Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestwood Wellness And Recovery Center during CMS and state inspections, most recent first.
A resident with schizoaffective and bipolar disorders, known for delusions and disruptive verbal behaviors, shared a room with another conserved resident diagnosed with schizophrenia and delirium. On the morning of the incident, a CNA heard the first resident loudly state, “I’m going to kill you,” but did not enter the room to assess safety, did not place eyes on the residents, and did not effectively report this behavioral change to the SC or an LN as required by the facility’s crisis intervention policy and CNA job description. Staff later reported that the first resident had been making daily death threats toward the roommate, yet there was no CNA documentation of such threats in the progress notes, and the DON, ADON, Wellness and Recovery Director, and LNs were unaware of them. Feeling threatened when the first resident put her fists up as if to fight, the roommate struck her in the face multiple times, causing facial and neck redness and bruising that lasted for over two weeks, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident with schizoaffective disorder and bipolar type, but with intact cognition on BIMS, told an LPN that people were coming into her room and "rape her" when she was not fully awake, and a subsequent note by social services documented that a peer was having sex with her without consent. The Wellness and Recovery Director and the Administrator conducted an internal investigation after the allegation was discussed in a team meeting, and an SOC 341 later reflected that the conservator’s office was informed of non-consensual sex by a peer. Despite a facility policy requiring immediate reporting of reality-based abuse allegations to the Administrator and external authorities, and the Administrator’s own description that such allegations should be reported to police, social services, CDPH, and the Ombudsman within two hours, the allegation was not reported to these required agencies.
Surveyors found that the facility did not review or update its emergency preparedness plan within the required annual timeframe, as the last update was in 2023. Staff confirmed the absence of a current plan, affecting planning for all residents.
Surveyors identified that the facility did not update its emergency preparedness plan (EPP) policies and procedures within the required annual timeframe. Staff confirmed the last review was in 2023, resulting in a deficiency for not maintaining current EPP documentation for all residents.
Surveyors identified that the facility did not maintain an annually updated emergency preparedness communication plan, as required by regulation. Staff confirmed the last review was in 2023, resulting in the absence of a current communication plan for all residents.
Surveyors identified that the facility did not provide evidence of an annual update to its emergency preparedness plan (EPP) training and testing program. The last documented review was in 2023, and staff confirmed no subsequent update had occurred, resulting in noncompliance with regulatory requirements for emergency preparedness.
A failed water flow test revealed that the facility's sprinkler system alarm did not activate within the required timeframe, as the water flow was tested for over 90 seconds without initiating the alarm. Staff were unaware of the malfunction, and this deficiency affected all residents and smoke compartments in the facility.
A smoke detector outside a resident room failed to activate the fire alarm system during two separate tests with artificial smoke. Staff could not determine the cause at the time, but noted the proximity of an AC vent, which may have affected the detector's function. This issue impacted 14 residents in one smoke compartment.
Surveyors found a suspended power strip in a resident area, plugged into a television and positioned about one foot off the ground. Staff confirmed the power strip was accidentally suspended, indicating a failure to maintain electrical equipment according to NFPA standards.
A review of facility records and staff interviews revealed that the fire watch policy did not specify that a fire watch would be implemented within four hours of the fire alarm system being out of service, as required. This omission affected all residents in the facility.
A review of facility records and staff interviews revealed that the fire watch policy lacked required language specifying that a fire watch must be implemented if the sprinkler system is out of service for more than ten hours. This omission affected all residents and smoke compartments in the facility.
The facility did not document the results of the DON's annual TB infection screening on the required form, as confirmed by a review of personnel records and acknowledgment from Human Resources.
Two residents with schizoaffective disorder and intact cognition were permitted to self-administer oxygen per physician orders, but the MARs lacked a section for LPNs to document oxygen administration. The facility also did not formally assess the residents' ability to self-administer oxygen or provide required education, contrary to facility policy.
Surveyors observed that opened packages of frozen fried eggs, soy chicken patties, and soy beef patties were stored in the kitchen freezer without required labels or dates. The Food Service Supervisor confirmed these items had been opened and should have been labeled with an open date according to facility policy.
