON to ensure daily cycle counting and documentation of controlled drugs in the MedBank system.
Incomplete and inaccurate documentation was found for two residents. One resident’s record contained conflicting accounts of a transfer incident, with charting describing a witnessed fall even though the DON stated no fall occurred and the resident was sent out for neck and back pain at his request; transfer and hospital paperwork also listed the event as a fall. Another resident had meds left in a cup at the cart, and an LVN admitted signing the MAR as administered even though the meds were not given.
Failure to Offer Influenza Vaccines: The facility failed to ensure flu vaccines were offered to two residents. During record review, the IP stated one resident did not receive a flu vaccine and there was no documentation that it was offered, and another resident had no immunization record because the IP had missed recording and verifying it. The facility policy required annual flu vaccine offers to residents without contraindications.
The facility failed to maintain functional Hoyer lift equipment and appropriate maintenance records. One of two Hoyer lift battery chargers in the charging station was not charging batteries, and two cognitively intact residents reported past episodes where the Hoyer lift stopped working due to dead batteries while they were suspended in full body slings, one in bed and one in a wheelchair. The Maintenance Supervisor acknowledged that no maintenance logs or work orders were kept for the Hoyer lifts, and the Administrator was unaware of any official P&P specific to the Hoyer lift or an owner’s manual for the batteries, despite a facility policy requiring charged batteries and a maintenance policy assigning responsibility for keeping equipment safe and operable.
Three cognitively intact residents who required extensive or maximal assistance with ADLs, toileting, and transfers reported prolonged call light response times, ranging from 20–30 minutes to as long as an hour and a half, when requesting help such as urinal emptying, getting out of bed, breathing treatments, ice, and incontinence care. One resident described feeling terrible and shaky when not assisted out of bed at his preferred time, another became angry and sometimes went to the nurse’s station where staff were observed sitting, and a third felt frustrated after waiting up to an hour. CNAs reported feeling rushed and caring for 15–23 residents when short staffed, and one did not take scheduled breaks, while the facility’s Resident Rights policy required staff to treat residents with kindness, respect, and dignity and to assist them in exercising their rights.
Two residents with intact cognition experienced failures in timely and accurate medication administration. One resident with chronic pain had a scheduled dose of topical Diclofenac gel given more than three hours past the ordered time. Another resident reported delays in receiving breathing treatments and not receiving a stomach medication; MAR review showed that both a scheduled Ipratropium/Albuterol nebulizer treatment and a Pantoprazole dose were not documented as administered at a scheduled time, contrary to facility policy requiring medications to be given within one hour of the prescribed time and fully documented.
A cognitively intact, blind resident was unable to make and receive private phone calls after in-room landlines were removed and the facility declined to allow installation of a private landline at the resident’s expense. The resident relied on a voice-controlled device that only allowed outgoing calls on speaker, eliminating privacy, and reported that a previously available cordless phone was no longer working. Staff described routing calls through the nurse’s station and inconsistently referenced portable phones for privacy, while family members reported they could no longer directly reach the resident, often encountering unanswered or busy lines and having to wait for return calls on speaker. These actions and inactions conflicted with facility policies guaranteeing residents easy access to telephones and the right to use a telephone in privacy.
A resident who shared a room with another resident diagnosed with head lice did not have a care plan developed to address her risk of contracting lice. The at-risk resident was later found to have live lice and received treatment, but there was no documentation of ongoing monitoring for lice or related symptoms as required by facility policy.
Two residents experienced significant delays in call light response, with one waiting up to an hour for toileting assistance and another waiting up to 45 minutes for a breathing treatment, both relying on staff for essential care. Staff interviews confirmed frequent short staffing, leading to high resident assignments for CNAs and LVNs, missed care tasks, and inability to provide timely responses to resident needs.
A CNA's employee file lacked documentation of completed skills competency verification, as confirmed by the Administrator during record review. Facility policy requires all nursing staff to meet competency requirements and demonstrate ability to identify, document, and report resident changes of condition, but this was not documented for the CNA.
A resident with dementia and major depressive disorder had a psychotropic medication discontinued by the IDT without notifying the responsible party or hospice provider, as required by facility policy. This omission resulted in the RP and hospice not being included in the care planning and decision-making process.
A resident requested copies of their medical records, but the facility did not provide the records within the two business days required by its policy. Instead, the records were sent 15 days after the request, resulting in a violation of the resident's rights.
A resident who required substantial assistance for toileting experienced a 40-minute delay in call light response, resulting in incontinence and emotional distress. Staff interviews confirmed frequent short staffing, with CNAs assigned to care for up to 24 residents per shift and unable to respond to call lights promptly, leading to unmet resident needs.
A resident with a history of fluid overload was still marked as being on a fluid restriction, as indicated by a green sticker on the door and an outdated care plan, even though the fluid restriction order had been discontinued months earlier. The care plan was not updated to reflect the change, contrary to facility policy requiring accurate clinical records.
A resident with a history of constipation and recent episodes of diarrhea did not have Docusate Sodium held as ordered during loose stools, and was not administered Imodium or Loperamide as prescribed for diarrhea. The DON confirmed that medications were not given or withheld according to physician orders, contrary to facility policy.
A resident did not receive prescribed doses of Apixaban and Metoprolol at the scheduled time due to the medications not being available in the medication cart, resulting in a delay of several hours before administration. The nurse on duty confirmed the delay and that the facility's policy requiring medications to be given within one hour of the scheduled time was not followed. The DON also acknowledged the deviation from both physician orders and facility policy.
A resident reported feeling uncomfortable and unsafe after an LVN entered her room and kissed her. The incident was not reported to the appropriate authorities in a timely manner, as required by the facility's policy. The delay in reporting led to the resident experiencing increased anxiety, for which she was prescribed medication.
A resident with severely impaired cognition was not protected from physical and verbal abuse by another resident. Despite witnessing verbal abuse and reporting it to an LVN, no intervention occurred, leading to a subsequent physical assault. The facility's abuse prevention policy was not followed, as no protective measures were taken.
The facility failed to report a resident-to-resident physical abuse incident to the CDPH and local ombudsman within the required timeframe and did not conduct a thorough investigation. The DON confirmed the incident but did not provide evidence of timely reporting, and the investigation was limited to a few interviews, contrary to the facility's policy.
The facility failed to implement IDT recommendations for monitoring two residents involved in a physical altercation. Despite the IDT's advice to monitor for mood changes and delayed injury symptoms, no documentation of such monitoring was found for several days. This oversight contravenes the facility's policy on comprehensive, person-centered care plans, which require regular updates and monitoring following significant changes in a resident's condition.
The facility failed to follow its policy for documenting resident assessments after a verbal altercation involving a resident who threatened others. The DON confirmed that the LVN did not document initial assessments for the involved residents, violating the facility's policy requiring nurses to record changes in residents' conditions.
The facility failed to provide sufficient staffing, resulting in delayed call light response times for three residents. A resident reported wait times of 30 to 45 minutes, with the worst being two hours, while another experienced one and a half to two-hour delays. CNAs felt rushed, caring for up to 16 residents due to staff call-outs, which occurred one to two times a week. The facility's staffing policy was not met, leading to increased wait times for residents' basic needs.
