Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Crest Post-acute during CMS and state inspections, most recent first.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors observed a dirty main kitchen with grease and grime on the stove hood, buildup on pipes, drains, the toaster, the steamer descaler, and the portable cooler unit. Food storage issues included an unlabeled and undated rice container, brisket, and red gelatin dessert, an inadequately covered box of sliced mushrooms, and expired yogurt; the FSD and CDM confirmed the conditions.
A facility failed to maintain two resident shower rooms in a clean, homelike condition. Observations found chipped laminate on countertops, chipped and unadhered paint around shower stalls, water damage near one shower room, and flooring in disrepair in multiple areas, and the DON confirmed the rooms were in disrepair and did not represent a safe and aesthetic homelike environment.
Unsafe Shower Room Conditions: Two shower rooms were observed in disrepair, including an open hole in the floor and a wall-mounted temperature control apparatus with the lid off, exposing small wires and sharp edges. The DON confirmed the conditions and agreed they could pose a safety issue for residents using the area.
Failure to Provide Ordered PT Services: Five residents did not receive PT at the frequency ordered on their PT evals. Three residents ordered PT 5x/week and two residents ordered PT 3x/week missed multiple sessions over two consecutive weeks. Residents with dx including muscle weakness, unsteady gait, dementia, arthritis, paralysis, and a lower back fracture reported missed or absent therapy, and the DR confirmed the ordered schedules were not followed after a PTA quit.
A CNA did not follow care plans for two residents who required two-person assistance for transfers and ambulation. One resident with muscle weakness, unsteady gait, and dementia was transferred alone and fell to the floor when he could not bear weight. Another resident with a back fracture, weakness, and poor coordination was walked alone, fell, and sustained a skin tear when the CNA grabbed his arm. The DON confirmed both residents were supposed to have help from two staff members.
A nurse failed to wear gloves or other PPE while preparing phenytoin, a hazardous medication, for a resident. The pharmacy label identified the drug as hazardous, and the nurse later confirmed gloves were expected but were not used. The DON stated staff were expected to follow the precautionary instructions on the pharmacy label.
A resident with anxiety, HTN, and a thoracic vertebra fracture had controlled meds, including tramadol and Ativan, signed out on the CDR without matching entries on the MAR. The DON confirmed the records did not reconcile, and facility policy required the MAR to be completed immediately after medication administration.
Two residents with glaucoma continued receiving latanoprost eye drops after the opened bottles had passed the manufacturer’s beyond-use date. During cart review, the LPN confirmed both bottles were expired, yet the MARs showed each resident received the drops 16 times past expiration. The DON stated staff were expected to check expiration dates before administration and follow the shortened beyond-use dating for ophthalmic drops.
Surveyors found opened inhalers, an insulin pen, and eye drops in medication carts without open-date labels, along with expired medications still available for use. An LPN confirmed the unlabeled and expired items, and the DON stated staff were expected to check expiration dates before administration and that home meds were not permitted in the cart unless approved and labeled by the pharmacy.
A resident with diabetes, dementia, and chronic kidney disease experienced a significant decrease in brief changes and elevated blood glucose levels, but staff failed to recognize or report these changes to the MD or DON as required. Additionally, a lab order was not completed due to lack of follow-up after an initial refusal, and the MD was not informed that the labs were not drawn. The resident's condition deteriorated, leading to hospitalization and death.
A resident with multiple risk factors, including recent surgery, malnutrition, and incontinence, developed a stage 2 pressure ulcer after staff failed to perform and document required skin assessments and apply preventative treatments as ordered. Despite care plans and physician orders, CNAs and nursing staff did not identify or report skin changes, and interviews confirmed gaps in training and compliance with facility policy.
A facility failed to notify the MD about a resident's cognitive decline, despite assessments indicating severe impairment. The resident, diagnosed with Alzheimer's and dementia, was still listed as their own decision-maker. The facility's policy required notifying the MD of significant changes, but this was not done, leading to a deficiency.
A resident with severe cognitive impairment reported rough handling by a male staff member, but the facility failed to report the abuse allegation to authorities as required by their policy. The administrator, also the abuse coordinator, did not report the incident, believing it was unsubstantiated due to the resident's condition. No documentation of an investigation was found, and the responsible party was not contacted.
The facility failed to investigate an abuse allegation reported by a resident with severe cognitive impairment and did not report it to authorities. Additionally, the facility did not ensure the Behavior Management Committee reviewed the extended use of PRN Lorazepam for another resident with moderate cognitive impairment and anxiety disorder, lacking documentation of the rationale for the medication's extended use.
A resident was prescribed Lorazepam for an extended period without documented rationale, exceeding the 14-day limit for PRN psychotropic drugs. The facility's administrator and DON confirmed the absence of necessary documentation in the resident's medical record, which could lead to unsafe medication use.