A resident with a history of schizoaffective disorder and anxiety was verbally and physically assaulted by another cognitively intact resident with schizophrenia and substance abuse history. The aggressor yelled derogatory names and struck the resident on the head, then chased him down the hallway before staff intervened. The incident resulted in increased anxiety and emotional distress for the victim.
A client eloped from a facility due to a malfunctioning door lock and staff oversight. The client exited through a door with a faulty magnetic lock, and a TOA, unfamiliar with residents, mistook her for an employee. Program Staff saw the client outside but assumed she was with another staff member, leading to the client being missing for eight hours.
A resident with a history of aggressive behavior physically abused two other residents in separate incidents. The first incident involved the resident striking another resident in the face, causing injuries. The second incident involved the resident choking another resident. Despite being on frequent welfare checks, the aggressive resident's behavior was unpredictable, and the facility failed to manage the situation effectively.
The facility did not label and date food containers and product bags after opening, as observed in the freezer and refrigerator. Items such as frozen breaded fish, frozen french toast, and fresh pepperoni were found open and unlabeled. A staff member acknowledged forgetting to label the items, and the Food Service Supervisor confirmed the requirement for labeling with an open date.
Failure to Intervene on Verbal Threats Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own crisis intervention and reporting policies. The facility’s Crisis Intervention Program required staff to recognize early warning signs of crisis, such as changes in behavior, mood, or thinking, and to provide early intervention when a resident exhibited increased acting-out behaviors. The CNA job description required CNAs to immediately report all changes, including agitation, to the Shift Coordinator (SC). On the day of the incident, a CNA heard one resident yelling, “I’m going to kill you,” but did not enter the room to assess the situation, ensure safety, or investigate what was happening, and did not effectively report this change in behavior to nursing staff or the SC. The resident who was later physically abused (Resident 1) had a history of schizoaffective disorder, bipolar type, and was conserved. An Annual MDS indicated this resident had delusions, verbal behavioral symptoms directed toward others, intruded on others’ privacy and activities, and significantly disrupted the care or living environment of others. Staff interviews confirmed that this resident had delusions involving being married to Elvis and yelling about wanting to kill a woman she believed was after her husband. However, review of progress notes from 5/5/25 through 12/25/25 showed no CNA documentation that any CNA had witnessed or reported verbal death threats during these recurring delusions. The resident who committed the physical abuse (Resident 2) was also conserved and had diagnoses of schizophrenia and delirium, with documented delusions. On the day of the incident, Resident 2 reported feeling threatened when Resident 1 put her fists up as if they were going to fight, and Resident 2 hit Resident 1 in the face approximately three times. Staff interviews indicated that Resident 1 had been making daily verbal death threats toward Resident 2, but the licensed nurses, DON, ADON, and Wellness and Recovery Director all confirmed they had not been notified of these threats or of the specific statement, “I’m going to kill you,” made that morning. A licensed nurse stated that if the CNA had reported the observed threat, she would have assessed the situation, determined whether the statement was related to a delusion or directed at the roommate, and attempted to redirect or separate the residents. As a result of the unreported threat and lack of timely intervention, Resident 1 sustained reddened areas and bruising on the neck and right side of the face, with bruising that persisted for 15 days.
Failure to Report Resident’s Allegation of Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to CDPH, the police, and the local Ombudsman as required. The facility’s abuse prevention policy stated that staff must immediately report any suspicions of client abuse to the Administrator, and that all reality-based accusations must be immediately investigated and reported to officials in accordance with state law, including CDPH. The resident involved had schizoaffective disorder, bipolar type, and was conserved, with a documented history of hallucinations and delusions. However, the resident’s most recent BIMS score was 15/15, indicating intact memory, orientation, and judgment. On one occasion, a licensed nurse reported via internal communication that the resident stated people came into her room and “rape her” when she was not fully awake. This information was relayed to the Wellness and Recovery Director (WRD) and the Director of Nurses. The WRD documented in a Social Services Note that the resident told a nurse she felt a peer was coming into her room and having sex with her without her consent, and noted that the statement was similar to previous unverifiable accusations. The WRD and Administrator subsequently conducted an internal investigation after a team meeting where the allegation was discussed. An SOC 341 form later showed that the WRD had emailed the resident’s conservator’s office stating that a peer was having sex with the resident without her consent and that the facility had investigated the allegation. During interviews, the resident became visibly distressed and denied making the statements attributed to her, while the nurse involved denied that the resident had said she was raped and characterized the communication as related to the resident’s fixation on becoming pregnant. The Administrator acknowledged that, according to facility procedure, allegations of sexual abuse should trigger immediate steps to protect residents and notification of police, social services, CDPH, and the Ombudsman within two hours, and confirmed that this allegation was not reported to those authorities.