The facility failed to administer and document treatments as prescribed for two residents, leading to potential risks of worsening skin conditions and infections. The Treatment Administration Records (TAR) showed multiple instances where treatments for moisture-associated skin damage and a fungal infection were not documented as administered. The Director of Nursing confirmed the missing documentation, indicating a failure to adhere to professional standards of quality care.
A resident with severe cognitive impairment and multiple health conditions developed a facility-acquired pressure ulcer due to the LTC facility's failure to follow its pressure injury prevention policy. The resident's skin condition was not regularly assessed or documented, and there was a lack of communication with the physician. The resident experienced pain, and the ulcer required further medical evaluation.
The facility failed to implement proper infection control practices, including a treatment nurse with long artificial nails, a frayed linen cart cover, housekeeping carts without lids, and lack of PPE in rooms on Enhanced Barrier Precautions. These deficiencies were confirmed by the Infection Preventionist Nurse and contradicted facility policies.
The facility did not follow its policy on Advance Directives for three residents, failing to document whether assistance was offered, accepted, or declined. The current form lacks a section for this documentation, and the Director of Admissions confirmed the absence of a process to ensure compliance with the policy.
A resident was prescribed psychotropic medications for depression and anxiety without documented informed consent, contrary to the facility's policy. The resident reported not being included in the decision-making process for these medications, and a review confirmed the absence of required consent forms.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a bed-bound resident while assisting with meals. The CNA acknowledged the inappropriate action, which contradicted the facility's policy requiring staff to assist residents with meals in a manner that ensures safety, comfort, and dignity. This oversight had the potential to negatively impact the resident's emotions, behavior, and social needs.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their psychosocial and physical needs. One resident's call light was clipped to a curtain, making it unreachable, while another's was on the floor. Both residents required assistance with daily activities, and their care plans emphasized the importance of accessible call lights.
A facility failed to inventory and document a resident's personal belongings upon admission, as required by their policy. The resident reported missing clothing items, but the Personal Belonging Inventory Checklist was blank, and no inventory sheet was found in the medical records. The Social Services Director confirmed that the inventory should have been conducted and documented.
A resident experienced significant weight loss over several months, but the facility failed to complete a change of condition assessment and notify the physician. Despite documented weight loss percentages indicating a significant change, there was no record of physician notification, contrary to the facility's policy.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for four sampled residents: Resident 107, Resident 76, Resident 14, and Resident 85. During interviews, Resident 107 stated the call light was not answered timely and described waiting a long time for it to be answered. Resident 76 stated it took staff a long time to answer the call light. Resident 85 stated they waited over an hour for a pain pill because staff took too long to answer the call light. Resident 14 also stated the call light was not answered timely. Record review showed Resident 107 was alert and oriented and required substantial assistance with activities of daily living. Resident 76 had a BIMS score of 15, indicating cognitive intactness, and was dependent with activities of daily living. Resident 85 had a BIMS score of 15 and required substantial/maximal assistance with activities of daily living. Resident 14 had a BIMS summary score of 15 and was dependent with activities of daily living. The facility policy titled "Answering the Call Light" stated to answer the resident's call as soon as possible.
Failure to Notify Physician and Resident Representative of Abuse Allegation and Changes in Condition
Penalty
Summary
The facility failed to notify the physician and resident representative of an alleged abuse incident involving Resident 81. Resident 81 had a BIMS score of 15, indicating cognitive intactness, and stated during observation that his roommate hit him on 4/3/26, causing a bruise to his right forearm. CNA 1 stated Resident 81 reported that Resident 109 struck him and that a fresh mark was seen on the forearm that day. The DON stated the allegation was not reported to the facility until 4/9/26, when the State Surveyor notified her, and that no assessment was completed until that date. The DON also confirmed that no physician or responsible party notification was made until 4/9/26. The facility also failed to notify the resident representative of changes in condition for Resident 83 and Resident 4. Resident 83 had a BIMS score of 10, indicating moderate cognitive impairment, and change in condition evaluations dated 5/9/26 and 5/11/26 documented an open wound to the left foot, redness and swelling to the right lower leg, and a skin tear to the left forearm. The QA Nurse stated only the resident was notified and no resident representative was notified. Resident 4 had a BIMS score of 3, indicating severe cognitive impairment, and a change in condition evaluation dated 5/8/26 documented weight loss. The QA Nurse stated no resident representative was notified and only the resident was notified.
Falls Prevention and Safe Transfer Failures
Penalty
Summary
The facility failed to ensure floor mats were in place on both sides of the bed for one resident identified as being at risk for falls. The resident’s care plan included floor mats to the left and right side of the bed, and during observation the resident was sleeping in bed without fall mats at the bedside. A CNA later stated the resident did not have fall mats at bedside. The facility also failed to implement the Falling Star fall prevention program for another resident. That resident’s care plan included the Falling Star program, which called for a Falling Star identifier on the outside of the room door and on assistive devices as applicable. During observation and interview, the DSD stated there was no Falling Star on the resident’s name plate. Staff interviews showed confusion about the meaning of room identifiers, with CNAs stating the happy face sticker indicated fall risk, while the DON stated the happy face sticker indicated enhanced barrier precautions and the gold star on a name plate indicated participation in the Falling Star program. The facility failed to safely transfer a resident using a Hoyer lift. The resident had a BIMS score of 15 and was completely dependent for bathing and showers. During the transfer, the resident stated he was transferred alone by one CNA even though two CNAs were supposed to assist, and he reported the Hoyer tipped over and he hit the back of his head and neck on the foot board of the bed. The incident report written by a CNA stated the bed tilted when the resident’s weight shifted. The facility’s competency evaluation for mechanical lift transfers directed staff to raise the lift until the resident and sling were elevated and clear of the bed or wheelchair/geri-chair. The facility also failed to evaluate and train staff on a resident’s personal shower chair before allowing its use. The resident had complete quadriplegia, was completely dependent for bathing and showers, and preferred to use his own shower chair from home. The care plan stated maintenance would evaluate the chair for safety and therapy would educate the resident on safety, but the chair was not evaluated for safety until after the fall. During the shower, the chair rolled, flipped on its side, and threw the resident to the shower floor, causing him to hit his head on the wall and face on the floor, with a nosebleed and severe pain. Staff stated the chair was too heavy for the resident, was unsafe, and that they had not been trained on its use or operation.
Incomplete Dialysis Communication and Post-Dialysis Assessments
Penalty
Summary
Safe, appropriate dialysis care/services were not provided when the facility failed to ensure Hemodialysis Communication Observation/Assessment (HCOA) forms were accurately completed for three sampled residents receiving dialysis. Resident 7 had diagnoses including diabetes mellitus with hyperglycemia and an MDS showing intact cognition with a BIMS score of 15. The OSR indicated dialysis three times per week on Monday, Wednesday, and Friday. Review of Resident 7’s HCOA forms for April and May 2026 showed multiple missing entries, including missing arrival time post dialysis, licensed nurse signature, date, and several blank sections to be completed by the licensed nurse after dialysis. The MDSN stated Resident 7 should have been assessed after dialysis and the HCOA form should have been fully completed. Resident 5 had diagnoses including type 2 diabetes mellitus and end stage renal disease, with an MDS showing a BIMS score of 15 and an OSR indicating hemodialysis three times per week on Tuesday, Thursday, and Saturday. Review of Resident 5’s HCOA forms showed a missing licensed nurse signature and date on one form and a blank post-dialysis section on another. The MDSN stated the post-dialysis treatment portion should have been completed by the nurse and that all residents returning from dialysis should be assessed for bleeding. Resident 83’s HCOA forms for April and May 2026 also contained multiple blank sections, including missing entries from the dialysis center and missing post-dialysis completion by the licensed nurse. The QA Nurse stated the HCOA forms were blank and should have been completed.