The facility failed to maintain sanitary conditions during meal preparation and service. Pizzas were served at unsafe temperatures, and an employee did not follow proper hand hygiene and glove use while preparing salad. The Food Services Director acknowledged the lack of a specific policy for safe food holding temperatures, and the Culinary Director noted repeated infractions by the new hire involved.
The facility failed to keep the dumpster closed, as required by the U.S. FDA 2022 Food Code and facility policy. Observations showed the dumpster was open, confirmed by the FSD, who stated it had always been left open. The DON acknowledged the regulation to keep lids closed, while the Administrator was unsure of expectations but preferred the dumpster to be closed. This could potentially affect all 56 residents.
The facility failed to administer oxygen therapy correctly for three residents, leading to deficiencies in respiratory care. One resident received higher oxygen flow rates than prescribed, another received significantly less than ordered, and a third had a malfunctioning humidifier bottle on their oxygen concentrator. These issues were confirmed by staff, highlighting a lack of adherence to physician orders and proper equipment checks.
A facility failed to maintain effective infection control for residents with urinary catheters and those receiving respiratory care. A resident's catheter bag was observed dragging on the floor, contrary to policy. Respiratory equipment for two residents was improperly stored, with tubing and nebulizer parts left exposed, risking contamination. Staff interviews confirmed these practices violated infection control protocols.
The facility failed to accurately code oxygen use on the MDS assessments for two residents, despite documentation of oxygen administration in their MARs. Interviews with staff confirmed that the residents' oxygen use should have been reflected on the MDS, as per CMS guidelines. This deficiency highlights a lapse in the facility's assessment process.
A facility failed to ensure a Level I PASRR accurately reflected a resident's serious mental disorder and prescribed psychotropic medication. The resident, diagnosed with bipolar disorder and prescribed Depakote, had a PASRR completed after a temporary evacuation that incorrectly indicated no serious mental illness. Interviews revealed confusion among staff about responsibility for PASRR accuracy, with the DON acknowledging the error and the Administrator emphasizing the need for accurate PASRRs.
A facility failed to create a comprehensive care plan for a resident with a cardiac pacemaker, despite the resident's medical history and facility policy requirements. The care plan lacked documentation for pacemaker care and monitoring, as acknowledged by the DON and Administrator.
A facility failed to address pharmacy recommendations for a resident receiving antipsychotic medications. The resident, with a history of schizophrenia and bipolar disorder, required timely AIMS assessments as per the pharmacy's recommendation. However, the assessments were delayed, and the Director of Nursing acknowledged the oversight. The Pharmacy Consultant and Administrator expected adherence to the recommendations.
A resident with anxiety disorder received PRN phenobarbital without a stop date, contrary to facility policy requiring a 14-day limit unless extended with documented rationale. Despite multiple administrations over months, staff interviews revealed a lack of adherence to policy, with the Medical Director unaware of restrictions and the DON acknowledging the oversight.
A facility failed to maintain a medication error rate below 5%, affecting two residents. One resident received chewable aspirin instead of delayed release, and another was given metoprolol without a pulse check. Both errors were acknowledged by the LVNs involved, who admitted to not following proper medication administration protocols.
A facility failed to maintain a complete medical record for a resident with a cardiac pacemaker, missing crucial details such as the model, serial number, and implant date. Despite the resident's intact cognition and a care plan indicating the risk of pacemaker malfunction, the required information was not documented, which was acknowledged as an oversight by the DON and Administrator.
The facility did not update daily staffing postings with actual hours worked for 24 days, affecting 56 residents. Staff were unaware of the requirement to update postings every shift, and no specific person was assigned to this task for after-hours and weekends. The facility lacked a policy on staff postings.
A resident with multiple diagnoses, including dementia and diabetes, was found with an unexplained injury that was not reported to CDPH within the required timeframe. The DON did not document the injury or inform the administrator, resulting in a three-day delay in reporting.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain food safety requirements in the main kitchen by allowing multiple sanitation and storage deficiencies to be present during survey observations. The hood above the stove had an accumulative buildup of grease and grime, pipes and drain hoses under counters had accumulative buildup of grime and webbing, the flooring and air gap drains had dirt buildup, the dishwasher pipes and face had mineral and corrosive buildup, the toaster had breadcrumb buildup, the scale inhibitor apparatus on the wall attached to the steamer had mineral buildup, and the portable cooler unit had dirt buildup on the filters and plastic throughout the unit. Food storage and labeling were also not maintained in accordance with facility policy. An 18-quart dry rice container was not labeled or dated, a large brisket in the refrigerator was not labeled or dated, a container of red gelatin dessert that had been partially served was not labeled or dated, an open cardboard box of sliced mushrooms was inadequately covered, and an unopened container of Yoplait yogurt remained in the refrigerator past its expiration date. The Food Service Director and Certified Dietary Manager both confirmed that the kitchen was not clean to acceptable standards and acknowledged the unlabeled, undated, and expired food items observed by surveyors.