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain its emergency preparedness plan (EPP) in accordance with federal regulations, which require the plan to be reviewed and updated at least annually. During a record review and interview with staff, surveyors requested the EPP and found that the most recent update was dated 11/15/23. Staff confirmed that the last review of the EPP occurred in 2023, and no updated version was available for the current year. This deficiency was identified during a survey on 6/9/25, where it was determined that the EPP had not been reviewed or updated within the required annual timeframe. The lack of an updated EPP could impact the facility's ability to ensure proper planning and preparation for the health and safety of all 90 residents, as the plan may not reflect current risks or procedures.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan. The facility will continue to maintain the emergency preparedness plan every year by reviewing and updating the plan annually. The facility shall update the EPP on June 26, 2025, during the QA Committee meeting. The facility shall include the EPP review and update as part of the facility's annual review for all facility Policies and Procedures, to be conducted in January 2026 and then each consecutive year in the following January. The update will be communicated to staff during the all-staff meeting scheduled for June 26, 2025, coordinated by the Administrator and facility Environmental Services Supervisor. Further issues regarding the EPP annual update and approval will be received during the QA process and brought to the QAPI Committee for review. The Environmental Services Supervisor, Administrator, and QA Manager will be responsible to ensure ongoing compliance.
Failure to Annually Update Emergency Preparedness Plan Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its emergency preparedness plan (EPP) policies and procedures as required. During a record review and interview with staff, it was found that the EPP had not been updated annually, with the last documented review occurring in November 2023. Staff confirmed that the most recent review date was in 2023, indicating that the required annual update had not been completed. This deficiency was identified during a survey in which the EPP was specifically requested and examined. The lack of an updated EPP could result in the absence of proper planning and preparation to protect the health and safety of all 90 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan (EPP). The facility shall continue to ensure the emergency preparedness plan has updated policies and procedures. The facility shall update the emergency preparedness plan policies and procedures by June 26, 2025, during the QA Committee meeting. The facility shall include the reviewed and updated emergency preparedness plan policies and procedures as part of the annual review for all facility policies and procedures to be conducted in January 2026, and then each consecutive year in the following January. Further issues regarding the facility's emergency preparedness plan's policies and procedures shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and Director of Nursing shall be responsible to ensure ongoing compliance. This page is purposefully left blank.
Failure to Annually Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring an annually reviewed and updated emergency preparedness communication plan. During a record review and interview with staff, surveyors found that the emergency preparedness plan (EPP) had not been updated since 11/15/23, and staff confirmed that the last review occurred in 2023. As a result, the facility did not have an up-to-date communication plan as required, affecting the planning and preparation for the health and safety of all 90 residents. No additional details regarding the medical history or condition of the residents at the time of the deficiency were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining an updated communication plan. The facility shall continue to maintain an updated communication plan and review it annually. The facility shall update the emergency preparedness communication plan by June 26, 2025, during the QA Committee meeting. The communication plan shall be included when the facility reviews the emergency preparedness plan annually in January 2026 and each year consecutively in the following January. Further issues regarding the facility's development of a communication plan as part of the emergency preparedness plan shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance.
Failure to Annually Update Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness requirements by not updating its emergency preparedness plan (EPP) training and testing program on an annual basis. During a record review and interview with staff, it was found that the last update to the EPP training and testing program occurred in November 2023, and no subsequent annual update was provided as required. Staff confirmed that the most recent review date was in 2023, indicating that the program had not been reviewed or updated within the required timeframe. This deficiency was identified during a survey in which the facility was unable to produce documentation of an updated EPP training and testing program. The lack of an annual update could affect the facility's ability to ensure proper planning and preparation for emergencies for all 90 residents. The findings were based solely on the absence of the required annual review and update of the emergency preparedness training and testing program.