Insufficient CNA Staffing and Missed Shower Documentation
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and did not follow its Facility Assessment when CNA staffing levels were below the planned ratios. Nursing Staffing Assignments showed that on 12/3/25, 92 residents were cared for by nine CNAs on the morning shift and seven CNAs on the evening shift; on 12/10/25, 99 residents were cared for by seven CNAs on the morning shift and eight CNAs on the evening shift; and on 12/24/26, 94 residents were cared for by seven CNAs on the morning shift and six CNAs on the evening shift. The Facility Assessment dated 12/18/25 indicated CNA/RNA staffing ratios of 1 to 8-9 residents on day shift, 1 to 11 residents on evening shift, and 1 CNA to 16 residents on night shift, and the DSD stated the facility did not meet those staffing requirements. During interviews, CNA 16 stated she normally worked the morning shift and had 11 residents that day, but when the facility was short staffed she had up to 15 residents and sometimes showers or repositioning were missed. CNA 18 stated that when the facility was short staffed, CNAs had up to 18 residents, call lights took longer to answer, and showers were sometimes missed. The DSD stated she took over the position because the previous DSD was not scheduling enough CNAs to meet resident needs and she did not ensure showers were completed. Review of the shower sheets showed no shower sheets on 12/3/25, 12/10/25, or 12/24/25. The facility policy for bathing required documentation of the shower date and time, staff involved, assessment data, resident tolerance, refusal reasons if applicable, and the recorder's signature and title.
Missing CNA Competency Documentation
Penalty
Summary
The facility failed to provide documentation of competency and skills performance for three of five sampled CNAs: CNA 8, CNA 10, and CNA 11. During a concurrent interview and record review with the DSD, CNA 8’s personnel file showed the last competency was completed on 3/1/25, and the DSD stated the next competency was due on 3/1/26 but had not been completed. CNA 10’s personnel file showed the last competency was completed on 3/23/25, and the DSD stated the next competency was due on 3/23/26 but had not been completed. CNA 11’s personnel file showed the last competency was completed on 3/1/25, and the DSD stated the next competency was due on 3/1/26 but had not been completed. The facility provided a policy titled Competency Evaluations dated 12/2026, but it did not address how often competencies should be completed.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five of five sampled CNAs: CNA 7, CNA 8, CNA 9, CNA 10, and CNA 11. During concurrent interview and record review with the Director of Staff Development, each CNA's personnel file was reviewed and no performance evaluation was found for any of the five employees. The Director of Staff Development stated that no performance evaluation had been completed for each of these CNAs. The personnel file for CNA 7 showed a hire date of 4/12/23, and the personnel files for CNA 8, CNA 9, CNA 10, and CNA 11 showed hire dates of 3/1/23. The facility's policy and procedure titled, Performance Evaluations, dated 9/2020, stated that a performance evaluation would be completed on each employee at the conclusion of the 90-day probationary period and at least annually thereafter.
Infection Control Failures With Laundry Storage, Dirty AC Unit, and EBP Noncompliance
Penalty
Summary
The facility failed to implement infection control practices when residents’ clean personal laundry was stored in the Housekeeping/Laundry Supervisor’s office rather than in a separate designated space. During observation, the clean laundry was kept in the office with chemicals, cleaning materials, an office desk, a microwave, filing cabinets, and personal belongings located about two feet away. The Housekeeping/Laundry Supervisor stated there was nowhere else to store the laundry. The facility’s Laundry and Bedding, Soiled policy stated that clean linen is kept separate from contaminated linen and that separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination. The facility also failed to keep a portable AC in the laundry room clean; thick gray debris was observed in the front and side vent grills, and the Housekeeping/Laundry Supervisor stated it was not clean. In addition, two CNAs entered Resident 108’s room for high-contact care while the resident had an Enhanced Barrier Precautions sign posted, but they did not wear gowns. The CNAs changed the resident’s brief, clothing, and linens without gowns, and one CNA stated they should have worn a gown. Resident 108’s care plan required Enhanced Barrier Precautions during high-contact resident care activities because of a chronic arterial ulcer to the left 2nd toe, and the facility’s Enhanced Barrier Precautions policy required gown and glove use for activities such as dressing, hygiene, linen changes, brief changes, and wound care.
Call Lights Not Accessible or Working in Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to ensure that a working call system was available in resident bathrooms, bathing areas, and at the bedside for multiple residents. Resident 51’s MDS dated 3/27/26 showed a BIMS score of 15, indicating cognitive intactness. During an interview on 4/15/26, Resident 51 stated that staff sometimes did not give him his call light. On 4/16/26, a CNA observed Resident 51 sleeping in bed while his call light was on the nightstand about three feet away, and the CNA stated the resident could not reach it. Resident 49 was observed in bed on 5/11/26 with an empty water jug and pressed the call light to request water, but the call light did not activate. Resident 49 stated the call light was not working, and the DM later inspected the system and stated it was not operational because the cable needed to be replaced. On 5/13/26, the DM inspected shower room call systems in halls 200, 400, and 500 and found call lights in three of four shower rooms inaccessible to residents because strings were missing or the call lights were placed outside the shower stalls. The facility policy stated residents are to have a means to call staff from the bed, toileting/bathing facilities, and from the floor.
Unsafe Storage of Laundry Supplies Near Washing Machine
Penalty
Summary
The nursing home failed to maintain a safe environment when multiple cardboard boxes containing commercial detergents, bleach, and soap solutions were stored behind the washing machine in the laundry room. During observation, the boxes were placed approximately one to two inches from the back of the washing machine, where electrical wiring, tubing, water hoses, and a heat-emitting motor were located. During interview, the Housekeeping and Laundry Supervisor stated the cardboard boxes should not have been there, and the Housekeeping and Laundry Manager stated there was no policy for safely storing supplies.
Staff spoke other languages while providing care
Penalty
Summary
The facility failed to ensure that three sampled residents were treated with respect and dignity when staff conversed in a language other than the residents' primary language while providing care. Resident 79's MDS dated 12/18/25 showed a BIMS score of 15 and the admission record listed English as the primary language. During interview, Resident 79 stated CNAs spoke other languages in his room, which made him feel disrespected and isolated, and he believed staff were talking about him based on the looks they gave each other while providing care. Resident 23's MDS showed a BIMS score of 15 and the admission record listed English as the primary language. Resident 23 stated he did not like when CNAs came into his room and spoke their own language to each other, and said, "I am not stupid I know they are talking about me," adding that the Hispanic and Filipino CNAs had their own cliques. Resident 81's MDS showed a BIMS score of 15 and the admission record listed English as the primary language. Resident 81 stated CNAs spoke Spanish while providing care and that he did not like it because he thought they were talking about him sometimes. CNA 1 and CNA 2 both stated staff should not speak languages the resident does not speak because residents may think staff are talking about them. The facility policy stated employees shall treat all residents with kindness, respect, and dignity, and that English must be spoken at all times when in resident areas.