Shower Rooms Not Maintained in Clean, Homelike Condition
Penalty
Summary
The facility failed to maintain a clean, homelike environment in two of three resident shower rooms. During observation, shower room one had chipped laminate along the countertops, paint chipped and not adhering to the walls around the shower stall, and flooring in disrepair in front of the shower stall. Shower room two had water damage on the wall at floor level outside the shower room between the shower room and supply storage, paint chipped and not adhering to the walls around the shower stall, and flooring in disrepair in front of the shower stall, by the door, and within the shower stall. The facility policy titled, Quality of Life - Homelike Environment, stated that staff and management shall maximize the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment. During a concurrent observation and interview, the DON confirmed that the shower rooms were in disrepair and did not represent a safe and aesthetic homelike environment for residents.
Unsafe Shower Room Conditions
Penalty
Summary
The facility failed to keep common shower areas free from accident hazards when two of three shower rooms were observed to be in disrepair. One shower room had an open, uncovered hole in the floor across from the shower stall that was large enough for a pipe fitting. A second shower room had what appeared to be a temperature control apparatus on the wall with the lid off, exposing small wires and sharp edges. During observation and interview with the DON, the DON confirmed the shower rooms were in disrepair and agreed that the hole in the floor and the open temperature apparatus could create safety issues and pose a potential risk of injury to residents using the area.
Failure to Provide Ordered PT Services
Penalty
Summary
The facility failed to provide ordered PT services for five sampled residents when the frequency of therapy documented on their PT evaluations was not met. Residents 1, 34, and 41 were evaluated for PT five times a week, but the Director of Rehabilitation confirmed they did not receive PT at that frequency during the weeks of 12/21/25 through 12/27/25 and 12/28/25 through 1/3/26. Resident 1 had diagnoses including muscle weakness, unsteady on feet, dementia, and anxiety; Resident 34 had diagnoses including muscle weakness, unsteady on feet, and arthritis; and Resident 41 had diagnoses including a lower back fracture, muscle weakness, unsteady on feet, and lack of coordination. Resident 1 stated he did not think he was getting PT as much as he was supposed to during the last two weeks of December, Resident 34 stated she did not get PT five times a week for the month of December and the beginning of January, and Resident 41 stated he only got PT three times the week of 12/21/25 and two times the week of 12/28/25. Residents 9 and 13 were also evaluated for PT three times a week, but the Director of Rehabilitation confirmed they did not receive PT at that frequency during the same two-week period. Resident 9 had diagnoses including muscle weakness, unsteady on feet, and dementia, and stated he never received PT for the week of 12/21/25 and the week of 12/28/25, saying no one even showed up. Resident 13 had diagnoses including paralysis to the right side of the body, unsteady gait and walking, and high blood pressure, and stated she only got PT once during the week of 12/21/25 and none at all during the week of 12/28/25. During record review, the Director of Rehabilitation reviewed the PT evaluations and treatment plans and confirmed the ordered therapy frequencies were not followed. The facility policy on Rehabilitation Services stated that rehabilitation services were to provide professional rehabilitation services when prescribed by physicians, and the Director of Rehabilitation confirmed the policy was not followed because a PTA quit the last week of December.
Failure to Follow Two-Person Assistance Care Plans
Penalty
Summary
The facility failed to implement an individualized, person-centered care plan for two residents who were both identified as needing two-person assistance for transfers and walking. Resident 9 had diagnoses including muscle weakness, unsteady on feet, and dementia, and his care plan and PT evaluation both indicated maximum assistance and use of two persons during transfers. On 12/31/25, CNA 3 attempted a stand-and-pivot transfer from bed to wheelchair by herself, and Resident 9 was too weak to bear weight and was lowered to the floor. During interview, Resident 9 stated CNA 3 was helping him into his wheelchair by herself, he lost his balance and slipped to the floor, and he told her he needed another person but she ignored him. Resident 41 had diagnoses including fracture to lower back, muscle weakness, unsteady on feet, and lack of coordination, and his care plan and PT evaluation indicated maximum assistance with transfers and walking with two persons. On 12/29/25, CNA 3 walked Resident 41 to the bathroom by herself; Resident 41 lost his balance and fell to the floor, and when CNA 3 grabbed his right arm, a skin tear occurred. Resident 41 stated CNA 3 was helping him walk by herself and he fell, and a confidential witness reported seeing CNA 3 walking him alone, him losing balance and falling, and CNA 3 causing the skin tear when she grabbed his arm. The DON confirmed CNA 3 was supposed to get help for both residents, and the facility policy stated a comprehensive, person-centered care plan with measurable objectives and timetables was to be developed and implemented for each resident.