Plan Of Correction
The facility recognizes the importance of developing and maintaining an emergency preparedness training and testing program. The facility shall continue to provide an EPP training and testing program update annually. The Emergency preparedness training and testing program shall be reviewed June 26, 2025 during the QA Committee meeting. The emergency training and testing program shall be included in the annual review of facility policy and procedures in January 2026 and then each year consecutively in the following January. Further issues regarding the training and testing program of the EPP shall be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or more frequent if necessary. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Sprinkler System Water Flow Alarm Failure
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 Life Safety Code requirements. During a tour and inspection, the water flow test was conducted at the inspector test valve located in an exterior electrical closet near the generator. The test revealed that the water flow alarm did not activate within the required 90 seconds, as the water flow was tested for over 90 seconds without initiating the alarm. The last documented water flow test was during the annual inspection on 5/16/25. Staff interviewed during the inspection were unaware that the water flow alarm was not functioning as required. This deficiency affected all 90 residents and all ten smoke compartments in the facility, as the lack of a functioning water flow alarm could delay sprinkler protection in the event of a fire. Records of system design, maintenance, inspection, and testing were maintained, but the failure to ensure the water flow alarm's proper operation led to the cited deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System, including the water flow test. The repair and retest of the Sprinkler System was conducted and completed by Environmental Services Supervisor June 9, 2025. The facility will continue to complete the Sprinkler System flow test monthly in July, August, and September—then will revert back to normal quarterly testing in October. Further issues regarding the facility Sprinkler System will be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or as necessary. The Administrator, Environmental Services Supervisor, QA Manager, and maintenance staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Smoke Detector Failed to Initiate Fire Alarm During Testing
Penalty
Summary
During a facility tour and staff interview, surveyors observed that a smoke detector located outside resident room 209 failed to initiate the fire alarm system when tested with artificial smoke. The test was conducted twice, and on both occasions, the alarm did not activate. Staff present during the testing were unable to provide an explanation for the malfunction at the time of the observation. It was noted that the air conditioning vent was approximately 36 inches from the smoke detector, and staff speculated that airflow from the vent might be interfering with the detector's ability to sense smoke. This deficiency affected 14 out of 90 residents in one of ten smoke compartments, as the non-functioning smoke detector could delay notification to emergency forces in the event of a fire.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the smoke detectors and fire alarm system. The facility contacted Sa-Fire to inspect the current locations of the smoke detectors. Facility plans to move / re-locate the 4 ceiling mount smoke detectors away from the proximity of the air registers that may have affected the smoke detectors, causing the testing issues. Sa-Fire will be placing the system on test to complete the work, and the annual fire alarm inspection is scheduled to be completed July 25, 2025. The detectors will be re-tested at that point. Further issues regarding the fire alarm system and/or the smoke detectors will be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Improper Use of Suspended Power Strip in Resident Area
Penalty
Summary
During a facility tour, surveyors observed a suspended power strip in the Trinity center, approximately one foot off the ground and plugged into a television. Staff confirmed that the power strip had been accidentally suspended by facility personnel. This observation indicated that the facility failed to maintain electrical equipment in accordance with regulatory requirements, specifically regarding the proper use and placement of power strips as outlined by NFPA standards. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining electrical equipment. The facility shall continue to properly maintain electrical equipment. Environmental Services Supervisor removed the suspended power strip in the Trinity Center June 9, 2025. In-service was provided to maintenance staff on NFPA code and to look for during room inspections, specific to power strips. Power strip audits will be conducted monthly, using the facility Monthly Maintenance Log. Further issues regarding electrical equipment shall be received during the facility QA process and brought to the QAPI Committee for review and discussion. The Environmental Services Supervisor, Administrator, maintenance staff, nursing staff, and housekeeping staff shall be responsible to monitor for ongoing compliance. This page is purposefully left blank.