Delayed Investigation of Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, when an allegation that Resident 81’s roommate had hit him was not investigated timely. According to the Resident to Resident Altercation Investigation for Resident 81, a CNA stated that Resident 81 reported on 4/3/26 that his roommate had hit him. The DON stated in interview that the alleged abuse occurred on 4/3/26, but the abuse allegation was not reported to the facility until 4/9/26, and the investigation did not begin until 4/9/26, which was 6 days after the alleged abuse was reported to facility staff. The facility policy stated that all reports of resident abuse are to be thoroughly investigated and that within five business days of the incident, the administrator will provide a follow-up investigation report.
Delayed Reporting of Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported timely for one resident who was cognitively intact, with an MDS dated 2/1/26 showing a BIMS score of 15. During an observation and interview on 4/9/26, the resident stated that his roommate hit him the prior week and that he blocked the hit with his right forearm, resulting in bruising; several bruises in various stages of healing were observed on the right forearm. The resident stated he informed CNA 1 on 4/3/26, the day of the altercation, that he had been physically struck by the roommate. CNA 1 stated that on 4/3/26 the resident reported a physical altercation with the roommate and said the roommate struck his right forearm, and CNA 1 observed what appeared to be a fresh mark on the forearm that day. A review of the roommate’s NRC showed the roommate was moved to another room on 4/3/26. The DON stated the abuse allegation was not reported to the facility until 4/9/26, and that CNA 1 assumed the nurse was aware and did not report it. The DON also stated abuse allegations with injuries should be reported within 2 hours and no injuries within 24 hours to the state, LTC Ombudsman, and local law enforcement, but the alleged abuse was not reported to those authorities until 4/9/26, six days after it was first reported to staff.
PASRR Screening Not Completed Accurately for a Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete PASRR screening for one sampled resident with a positive Level I screen. Resident 4’s PASRR Level I screening dated 2/20/24 was marked positive, and during interview the QA Nurse stated that no Level II PASRR had been completed for the resident. The record review showed Resident 4 had diagnoses of bipolar disorder, psychosis, dementia, and adjustment disorder with mixed anxiety and depressed mood. A later PASRR Level I screening dated 11/14/25 was also reviewed and showed the answer to the question about a serious diagnosed mental disorder was marked No. During interview, the QA Nurse stated the PASRR had been filled out incorrectly because the resident had a diagnosis of mental illness and was taking medication for mental illness. The facility policy titled admission Criteria PASARR stated that if the Level I screen indicates the individual may meet criteria for MD, ID, or RD, the person is referred for the Level II screening process.
Failure to Implement Fall-Related Care Plans
Penalty
Summary
The facility failed to implement care plans for two sampled residents, Resident 51 and Resident 70. Resident 51’s comprehensive care plan identified a fall risk and included interventions such as floor mats to the left and right side and keeping the call light within reach. During a concurrent observation and interview, Resident 51 was found sleeping in bed with the call light pad on the nightstand approximately three feet from the bed, and the CNA stated the resident would not have been able to reach it. The same CNA later stated that Resident 51 did not have fall mats at the bedside. Resident 70’s care plan identified a fall risk after an unwitnessed fall and included the Falling Star fall prevention program, which called for placing a Falling Star identifier on the outside of the room door and on assistive devices as applicable. During a concurrent observation, interview, and record review, the DSD stated there was no Falling Star on Resident 70’s name plate. The facility’s policy and procedure for comprehensive person-centered care plans stated that each resident’s care plan includes measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs and is developed and implemented for each resident.
Medication Not Available for Ordered Inhaler
Penalty
Summary
The facility failed to administer medication according to the physician order for one resident who had an order for Trelegy Ellipta inhalation aerosol powder, 100-62.5-25 mcg/act, one inhalation daily. The resident's order summary showed the medication order, and the communication result report showed that Trelegy was reordered from the pharmacy on 5/12/26 at 2:47 p.m. During a concurrent observation and interview on 5/13/26 at 8:20 a.m., RN 1 prepared the resident's medications for administration but there was no Trelegy inhaler available, and RN 1 stated there was no Trelegy inhaler available to administer. The facility policy on medication ordering and receiving from pharmacy stated medications should be reordered three to four days in advance of need to assure an adequate supply is on hand.
Failure to Provide Ordered Repositioning for Resident with Stage 4 Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with a stage 4 pressure injury to the coccyx. The resident’s MDS dated 3/27/26 indicated the resident was dependent for rolling left and right and for sit-to-lying, and the resident had a stage 4 pressure injury upon admission. The resident’s care plan for skin integrity, initiated 3/23/26, included treatment administration, monitoring for effectiveness, and a low air loss mattress, but it did not include turning and repositioning interventions. During interviews, the Treatment Nurse, QA Nurse, and MDSN stated that residents with pressure injuries should have turning and repositioning every two hours and that the resident’s care plan did not indicate turn and reposition. The resident’s OSR dated 4/28/26 showed orders for q2h repositioning while in bed during day time with wedge every day shift and every evening shift, starting 4/8/26. However, the resident’s DSR for February, March, and April 2026 showed multiple instances where the resident was not turned and repositioned for extended periods, including periods of 8, 10, 14, 18, 22, and 24 hours in a day. The documentation also showed several entries of self-repositioning and one refusal to turn and reposition. The QA Nurse and MDSN stated the resident would not be able to turn and reposition himself. The facility policy titled Prevention of Pressure Injuries stated residents at risk should be repositioned as indicated on the care plan and on an individualized schedule determined by MD order. The record review showed the resident had a stage 4 pressure injury, was dependent for mobility, had orders for q2h repositioning, and yet the care plan did not include turn and reposition interventions while the documentation reflected repeated missed repositioning opportunities.
Inaccurate nutritional assessment for resident receiving enteral feeding
Penalty
Summary
The facility failed to ensure the nutritional assessment was accurate for one resident who had a feeding tube and was receiving enteral nutrition. During observation, the resident was in bed with a feeding tube attached to a pole and connected to a bottle labeled Jevity 1.5. The resident’s Dietitian Note dated 4/9/26 documented Jevity 1.2 at 72 mL/hr for 20 hours, providing 1728 kcal/day, 80 gm protein/day, and 1152 mL free water/day. Record review showed the Medication Administration Record documented the resident received Jevity 1.5 from 3/3/26 to 5/12/26, and the Order Summary Report also listed Jevity 1.5 at 72 mL/hr for 20 hours. During interview, the RD stated she had recommended Jevity 1.2 and was not aware it had been changed to Jevity 1.5, and stated she did not look at her notes and needed a better system and self-audit. An LVN stated there was a time the facility had no supply of Jevity 1.2, the doctor was called and approved Jevity 1.5, and there was no documentation notifying the RD of the formula change.
Missing Physician Progress Notes for Resident
Penalty
Summary
The facility failed to ensure physician progress notes were completed for Resident 90 for the months of February, March, and April 2026. During record review, the Medical Records Director reviewed Resident 90’s physician progress notes and stated there were no notes for those three months, adding that physicians usually fax the notes. The Minimum Data Set Nurse also reviewed the record and stated she could not find the physician progress notes for the last three months, and stated that physician progress notes should be completed monthly. The facility’s policy on Physician Visits stated the attending physician must visit residents at least once every thirty days for the first ninety days after admission and then at least every sixty days thereafter, and must complete relevant documentation at each visit. The facility’s policy on Physician Progress Notes stated the attending physician must write, sign, and date the physician progress notes upon each visit.