Failure to Use PPE When Handling Hazardous Medication
Penalty
Summary
The facility failed to ensure professional standards were followed when nursing staff handled a hazardous medication without appropriate PPE. During a medication pass observation on 1/13/25 at approximately 8:30 a.m. with LN 4, the nurse prepared three medications for Resident 23, including phenytoin 100 mg, 2 capsules. The pharmacy label on the bubble pack identified the medication as hazardous, but LN 4 prepared the medications without wearing gloves or any other PPE. During an interview on 1/13/25 at 9:05 a.m., LN 4 stated the expectation was to use gloves when handling phenytoin and confirmed that no gloves were worn during medication preparation or administration. Later that day, the DON stated that proper precautions, including the use of gloves, were expected during medication administration and that nursing staff were expected to follow precautionary instructions listed on the pharmacy label.
Inaccurate Controlled Medication Documentation
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications when random controlled medication audits for one resident did not reconcile. Resident 16 was admitted with diagnoses including anxiety, high blood pressure, and a fracture of the thoracic vertebra. The resident had an order for tramadol 50 mg by mouth every 6 hours as needed for moderate to severe pain, and the Controlled Drug Record showed 1 tablet signed out on 8/11/25 at 5 pm, 12/20/25 at 8:15 am, 12/24/25 at 7:30 am, and 12/31/25 at 7:30 am, but the Medication Administration Record did not show tramadol was administered on those dates and times. Resident 16 also had an order for Ativan 0.5 mg by mouth every 12 hours as needed for anxiety. The Controlled Drug Record showed 1 tablet signed out on 10/1/25 at 5 am, but the MAR did not show Ativan was administered on that date. During a concurrent interview and record review, the DON confirmed the CDRs and MARs for Resident 16's tramadol and Ativan were not accurate and stated that when a controlled medication is administered, it is signed out of the CDR and the MAR, and the dates and times must reconcile between the two records. The facility policy stated that the medication administration record must be completed immediately after the medication is given and before the staff member reports off duty.
Expired Latanoprost Eye Drops Administered Past Beyond-Use Date
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors when Resident 9 and Resident 29 continued to receive latanoprost ophthalmic solution after the medication had expired. During a concurrent record review and inspection of Medication Cart 1, two opened bottles of latanoprost for the two residents were found; the bottles had been opened on 11/14/25, and the manufacturer labeling stated that an opened bottle may be stored at room temperature for 6 weeks. The Licensed Nurse confirmed that both bottles had expired on 12/26/25 and stated that nursing staff had continued to administer the eye drops beyond the expiration date, acknowledging that medication can be less effective when used beyond expiration. Resident 9 had a physician’s order for latanoprost ophthalmic solution 0.005%, 1 drop in both eyes at bedtime for glaucoma, and the December 2025 and January 2026 MAR showed the medication was administered 16 times past expiration. Resident 29 had the same medication order for glaucoma, and the December 2025 and January 2026 MAR showed the medication was also administered 16 times past expiration. The DON stated nursing staff were expected to check medication expiration dates before administration and that an earlier expiration date after first use was to be added to the medication label to ensure effectiveness. The facility policy required opened dates to be documented and stated that shortened beyond-use dates for medications such as ophthalmic drops were to follow manufacturer recommendations.
Unlabeled opened medications and expired drugs found in medication carts
Penalty
Summary
The facility failed to ensure opened multi-dose medications and biologicals were labeled with an open date and discard date, and expired medications were not available for resident use. Facility policies reviewed by surveyors stated that medication expiration dates must be checked, expired medications must not be administered, applicable medications must have a date-opened label, and manufacturer recommendations for beyond-use dating must be followed. The policies also stated that insulin vials and pens are to be labeled with the date initially opened, and outdated medications are to be removed from inventory and disposed of. Another policy stated that medications brought from outside the facility, when deemed necessary, must be properly labeled in accordance with facility policy and verified by a licensed pharmacist. During inspection of medication cart 3, surveyors found an opened Trelegy inhaler, an opened Anoro inhaler, and an opened Lantus Solostar insulin pen that were all unlabeled and lacked an open date. A nurse confirmed the medications were available for use but did not have labels showing when they were opened, and stated the insulin pen was believed to be stable for only 28 days at room temperature. During inspection of medication cart 1, surveyors found two opened bottles of latanoprost that had been opened on 11/14/25 and were expired, as well as an albuterol inhaler that had expired in 1/2025. The nurse confirmed the latanoprost had expired and stated the albuterol inhaler should not have been available in the cart for administration. The DON stated staff were expected to check medication expiration dates before administration and that medications needing a discard date should have that date added to the label; he also stated home medications were not permitted in the medication cart unless approved by the physician and labeled by the pharmacy.