Incomplete Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than four hours of the fire alarm system being out of service, as required. Staff confirmed that the policy lacked a defined time frame for initiating a fire watch. This deficiency affected all 90 residents across ten smoke compartments.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the fire alarm system, and shall update the fire watch policy. When the fire alarm system is "out of service," the facility's fire watch policy shall include language stating, "fire watch will be implemented after no more than four hours of the fire alarm system being out of service." The updated Fire Watch Policy will be reviewed, updated, and adopted June 26, 2025, during the QA Committee meeting. Further issues regarding the fire alarm system fire watch policy shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, DON, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than ten hours of the sprinkler system being out of service. Staff confirmed that the required time frame was not included in the policy. This deficiency affected all 90 residents across ten smoke compartments, as the policy omission could impact the facility's response during a sprinkler system impairment.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System. When the Sprinkler System is out of service, the facility shall update the Fire Watch policy to include language indicating "fire watch will be implemented after no more than ten hours of the sprinkler system being out of service." The updated Fire Watch policy will be reviewed, updated, and approved June 26, 2025 during the QA Committee meeting. Further issues regarding the Fire Watch policy or the sprinkler system shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Documentation of TB Screening for DON
Penalty
Summary
The facility failed to provide documented evidence of the results of the Director of Nursing Services' (DNS) annual tuberculosis (TB) infection screening on the required examination form. During a review of the DNS's personnel record, it was found that the most recent annual TB exam did not indicate whether the result was positive or negative for TB. This omission was confirmed during an interview and record review with Human Resources, who acknowledged that the TB exam documentation for the DNS was incomplete and lacked the necessary result information.
Plan Of Correction
DNS's personnel record was reviewed by DNS, Clinical Care Manager, Medical Director, and Administrator on 6/5/2025. The document was corrected and updated to reflect a negative TB result on 6/7/2025. The facility's Clinical Care Manager, DNS, Medical Director, and Administrator are responsible for the correction. Results of TB screening, examinations, and completion of forms will be conducted by the Clinical Care Manager. The Facility QA Manager will perform quarterly audits of initial health exams and annual exams to monitor for ongoing compliance. The DNS personnel file was corrected on 6/7/2025. Further issues regarding Employee Health Exams and/or Health Records will be brought to the QA/QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, and Administrator shall be responsible to monitor for ongoing compliance.
Failure to Document and Assess Oxygen Self-Administration
Penalty
Summary
The facility failed to ensure proper documentation and assessment related to oxygen administration for two patients. Specifically, the Medication Administration Records (MARs) for both patients did not include a section for licensed nursing staff to document the administration of oxygen, despite physician orders allowing the patients to use oxygen at specified rates via nasal cannula. The Director of Nursing Services confirmed that there was no place in the MARs for this documentation. Additionally, the facility did not conduct formal assessments to determine the patients' ability to safely self-administer oxygen, nor did it provide formal education to the patients regarding self-administration, as required by facility policy. Both patients involved had a diagnosis of schizoaffective disorder and were assessed as cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The facility's policies required interdisciplinary team assessments of cognitive, physical, and visual abilities for self-administration of medications, as well as patient instruction and demonstration of self-administration skills. These steps were not completed for either patient, resulting in incomplete health records and a lack of formal verification of their ability to self-administer oxygen safely.
Plan Of Correction
The facility recognizes the importance of maintaining complete and accurate health records. June 27, 2025. The facility shall continue to maintain complete and accurate health records. For Resident 3 and Resident 5, the oxygen administration was documented on MAR June 4, 2025. Formal education regarding self-administration of oxygen was completed on June 4, 2025, by the Clinical Nurse, and assessments will be performed by the Clinical Nurse Supervisor by July 15, 2025. The DNS, Clinical Care Manager, Director of Staff Development, LN Shift Supervisors, Medical Records Supervisor, and Nursing staff shall be responsible for the correction. Newly admitted patients with supplemental oxygen orders will have a self-administration evaluation assessment completed upon admission. Education on self-administration of supplemental oxygen will be provided upon admission. Residents with supplemental oxygen orders will have a self-administration evaluation assessment completed at least quarterly by licensed staff. Education on self-administration of supplemental oxygen will be provided at least quarterly, by licensed staff. Further issues regarding the content of health records and documentation of oxygen administration will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, Nurse Shift Supervisors, Nursing staff, Medical Records Supervisor, and Administrator shall be responsible to monitor for ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Failure to Label and Date Opened Frozen Food Products
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling and dating food product bags after opening them for use. During an observation in the kitchen's second freezer, open and unlabeled packages of frozen fried eggs, soy chicken patties, and soy beef patties were found. The Food Service Supervisor confirmed that these bags had been previously opened and that there was no apparent label present on any of the packages. A review of the facility's policy titled 'Labeling and Dating of Foods' indicated that newly opened food items are required to be closed and labeled with an open date and a use-by date according to guidelines. The Food Service Supervisor acknowledged that, per facility policy, products are to be labeled with an open date once the packaging is opened for use. The failure to follow this procedure was directly observed and confirmed during the survey.