Failure to Count and Document MedBank Narcotics Daily
Penalty
Summary
The facility failed to follow its MedBank Policies & Procedures regarding controlled drug cycle counts. During an interview, the DON stated there was no process in place to count narcotics in MedBank and that the facility was not counting narcotics daily in the system, even though the DON stated they should be counted daily. A review of the facility’s MedBank Policies & Procedures, dated 10/2025, showed that the DON is responsible for ensuring cycle counting of controlled drugs in the MedBank system is performed and documented on a daily basis.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to ensure that clinical documentation was complete and accurate for two sampled residents. For one resident with a BIMS score of 15 on the MDS, the record contained conflicting documentation about an incident on 4/13/26. The resident stated he was transferred by a CNA using a Hoyer lift when it tipped over and he struck his head and neck on the bed footboard, while the DON later stated there was no fall and that the resident was sent to the acute hospital for neck and back pain at his request. The resident’s CICE documented that he hit his neck and shoulder on the bed corner during transfer and complained of neck and back pain rated 8/10. The same resident’s chart also contained inconsistent entries in alert charting and transfer-related documents. Alert charting entries on 4/14/26 and 4/15/26 described the resident as being monitored for a witnessed fall or fall, while the DON stated those entries were mistakes and that staff had become confused because there were many falls. The discharge instructions from the hospital listed the reason for visit as fall, and the prehospital care report described the cause of injury as a fall from another level with a call type of falls. The transfer form had the reason for transfer left blank, and the DON stated the reason should have been documented in the CICE. For the second resident, a medication administration discrepancy was observed at the nurses’ station. Eight pills were found in a medication cup in the cart, and the LVN stated they were for the resident and had been refused. The LVN also stated the medications were due at 9 a.m. and admitted she signed the MAR as if the medications had been administered even though they were not given. The facility policy required that all services provided, and changes in condition, be documented in the medical record, and that clinical records accurately reflect the care given and the response of the resident.
Failure to Offer Influenza Vaccines
Penalty
Summary
The facility failed to ensure influenza vaccines were offered to two sampled residents, Resident 11 and Resident 60. During a concurrent interview and record review, the infection preventionist reviewed Resident 11's immunization record and stated that Resident 11 did not receive a flu vaccine and that there was no documentation showing the vaccine was offered. The infection preventionist also reviewed Resident 60's immunization record and stated that Resident 60 had no record of immunization, noting, "I missed it [to record Resident 60's immunization]. I did not get to verify." The facility policy titled, Influenza Vaccine, dated March 2022, stated that all residents and employees without medical contraindications are to be offered the influenza vaccine annually between October 1 and March 31, and that residents or their legal representatives are to receive information and education regarding the benefits and potential side effects prior to vaccination.
Failure to Maintain Functional Hoyer Lift Equipment and Maintenance Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure essential Hoyer lift equipment and related maintenance systems were functioning properly. One of two Hoyer lift battery chargers in the designated charging station was observed not charging the Hoyer lift battery, despite power reaching the charging port. Two cognitively intact residents, each with a BIMS score of 15 on their respective MDS assessments, reported prior incidents in which the Hoyer lift stopped working due to dead batteries while they were in full body slings—one while in bed and the other while in a wheelchair. The facility’s existing policy on using mechanical lifting machines required staff to make sure the battery is charged before use. The facility also lacked appropriate maintenance oversight and documentation for the Hoyer lifts and their batteries. The Maintenance Supervisor stated that no maintenance log was kept for the Hoyer lifts and that work orders were not being submitted for these devices. The Administrator reported not knowing whether there was an official P&P for the Hoyer lift and confirmed there was no owner’s manual for the Hoyer lift batteries, and he was not aware of any maintenance logs. This was inconsistent with the facility’s Maintenance Service policy, which assigned responsibility to the maintenance department and director to maintain equipment in a safe and operable manner and to develop and maintain a schedule of maintenance service.
Untimely Call Light Response for Residents Requiring Extensive Assistance
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for three cognitively intact residents who required extensive assistance with ADLs and mobility. One resident, who was dependent for sit-to-stand and bed-to-chair transfers and required extensive assistance with dressing, toileting, and transfers using a Hoyer lift, reported using the call light to have his urinal emptied and to get in and out of bed. He stated that call lights could take from 30 minutes to an hour and a half to be answered and that he preferred to get up at 6 a.m. but was sometimes not assisted out of bed until 8 a.m., which made him feel terrible and shaky because he wanted to get up. Another resident, with a BIMS score indicating intact cognition, reported using the call light to request breathing treatments and stated he typically waited 20–30 minutes for staff to respond. If no one responded within that time, he would go to the nurse’s station himself, where he observed nurses and CNAs sitting at the station, and he stated that the wait time made him feel angry. A third resident, also cognitively intact and requiring substantial/maximal assistance for toileting hygiene and transfers with a mechanical lift, reported using the call light to request ice and incontinence care. This resident stated that the worst wait time for a call light response was up to an hour, which made him feel frustrated. His care plan included interventions such as two-person extensive assistance for toileting, two-person total assistance with a mechanical lift for transfers, and offering toileting on rounds, upon request, and as needed. CNAs interviewed on the night shift reported feeling rushed and hurried, with one CNA assigned 15–17 residents and another 18–23 residents when the facility was short staffed, and one CNA stated she did not take her ten-minute breaks. The facility’s Resident Rights policy required employees to treat residents with kindness, respect, and dignity and to assist each resident in exercising their rights, but residents’ reports of prolonged call light response times and associated negative feelings demonstrated that this was not consistently achieved.
Failure to Administer and Document Medications Timely and as Ordered
Penalty
Summary
The facility failed to ensure medications were administered timely and in accordance with professional standards for two cognitively intact residents. One resident, with a Brief Interview for Mental Status (BIMS) score of 15 and chronic pain in the arm and leg, reported that medications were sometimes given on time and sometimes not, and that waiting for medications worsened the pain. Review of this resident’s physician orders dated 7/5/24 showed an order for Diclofenac Sodium 1% topical gel to be applied to the shoulders twice daily for chronic pain. Review of the Medication Administration Record (MAR) for February 2026, confirmed by the Director of Nursing (DON), showed that on 2/11/26 the 5 p.m. dose of Diclofenac gel was documented as administered at 8:17 p.m., which was 3 hours and 17 minutes after the scheduled administration time, outside the facility’s policy requirement that medications be administered within one hour of the prescribed time. A second resident, also with a BIMS score of 15, reported using the call light to request breathing treatments and having to wait 20–30 minutes before going to the nurse’s station. This resident further stated that a stomach medication was not received about a week prior, despite informing the nurse. Review of this resident’s MAR for February 2026 with the DON showed an order for Ipratropium/Albuterol 3 ml via nebulizer four times daily for shortness of breath or wheezing, with a start date of 7/26/25, and an order for Pantoprazole 40 mg delayed-release tablet by mouth once daily at 6 a.m. for esophagitis, with a start date of 1/24/26. On 2/18/26 at the 6 a.m. administration time, both the Ipratropium/Albuterol and Pantoprazole doses were left blank on the MAR, indicating they were not documented as administered, contrary to the facility’s medication administration policy requiring safe, timely administration as prescribed and documentation of the date and time medications are given.