Failure to Recognize and Report Change in Condition and Complete Ordered Labs
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including type 2 diabetes, dementia, and hypertensive chronic kidney disease. Staff did not recognize or report a significant change in the resident's condition, specifically a marked decrease in the frequency of daily brief changes, which was a notable deviation from her baseline of 15-20 changes per day. Multiple CNAs and a licensed nurse confirmed that the reduced number of brief changes was abnormal for this resident, yet this change was not documented or communicated to the Medical Director or Director of Nursing as required by facility policy. Additionally, the facility failed to ensure that a laboratory blood test ordered by the Medical Director was completed. After the resident initially refused the lab draw, staff did not follow up by placing a new lab slip in the requisition binder or entering a new electronic order, resulting in the lab not being drawn as instructed. The Medical Director was not notified that the labs were not completed, and there was no follow-up to ensure the order was fulfilled. Interviews revealed confusion among staff regarding responsibility for ensuring lab orders were carried out, and the DON acknowledged that it was his responsibility to follow up on lab work but did not do so in this case. The resident subsequently exhibited further signs of deterioration, including persistently elevated blood glucose levels, calling out for help, and a thready pulse with low oxygen saturation. Despite these changes, there was inadequate assessment and communication with the Medical Director. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock, acute respiratory failure, profound hyperkalemia, acute kidney injury, and other critical conditions. She was placed on hospice care upon return to the facility and passed away shortly thereafter.
Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received wound preventative measures as ordered, resulting in the development of a stage 2 pressure ulcer on the coccyx. The resident, who had a history of an intertrochanteric fracture with surgical repair, protein-calorie malnutrition, panic disorder, and hypokalemia, was assessed as being at moderate risk for pressure ulcers. The resident was also noted to be occasionally incontinent of urine and always incontinent of bowel, with moisture-associated skin damage to the buttocks and groin documented at admission. Despite care plans and physician orders indicating the need for regular skin assessments and the application of zinc oxide for skin maintenance, documentation from CNAs and nursing staff did not reflect any skin issues or changes for the resident over several weeks. Shower sheets and skilled services documentation consistently failed to note any redness, rash, or breakdown, even though the resident was at risk and had existing skin concerns. The facility's policy required frequent skin inspections and prompt reporting of any changes, but these procedures were not followed. Interviews with staff revealed that CNAs were not consistently documenting skin assessments or reporting changes, and there were acknowledged challenges with training and compliance among newer CNAs. Both the Director of Staff Development and the Administrator confirmed that staff did not adhere to the facility's skin assessment policy, and this lack of assessment and documentation contributed to the development of the pressure ulcer.
Failure to Notify MD of Resident's Cognitive Decline
Penalty
Summary
The facility failed to notify the Medical Director (MD) regarding the need to alter the healthcare decision-maker for a resident who was cognitively impaired. The resident, who had been diagnosed with Alzheimer's disease and dementia, had a St. Louis University Mental Status (SLUMS) examination score of 3 out of 30, indicating severe cognitive impairment. Despite this, the resident was still listed as their own Responsible Party (RP) and was only notified of an alleged abuse allegation. The facility's policy required prompt notification of changes in a resident's medical or mental condition to the resident, their physician, and their representative, but this was not adhered to in this case. The resident's Minimum Data Set (MDS) assessments showed a decline in cognitive function from moderately impaired to severely impaired over several months. Despite these assessments and the SLUMS examination results, the resident's capacity to make and understand decisions was not updated, and the MD was not notified. Interviews with facility staff, including the Administrator (ADMIN) and Director of Nursing (DON), revealed a lack of communication and documentation regarding the notification of the MD about the resident's cognitive status. The ADMIN admitted to not recalling whether the alleged abuse report was filed with the proper authorities and believed the Social Services Director (SSD) was investigating the allegation. The DON could not locate any documentation indicating that the MD was notified about the SLUMS examination results. The facility's failure to update the resident's decision-making capacity and notify the MD of significant changes in the resident's cognitive status contributed to the deficiency identified in the report.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving a resident who informed a Certified Nursing Assistant (CNA) that a male staff member was rough with her while assisting her in and out of bed. The resident described the staff member as tall, male, attractive, with light-colored hair, and claimed he grabbed her hard and intended to hurt her. Despite the resident's severe cognitive impairment due to Alzheimer's disease and dementia, the facility's policy required immediate investigation and reporting of such allegations to the appropriate authorities, which was not done. The facility's Abuse Prevention Program policy mandates a thorough investigation of abuse allegations, including interviews with all involved parties and reporting to the California Department of Public Health (CDPH) and other authorities within a two-hour timeframe. However, the facility administrator, who was also the abuse coordinator, did not report the incident, believing the allegation was unsubstantiated due to the resident's cognitive condition and the absence of a staff member matching the description. The administrator admitted to not recalling if the report was filed and assumed the Social Service Director (SSD) was responsible for the investigation. Upon review, it was found that there was no documentation of an investigation by the SSD, who also did not recall conducting one. The administrator acknowledged that the resident's care plan and documentation should have been updated to reflect the investigation, and the resident's responsible party should have been contacted. The failure to report the abuse allegation and properly document the investigation process was a significant oversight, potentially placing residents at risk for undetected abuse.