Failure to Ensure Private and Accessible Telephone Use for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact, blind resident had reasonable access to and privacy in the use of telephones, as required by resident rights and the facility’s own policies. The resident, who had a BIMS score of 15 and had lived in the facility for about six years, reported that landline phones were removed from resident rooms approximately six months prior and that the facility would not allow installation of a private landline in his room, despite policy stating residents may have private telephone lines at their own expense. The resident stated he could not use a cell phone due to blindness and instead relied on a personal voice-controlled device to make calls, which required use of speaker mode and did not allow him to receive incoming calls, eliminating privacy. He also reported that a previously available portable phone was no longer working and not available for his use. Staff interviews showed inconsistent and inadequate practices for providing private phone access. CNAs and the receptionist/hospitality staff indicated that residents generally make and receive calls at the nurse’s station, and that staff either bring residents to the nurse’s station or transfer calls there. One CNA and the receptionist stated that portable phones were available for private calls, but the resident and family members reported that staff had said the cordless phone was no longer available or not working. Family members stated they previously called the resident daily but now could not directly reach him; instead, they encountered busy signals, unanswered calls, or had to leave messages so the resident could call them back using his voice-controlled device on speaker, without privacy. The administrator confirmed the facility had upgraded the phone system and that replacing in-room phone lines would require opening walls, but there was no indication that alternative arrangements ensured the resident’s right to private telephone use, contrary to the facility’s Resident Rights and Telephones policies.
Failure to Develop and Implement Care Plan for Resident at Risk of Head Lice
Penalty
Summary
The facility failed to develop a care plan for a resident who was at risk for contracting head lice after her roommate was diagnosed with head lice. On review of records, it was found that when the first resident was observed with head lice, there was no care plan created for the second resident, who shared the room and was therefore at risk. The Infection Preventionist confirmed that a care plan should have been developed for the at-risk resident due to her close contact with the affected roommate, but this was not done. Further review showed that the at-risk resident was later found to have live head lice and received treatment. However, there was no documentation that she was monitored for head lice after the initial assessment and treatment. The Infection Preventionist stated that the resident should have been monitored every shift for signs of itching and for the presence of lice or nits, but the absence of documentation indicated that this monitoring did not occur. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, which was not implemented in this case.
Delayed Call Light Response Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two of five sampled residents. One resident, who is cognitively intact and dependent on staff for toileting and hygiene, reported using the call light for assistance with water and changing, and stated that the shortest wait time experienced was 30 minutes, with waits extending up to an hour. This resident expressed dissatisfaction with the wait times, indicating a desire to leave the facility. Review of the resident's care plan confirmed the need for assistance and the intervention to encourage use of the call light. Another resident, also cognitively intact and at risk for ADL/mobility decline, reported waiting up to 45 minutes for a breathing treatment after using the call light, leading the resident to go directly to the nurses' station for assistance. This resident's care plan included interventions for respiratory care and medication administration as ordered. Staff interviews revealed that CNAs and LVNs were frequently assigned high numbers of residents, especially during staff call-offs, with CNAs caring for up to 18 residents and LVNs for up to 32 residents per shift. Staff reported that short staffing occurred multiple times per week, making it difficult to meet resident care needs and resulting in missed showers and breaks. The facility's policy and procedure for call lights was requested but not provided during the survey.
Failure to Verify CNA Skills Competency
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) possessed the necessary skills and abilities to provide adequate nursing care to residents. During an interview and review of employee records with the Administrator, it was found that the CNA's skills competency checklist had not been completed, despite the CNA having signed the job description and having a documented performance objectives form. The Administrator confirmed that there was no evidence of completed skills competency verification for the CNA. Review of the facility's policy indicated that all nursing staff are required to meet specific competency requirements and demonstrate competency in identifying, documenting, and reporting resident changes of condition, but this was not documented for the CNA in question.
Failure to Notify Responsible Party and Hospice of Psychotropic Medication Discontinuation
Penalty
Summary
The facility failed to notify the responsible party (RP) and hospice provider when a psychotherapeutic medication, Quetiapine, was discontinued for a resident with diagnoses including senile degeneration of the brain, dementia, and major depressive disorder with severe psychotic symptoms. The resident was under hospice care and had an identified RP. The decision to discontinue the medication was made by the interdisciplinary team (IDT) following a recommendation from the physician's assistant, and the team agreed to the discontinuation. Upon review of the resident's medical record, there was no documentation that the RP or hospice provider had been informed of the medication change. The facility's policy requires the IDT, in conjunction with the resident and their family or legal representative, to develop and implement a comprehensive, person-centered care plan, including participation in care planning and notification of significant changes. The lack of documentation and notification meant that the RP and hospice provider were not included in the decision-making process regarding the resident's care.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure regarding access to personal and medical records for one resident. Specifically, a resident submitted an Authorization to Release Medical Records (ARMR) form, which was signed and dated, requesting access to their medical records. The Medical Records Director confirmed that the request was not for legal reasons and was made directly by the resident. Despite the facility's policy stating that residents may obtain copies of their records within two business days of an oral or written request, the records were not provided to the resident until 15 days after the request was submitted, as evidenced by a certified mail receipt. This delay resulted in a violation of the resident's rights to timely access their personal and medical records.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by delayed responses to call lights and unmet basic care needs for one resident. The resident, who was cognitively intact and required substantial to maximal assistance for toileting and was dependent for toilet transfers, reported waiting 40 minutes for assistance after activating the call light due to a full urinal. Unable to wait any longer, the resident urinated on himself and his bedding, resulting in emotional distress and feelings of worthlessness. The resident stated that call light wait times on evening and night shifts ranged from 20 minutes to two hours, and that staff did not respond promptly to requests for help. Interviews with CNAs confirmed that staffing levels were insufficient, with one CNA assigned to as many as 24 residents on some shifts and reporting that call lights were often answered late due to workload. Another CNA reported being assigned 12 to 20 residents and described short staffing as a common occurrence, making it difficult to meet residents' needs and requiring staff to skip breaks. The facility's policy requires sufficient nursing staff to provide care in accordance with resident care plans, but observations and staff interviews indicated that this standard was not met.
Failure to Update Resident Care Plan After Discontinuation of Fluid Restriction Order
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with a history of fluid overload. A Certified Nursing Assistant (CNA) identified that the resident had a green sticker on the door, indicating a fluid restriction was in place. Review of the resident's care plan showed an intervention for fluid restriction of 1500ml per day, which had not been updated. However, upon review of the resident's active orders with the Director of Nursing (DON), it was found that the fluid restriction order had been discontinued several months prior, but the care plan was not updated to reflect this change. The facility's policy requires that clinical records accurately reflect the care provided to ensure continuity of care, which was not followed in this instance.
Failure to Administer Medications per Physician Orders for Bowel Management
Penalty
Summary
The facility failed to administer medications according to physician orders for one resident who experienced multiple episodes of loose stools. The resident was prescribed Docusate Sodium for constipation with specific instructions to hold the medication if loose stools occurred. Despite this, the medication was not held on several occasions when the resident had documented episodes of loose stools, as confirmed by both the Activities of Daily Living flowsheet and the Medication Administration Record. The Director of Nursing acknowledged that the medication should have been withheld during these episodes, in accordance with the physician's orders. Additionally, the resident had physician orders for Imodium and Loperamide to be administered as needed for diarrhea. However, during at least two documented episodes of loose stools, neither medication was administered as ordered. The facility's policy and procedure required medications to be administered in accordance with prescriber orders, but this was not followed in the resident's case. The failures were confirmed through interviews and record reviews with the Director of Nursing.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician's orders for one resident. The resident was prescribed Apixaban for atrial fibrillation and Metoprolol for hypertension, both to be administered twice daily at 9 a.m. and another time. On the specified date, the resident did not receive these medications at the scheduled 9 a.m. time. Instead, the medications were administered at approximately 12 p.m., outside the facility's policy of administering medications within one hour of the prescribed time. The delay occurred because the medications were not found in the medication cart and had to be retrieved from the cubex machine. The resident, who was cognitively intact with a BIMS score of 15, reported the delay and noted that his blood pressure was elevated at the scheduled medication time, which was confirmed by the nurse on duty. The nurse acknowledged that the medications were not administered as ordered and that the facility's policy and procedure for timely medication administration was not followed. The Director of Nursing also confirmed that the medications were not given within the required timeframe and that the policy was not adhered to.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident in a timely manner to the California Department of Public Health and the local ombudsman. The incident involved a resident who reported that a Licensed Vocational Nurse (LVN) entered her room and kissed her on the corner of her mouth, making her feel uncomfortable and unsafe. The resident, who was cognitively intact with a BIMs score of 15, reported the incident to another LVN on the same day it occurred. However, the Director of Nursing (DON) did not report the incident to the appropriate authorities until several days later, which was not in compliance with the facility's policy requiring immediate reporting. The delay in reporting the incident resulted in the resident experiencing increased anxiety, for which she was prescribed hydroxyzine. The facility's policy and procedure on abuse reporting clearly stated that any suspicion of abuse must be reported immediately to the administrator and relevant authorities, with specific time frames outlined for different types of abuse. Despite this, the report of suspected abuse was not submitted within the required time frame, potentially leaving the resident unprotected from further abuse and causing emotional distress.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. Resident 1, who had severely impaired cognition with a BIMS score of 3, required substantial assistance with transfers. On one occasion, a Certified Nursing Assistant (CNA) witnessed Resident 2, who was cognitively intact with a BIMS score of 15, physically assaulting Resident 1 by hitting them in the chest. This incident was reported to Licensed Vocational Nurses (LVNs) but no immediate protective measures were taken. Prior to the physical assault, another CNA had observed Resident 2 verbally abusing Resident 1 by yelling and using profane language. This verbal abuse was reported to an LVN, who failed to intervene or separate the residents, potentially preventing the subsequent physical abuse. The facility's policy on abuse prevention, which mandates the protection of residents from abuse by others, was not adhered to, as evidenced by the lack of action taken to protect Resident 1 from further harm.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not submit the SOC 341, a report of suspected dependent adult/elder abuse, to the California Department of Public Health (CDPH) and the local ombudsman within the required timeframe for two residents involved in a resident-to-resident physical abuse incident. The Director of Nursing (DON) confirmed that the incident occurred on January 31, 2025, but was unable to provide evidence that the report was submitted within 24 hours as required by the facility's policy and state law. Additionally, the facility did not conduct a thorough investigation of the resident-to-resident physical abuse incident. The DON, who was responsible for the investigation, confirmed that only the Certified Nursing Assistant (CNA) who witnessed the incident, the charge nurse on duty, and the two residents involved were interviewed. The facility's policy requires a more comprehensive investigation, including interviewing all staff members who had contact with the residents during the period of the alleged incident and reviewing all events leading up to the incident. This incomplete investigation could potentially result in an incomplete understanding of the incident.
Failure to Implement IDT Recommendations for Resident Monitoring
Penalty
Summary
The facility failed to consistently implement the Interdisciplinary Team (IDT) recommendations for two residents involved in a physical altercation. The IDT had recommended monitoring both residents for mood changes and delayed signs or symptoms of injury following the altercation. However, upon review, it was found that there was no documentation of such monitoring for either resident from February 1 to February 4, 2025. The facility's policy and procedure on comprehensive, person-centered care plans require the IDT to develop and implement care plans that include measurable objectives and timetables to meet residents' needs. The care plans should be reviewed and updated when there is a significant change in a resident's condition. Despite these requirements, the facility did not document the necessary monitoring for the residents involved in the altercation, potentially leaving their physical and psychosocial needs unmet.
Failure to Document Resident Assessments After Verbal Altercation
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Change in Condition or Status' by not completing assessments for three residents following a verbal altercation incident. The incident involved a resident who had verbal altercations with another female resident and allegedly threatened two male residents. Despite these events, there was no documentation of assessments for the affected residents, which was a requirement according to the facility's policy. During an interview and record review, the Director of Nursing (DON) acknowledged that the Licensed Vocational Nurse (LVN) responsible had not documented the initial assessments for the residents involved in the verbal altercations. The facility's policy, dated February 2021, clearly stated that nurses must record information related to changes in a resident's medical or mental condition. The lack of documentation for the involved residents after the incident on February 12, 2025, was a direct violation of this policy.
Insufficient Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient staffing, resulting in delayed response times to call lights for three residents. Resident 1 reported that call lights took 30 to 45 minutes to be answered, with the worst wait time being two hours, occurring two to three nights a week. Resident 1 required substantial assistance for toileting hygiene and was dependent on staff for transfers. Resident 2 experienced wait times of one and a half to two hours for call lights to be answered at night, feeling forgotten by the staff. Resident 2 also needed substantial assistance for toileting hygiene and was dependent on staff for transfers. Resident 3 reported waiting 25 to 30 minutes for call lights to be answered during the graveyard shift, which happened a couple of times a week, causing skin irritation due to prolonged exposure to urine. Certified Nursing Assistants (CNAs) reported feeling rushed and hurried during their shifts, often caring for up to 16 residents when the facility was not fully staffed. This situation occurred one to two times a week due to staff call-outs. The facility's policy on staffing indicated that sufficient numbers of nursing staff should be provided to meet residents' needs, but the observed staffing levels did not align with this policy. The deficiency in staffing led to increased wait times for residents' basic needs, such as toileting and pain management, to be met.