Failure to Investigate Abuse and Manage Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the social services department met the needs of two residents, leading to deficiencies in care. For the first resident, an allegation of abuse was reported to a Certified Nursing Assistant, but the Social Service Director did not investigate or report the incident to the authorities. The resident, who had severe cognitive impairment due to Alzheimer's disease, described an incident involving a male staff member who was rough and allegedly intended harm. Despite the resident's impaired cognition, the facility's administrator and Social Service Director did not document or follow up on the investigation, nor did they notify the resident's family or update the care plan accordingly. In the second case, the facility failed to address the use of psychotropic medication for another resident. This resident, who had moderate cognitive impairment and an anxiety disorder, was prescribed PRN Lorazepam for an extended period without documented rationale. The facility's policy required that the Behavior Management Committee assess the appropriateness of such medications and consider gradual dose reduction. However, there was no documentation of the committee's review or discussion regarding the extended use of Lorazepam, nor was there any note from the provider justifying the extended prescription period. These failures highlight the facility's lack of adherence to its policies and procedures regarding abuse reporting and medication management. The Social Service Director did not fulfill their responsibilities to investigate and document the alleged abuse, nor did they ensure the Behavior Management Committee addressed the psychotropic medication use. This lack of action could have led to unreported abuse and inappropriate medication use, potentially affecting the residents' well-being.
Failure to Document Rationale for Extended Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for a resident who was prescribed Lorazepam for an extended period without documented rationale. The resident, who was not their own healthcare decision-maker, had diagnoses including dementia and anxiety disorder. The resident's Medication Administration Record indicated a prescription for Lorazepam to be administered every 8 hours as needed for anxiety over a 30-day period, which exceeded the 14-day limit for PRN psychotropic drugs without documented justification from the attending physician. During interviews and record reviews, both the administrator and the Director of Nursing confirmed the absence of documentation justifying the extended use of Lorazepam in the resident's medical record. The facility's interdisciplinary care team was expected to discuss and document the rationale for such prescriptions during their monthly meetings, but no such documentation was found for this resident. This oversight could contribute to the unsafe use of psychotropic medications, potentially placing residents at risk for adverse consequences.
Sanitation and Food Safety Deficiencies in Meal Preparation
Penalty
Summary
The facility failed to ensure sanitary preparation and service of meals, as observed during a survey. The temperature of pizzas being served to residents was initially recorded at 136 degrees Fahrenheit and later dropped to 122 degrees Fahrenheit, which is below the safe holding temperature. Despite this, the pizzas were served to residents. The Food Services Director (FSD) acknowledged that the staff should have discarded the pizzas and served those from the food warmer, but there was no facility policy specific to safe holding temperatures for foods. Additionally, improper hand hygiene and glove use were observed during food preparation. An employee, identified as [NAME] #7, was seen mixing lettuce with gloved hands, then touching a high-contact surface (the refrigerator door) without changing gloves or washing hands before continuing to prepare the salad. The Culinary Director noted that [NAME] #7 was a new hire and had been frequently written up for similar infractions. The FSD stated that she was not involved in the hiring or training of kitchen staff and would expect food to be discarded if such infractions were observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster used for refuse disposal was kept closed, as required by both the U.S. FDA 2022 Food Code and the facility's own policy. Observations on two consecutive days revealed that the dumpster behind the building was open, which was confirmed by the Food Services Director (FSD) during interviews. The FSD acknowledged that the dumpster should be closed and admitted that it had always been left open during her tenure. The dumpster was used to discard paper, containers from the kitchen, and nursing materials. Interviews with the Director of Nursing (DON) and the Administrator further highlighted the deficiency. The DON confirmed that regulations required the dumpster lids to be closed, while the Administrator expressed uncertainty about the expectations but stated a preference for the dumpster to be closed when possible. This failure to maintain the dumpster closed had the potential to attract vermin and pests, potentially affecting all 56 residents residing in the facility.
Oxygen Therapy Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of oxygen therapy for three residents, leading to deficiencies in respiratory care. Resident #204, who was admitted with chronic obstructive pulmonary disease and acute respiratory failure, was observed receiving oxygen at higher flow rates than prescribed. Despite an order for 2 liters per minute, observations showed the resident receiving 2.5 to 3 liters per minute. This discrepancy was confirmed by LVN #1, who acknowledged the incorrect setting. Resident #17, with a history of chronic respiratory failure, was also affected by improper oxygen administration. The resident's orders specified oxygen at 2 liters per minute to maintain adequate oxygen saturation. However, observations revealed the resident receiving less than 0.5 liters per minute. LVN #1 confirmed the incorrect setting and acknowledged her responsibility to ensure the correct flow rate. Resident #11, who had severe cognitive impairment and required oxygen therapy for ineffective gas exchange, was observed with a malfunctioning humidifier bottle on the oxygen concentrator. Although the oxygen was set at the correct flow rate, the humidifier bottle was not producing bubbles, indicating a potential issue with oxygen delivery. LVN #1 and LVN #2 confirmed the humidifier was not properly attached, which could lead to oxygen leakage. The DON and Administrator emphasized the importance of ensuring equipment functionality and adherence to physician orders.
Infection Control Deficiencies in Catheter and Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for residents with urinary catheters and those receiving respiratory care. Specifically, Resident #38, who had a suprapubic catheter due to obstructive uropathy, was observed multiple times with their catheter drainage bag dragging on the floor as they propelled themselves in a wheelchair. This was contrary to the facility's policy, which required catheter tubing and drainage bags to be kept off the floor to prevent infection. Interviews with facility staff, including Licensed Vocational Nurses and the Director of Nursing, confirmed that the catheter bag should not touch the floor due to the risk of bacterial contamination. Additionally, the facility did not adhere to its policy for storing respiratory equipment properly. Resident #204, who had chronic obstructive pulmonary disease and acute respiratory failure, was observed with nebulizer tubing lying on top of a nightstand and over-the-bed table, with fluid noted in the cannister. Resident #17's oxygen tubing was stored improperly on top of the oxygen concentrator, and Resident #37's nebulizer equipment was left connected to the machine with fluid and debris present. The facility's policy required that such equipment be stored in a bag when not in use to prevent contamination. Interviews with staff, including LVNs and the Director of Nursing, revealed that the facility's procedures for storing respiratory equipment were not consistently followed. Staff acknowledged that oxygen and nebulizer equipment should be stored in bags to prevent contamination and that nebulizer medication cups should be rinsed out if not fully used. The Administrator also confirmed that respiratory equipment should be stored appropriately, indicating a lapse in adherence to infection control protocols.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to accurately code oxygen use on the Minimum Data Set (MDS) assessments for two residents, leading to a deficiency in ensuring accurate resident assessments. Resident #17, who was admitted with a diagnosis of chronic respiratory failure, had orders for oxygen administration as needed to maintain oxygen saturation above 88%. Despite documentation in the Medication Administration Record (MAR) indicating oxygen was administered every shift during the lookback period, the MDS did not reflect this oxygen use. Interviews with the MDS Resource Staff, Director of Nursing (DON), and Administrator confirmed that the resident's oxygen use should have been coded on the MDS. Similarly, Resident #11, admitted with a medical history including dementia and anxiety disorder, had orders for oxygen administration to maintain oxygen saturation at 90% or greater. The MAR documented oxygen administration every shift during the lookback period, yet the MDS did not indicate the resident received oxygen therapy. Interviews with the MDS Resource Staff, DON, and Administrator reiterated that the resident's oxygen use should have been captured on the MDS. The deficiency was identified through a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides coding instructions for oxygen therapy. The manual specifies that oxygen use should be coded if administered continuously or intermittently during the lookback period. The failure to accurately code oxygen use on the MDS assessments for these residents highlights a lapse in the facility's assessment process, as confirmed by the staff interviews.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a Level I PASRR accurately reflected the presence of a serious diagnosed mental disorder and the use of prescribed psychotropic medication for a resident. The resident, who was admitted to the facility with an active diagnosis of bipolar disorder, was prescribed Depakote for this condition. However, the Level I PASRR completed upon the resident's return from a temporary evacuation did not indicate the presence of a serious mental illness or the use of psychotropic medication, resulting in a negative screening and no Level II evaluation being required. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring the accuracy of Level I PASRRs. The Medical Records Director was unaware of who was responsible, while the Marketing Director indicated that the DON reviewed PASRRs for accuracy. The DON acknowledged that the PASRR for the resident in question was completed incorrectly and should have indicated a serious mental illness, which would have triggered a Level II evaluation. The Administrator also stated that PASRRs should accurately reflect residents' histories and diagnoses.
Failure to Develop Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The resident, who was admitted to the facility with a medical history that included a cardiac pacemaker, atrial fibrillation, and a prosthetic heart valve, did not have a care plan that addressed the care and monitoring of the pacemaker. Despite the presence of a facility policy requiring care plans to include measurable objectives and timeframes, the care plan for this resident, last reviewed in August 2024, lacked documentation related to the pacemaker. Interviews with facility staff revealed an acknowledgment of this oversight. The Director of Nursing admitted that the care plan was not updated to reflect the resident's cardiac pacemaker status. The facility's Administrator also expressed that the expectation was for care plans to accurately reflect the resident's medical and health status, indicating a lapse in meeting this standard for the resident in question.