Failure to Administer and Document Treatments as Prescribed
Penalty
Summary
The facility failed to ensure that medications and treatments were administered according to physicians' orders for two residents, leading to potential risks of worsening skin conditions and infections. During an interview and record review with the Director of Nursing (DON), it was confirmed that medications and treatments should be administered and documented as per the physician's orders. However, the Treatment Administration Records (TAR) for two residents showed multiple instances where treatments were not documented as administered. For one resident, the TAR indicated that treatments for moisture-associated skin damage (MASD) to the coccyx and peri area were not documented as administered on several occasions. Specifically, there were no records of treatment being administered during evening and night shifts on multiple dates in January 2025. This lack of documentation suggests that the treatments may not have been provided as required, potentially compromising the resident's skin integrity and increasing the risk of infection. Similarly, another resident's TAR showed that Nystatin Powder, prescribed for a fungal infection, was not documented as administered on numerous dates in January 2025. The facility's policy and procedure for administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with proper documentation. The DON confirmed the missing documentation, indicating a failure to adhere to professional standards of quality care.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its policy and procedures for the prevention of pressure injuries, resulting in a deficiency related to the care of a resident, identified as Resident 79. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, diabetes, and end-stage renal disease, was at risk for developing pressure ulcers. Despite this risk, the facility did not consistently evaluate, report, or document changes in the resident's skin condition. The resident's treatment records indicated that the last treatment for blisters on the feet was conducted over a month prior to the survey, and there were no current orders for dressing changes. Observations and interviews revealed that the resident's feet had not been assessed or treated since late October, and the dressings had not been changed in a timely manner. The resident experienced pain during dressing removal, and a possible unstageable deep tissue injury was identified on the right heel. The facility's documentation, including the Nursing Weekly Summary and Resident Shower Log, inaccurately reported no new skin issues, and there was a lack of documentation regarding physician notification or wound assessment. The facility's policies required regular skin assessments and documentation of any changes, but these were not followed. The Treatment Nurse and Director of Nursing acknowledged the lack of assessment and documentation, and the resident's medical records did not reflect any communication with the physician regarding the skin condition. This oversight led to the development of a facility-acquired pressure ulcer on the resident's right heel, causing pain and necessitating further medical evaluation and treatment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations and interviews. A treatment nurse was observed with long artificial nails while providing wound care, which is against CDC guidelines as germs can live under artificial nails even after handwashing or using hand sanitizer. The Infection Preventionist Nurse confirmed that staff providing direct care should not have long artificial nails. Additionally, a linen cart containing clean linens was covered with a frayed mesh material that did not fully protect the linens from environmental contamination. The Housekeeping Manager acknowledged that the cover should be intact to protect the linens from dirt and microorganisms. The facility's policy requires clean linen to remain hygienically clean through protective measures, which was not adhered to in this instance. Furthermore, two housekeeping carts were observed with trash bins that lacked lids, instead being covered with towels and caution signs. The Infection Preventionist Nurse stated that the bins should have lids, as per the facility's policy to maintain a clean and safe environment. Lastly, three resident rooms on Enhanced Barrier Precautions lacked necessary PPE supplies, despite facility policy requiring PPE availability outside resident rooms. The Infection Preventionist Nurse confirmed the absence of PPE in these rooms, which is crucial for infection control, especially for residents with multi-drug resistant organisms.
Failure to Document Advance Directive Assistance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding Advance Directives (AD) for three residents, identified as Resident 32, Resident 40, and Resident 28. During a review of the records, it was found that these residents had not executed an Advance Directive, and there was no documentation indicating that assistance to develop an AD was offered, accepted, or declined. The Director of Admissions confirmed that there was no process in place to document whether assistance was offered, and the current form used by the facility did not have a section to indicate if assistance was offered, accepted, or declined. The facility's policy, dated 2000, requires staff to offer assistance in establishing advance directives if a resident or their representative has not done so. The policy also mandates that nursing staff document the offer of assistance and the resident's decision to accept or decline it in the medical record. However, this procedure was not followed for the three residents in question, potentially leaving the facility unaware of their wishes for medical treatment.
Lack of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 19, had informed consent forms for psychotropic medications prescribed by a physician. Resident 19 was admitted with diagnoses of major depressive disorder and anxiety disorder. During an interview, Resident 19 expressed that she had not been included in the decision-making process regarding her prescribed medications for anxiety and depression. A review of her medical records revealed that she was prescribed Nortriptyline, Fluoxetine, and Alprazolam on various dates, but there were no informed consent forms documented for these medications. The facility's policy and procedure on Psychoactive/Psychotropic Medication Use required that informed consent be obtained and documented in the medical record prior to the administration of psychotropic medications. During a review of Resident 19's medical record with a Registered Nurse Consultant, it was confirmed that informed consents were missing for the prescribed medications. The Registered Nurse Consultant acknowledged that informed consents should have been completed when the medications were ordered, as per the facility's policy.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during meal assistance. During an observation and interview, a CNA was seen standing over a resident while assisting with meals, which the CNA acknowledged was inappropriate. The resident, who was bed-bound and required assistance with meals, was in an upright position in bed during this interaction. The facility's policy on meal assistance clearly states that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, specifically noting that staff should not stand over residents while assisting with meals. This failure to adhere to the policy had the potential to negatively impact the resident's emotions, behavior, and social needs.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could potentially impact their psychosocial and physical needs. During an observation, Resident 186 was found lying in bed with the call light clipped to the curtain, making it unreachable. A Certified Nursing Assistant acknowledged the issue, and the resident's care plan indicated a need for assistance with activities of daily living due to generalized weakness and abnormal gait. The care plan also encouraged the use of the call light for assistance. Similarly, Resident 13's call light was observed on the floor, out of reach, and the resident was unaware of its location. A Licensed Vocational Nurse confirmed that call lights should not be on the floor and should be within reach. Resident 13 required substantial assistance for toileting hygiene and had a cognitive impairment, as indicated by a Brief Interview for Mental Status score of 00. The care plan for Resident 13 also emphasized the importance of having the call light within reach.
Failure to Inventory Resident's Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the inventory and documentation of personal property for a resident, identified as Resident 50. Upon admission, Resident 50's belongings were not inventoried and documented, as evidenced by a blank Personal Belonging Inventory Checklist (PBIC) dated February 2022. This oversight was discovered during an interview with the Social Services Director (SSD) and a review of the facility's records, which showed no reported missing clothing items for 2024, despite Resident 50's claim of missing a grey jacket, blue sweater, and black sweater. The SSD confirmed that the facility's policy required personal property to be inventoried and documented upon admission and updated as necessary. However, Resident 50's PBIC remained blank, and no inventory sheet was found in the medical records department. The SSD acknowledged that if Resident 50 had belongings, the PBIC should not have been blank. Additionally, a progress note from February 2022 indicated that Resident 50 and a significant other had received their belongings and found a radio they were looking for, suggesting that an inventory should have been conducted at that time.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to complete a change of condition assessment and notify the physician regarding a significant weight loss experienced by a resident. The resident, identified as Resident 66, experienced a series of weight losses over several months, which were documented in the Weights and Vitals Summary. The resident's weight decreased from 139 pounds in May to 116.6 pounds by November, marking a 16% weight loss over six months. The Registered Dietitian confirmed that the weight loss percentages over various periods were significant, yet there was no documentation of a change of condition form or physician notification. During a review of the facility's policy on changes in a resident's condition, it was noted that the policy requires prompt notification of the resident's physician in the event of significant changes in the resident's condition. However, the Registered Nurse Consultant confirmed that there was no documentation in the medical record indicating that the physician had been notified of the resident's significant weight loss. This oversight resulted in the physician being unaware of the resident's ongoing weight loss, which was a deviation from the facility's established procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 229 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Height Street Skilled Care | 2 mi | ★★★★★ | 19 | 0 |
| The Rehabilitation Center Of Bakersfield | 2.3 mi | ★★★★★ | 23 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 4.1 mi | ★★★★★ | 17 | 0 |
| The Orchards Post-acute | 4.3 mi | ★★★★★ | 33 | 0 |
| Valley Healthcare Center | 5.5 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bakersfield Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.