Failure to Address Pharmacy Recommendations for Antipsychotic Medication Monitoring
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident reviewed for unnecessary medications. The facility's policy required that recommendations be acted upon within 30 calendar days or per facility-specific protocols. The resident, who had a medical history of schizophrenia, bipolar disorder, and major depressive disorder, was receiving antipsychotic medications. The care plan included monitoring for adverse reactions and consulting with the pharmacy and medical doctor for dosage reduction when clinically appropriate. An Interim Medication Regimen Review recommended performing an AIMS test within 30 days of admission and every six months thereafter. However, the AIMS assessments for the resident were not completed in a timely manner, with the last assessment done only after the surveyor's inquiry. The Director of Nursing acknowledged the oversight and stated it was his responsibility to ensure the AIMS assessment was completed as recommended by the pharmacist. The Pharmacy Consultant confirmed that the AIMS test should be completed as requested, and the Administrator expected the facility staff to follow pharmacy recommendations.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication use was limited to 14 days for a resident with a diagnosis of anxiety disorder. The facility's policy on psychotropic medication use, revised in February 2024, specifies that PRN orders for psychotropic drugs should be limited to 14 days unless the attending physician documents a rationale for extending the order. However, the resident's order for phenobarbital, a medication used to calm anxiety, did not include a stop date, and the resident received the medication multiple times over several months without a documented rationale for extending the PRN order. Interviews with facility staff revealed a lack of awareness and adherence to the policy. The Medical Director was unaware of restrictions on using phenobarbital as a psychotropic for anxiety on an as-needed basis, and the Pharmacy Consultant expected the physician to clarify the duration of use before prescribing. The DON acknowledged that as-needed antianxiety medications should have stop dates but was unaware of why the resident's prescription lacked one. The Administrator expected staff to follow regulations concerning as-needed psychotropic medication, indicating a disconnect between policy and practice.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.55% during a survey. This deficiency affected two residents during medication administration. One resident, with a medical history including atrial fibrillation and a personal history of pulmonary embolism, was prescribed aspirin 81 mg delayed release tablets for stroke prevention. However, a Licensed Vocational Nurse (LVN) administered a chewable aspirin instead of the delayed release form as ordered. The LVN realized the error after returning to the computer to sign out the medications and acknowledged the mistake, stating she should have double-checked the order with the medication label. Another resident, with a medical history of atrial fibrillation and essential hypertension, was prescribed metoprolol succinate 25 mg with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the apical heart rate was below 60 beats per minute. An LVN administered the medication without checking the resident's pulse, which was later found to be 64 beats per minute. The LVN admitted to forgetting to check the pulse before administration and recognized the need to follow the physician's orders completely. Interviews with the Director of Nursing and the Administrator confirmed that nurses should compare medications with orders and obtain necessary vital signs before administration.
Incomplete Medical Record for Resident with Pacemaker
Penalty
Summary
The facility failed to maintain a complete medical record for a resident with a cardiac pacemaker. Specifically, the medical record for the resident did not include essential information such as the model and serial number of the pacemaker, as well as the date of its implantation. This oversight was identified during a review of the resident's care plan and medical records, which revealed that while the pacemaker brand and manufacturer's telephone number were documented, the model/serial number and implant date were missing. The resident, who was admitted to the facility with a medical history that included a cardiac pacemaker, paroxysmal atrial fibrillation, and cardiomegaly, had intact cognition as indicated by a BIMS score of 13. The facility's policy required that such information be documented in the medical record and on a pacemaker identification card upon admission. Interviews with the Director of Nursing and the Administrator confirmed that the necessary pacemaker information was not obtained or documented, which they attributed to an oversight.
Failure to Update Daily Staffing Postings
Penalty
Summary
The facility failed to ensure that daily staffing postings were updated every shift for a period of 24 days, from September 1, 2024, through September 24, 2024. This deficiency was identified through an observation on September 25, 2024, which revealed that the staff postings were not being updated with the actual hours worked. Instead, the postings only reflected the scheduled hours. This oversight had the potential to affect all 56 residents residing in the facility. Interviews conducted with facility staff revealed a lack of awareness and responsibility regarding the updating of staffing postings. The Staffing Scheduler stated she was instructed to post staffing for the previous, current, and next day but was unaware that updates with actual hours worked were required every shift. The Director of Nursing (DON) indicated that either he or the Staffing Scheduler should update the postings, but no specific person was assigned this task for after-hours and weekends. The Administrator also confirmed the lack of awareness about the requirement to update postings every shift and acknowledged the absence of a policy regarding staff postings.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident within the required 2-hour timeframe to the California Department of Public Health (CDPH). The facility's policy mandates immediate reporting of all allegations of abuse, neglect, exploitation, or injury of unknown origin to the Abuse Prevention Coordinator (APC) and subsequently to local CDPH, Long Term Care Ombudsman, and Local Law Enforcement. However, the Director of Nursing (DON) did not document the injury in the progress notes or update the administrator, resulting in a delay of three days before the injury was reported to CDPH. Resident 1, who had been admitted with diagnoses including a urinary tract infection, dementia, cognitive communication deficit, and diabetes, was observed with a circular, dark purple discoloration on her upper left arm. The injury was initially reported to the DON by a family member, but the DON did not document it or inform the administrator, leading to a failure in timely reporting. The administrator confirmed that the injury should have been reported immediately and acknowledged the delay in reporting to CDPH.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 135 citations issued within 25 miles in the last 12 months — 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oroville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oroville Hospital Post-acute Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Feather River Care Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Gridley Post Acute | 12.8 mi | ★★★★★ | 0 | 0 |
| River Valley Care Center | 17.9 mi | ★★★★★ | 1 | 0 |
| California Park Post Acute | 22 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.