Plan Of Correction
The facility recognizes the importance of storing, labeling, and dating food products in accordance with professional standards. The facility shall continue to store, label, and date food products in accordance with professional standards. The facility's Food Service Supervisor will begin utilizing a freezer-proof storage bag that works well with our permanent markers with no smearing. The Food Service Supervisor ordered for delivery on Friday, 6/13/2025. The facility will continue to utilize these to prevent labeling and dating issues in the freezer. Food Service Supervisor and the facility's Registered Dietitian have not seen any "smearing" or "smudging." The RD will include labeling, storing, and dating of food products in the freezer in the monthly audit. Further issues regarding storing, labeling, and dating of food products in accordance with professional standards will be received by the Food Service Supervisor or Registered Dietitian during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Food Service Supervisor, Registered Dietician, dietary staff, and Administrator shall be responsible for monitoring ongoing compliance. This page purposefully left blank.
Failure to Protect Resident from Verbal and Physical Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident was not protected from verbal and physical abuse by another resident. Specifically, one resident with a history of schizophrenia, psychoactive substance abuse, and visual hallucinations verbally assaulted another resident by yelling and calling him derogatory names, then physically assaulted him by striking him on the head with a closed fist. The aggressor continued to chase the victim down the hallway until staff intervened and separated the two individuals. Both residents were cognitively intact according to their most recent assessments. The facility's policy required all appropriate preventative measures to ensure residents are not at risk for abuse, but this was not followed in this instance. The assaulted resident, who had a history of schizoaffective disorder, bipolar type, and self-reported anxiety, reported feeling upset and experiencing tenderness in his head following the incident. The event resulted in increased anxiety and the potential for emotional stress for the resident who was attacked.
Plan Of Correction
The facility recognizes the importance of maintaining an environment that is free from abuse and neglect. The facility will continue to maintain an environment that is free of abuse and neglect. The facility intervened immediately when the incident involving Resident 56 occurred. Resident 38, the aggressor in this incident, was transferred to a different level of care immediately after the incident. Resident 38 will not return to the facility. The facility initiated a Care Plan on 5/24/25 to monitor Resident 56 for "feelings of being unsafe through the next review date." Interventions attached to the Care Plan included "Encourage Resident 56 to inform staff if he is feeling unsafe," "Provide Resident 56 with 1:1 contacts as needed for emotional support," and "Support Resident 56 with pro-social outlets to encourage feelings of safety in the milieu." Resident 56 was placed on routine monitoring immediately after the incident, with frequent Progress Notes reflecting his comfort, levels of anxiety, and safety. 5/24/25 0239 - "Resident was counseled on staying safe and letting us know if he is being bothered" 5/24/2025 0557 - Nurse Note "Resident has not shown any s/s of emotional distress" 5/24/2025 0851 - Alert Note "Resident denies any pain or discomfort" 5/24/2025 1302 - Nurses Note "No complaints of pain or discomfort" 5/24/2025 1428 - Welfare Check "No noted issues this shift. No statements of feeling unsafe" 5/24/2025 1514 - Program Note "Resident stated he is feeling fine... The writer encouraged Resident to seek staff if he felt unsafe" 5/24/2025 1538 - Welfare Check "Feeling fine, a little better". Asked if he has concerns about safety, he stated "No I think it was a one off, he even apologized to me" 5/24/2025 - Welfare Check "Had an okay day" and felt safe in the facility 5/24/2025 2209 - Welfare Check "I am doing good and feel safe here" 5/25/2025 1356 - Nurses Note "Compliant with neuro checks... no c/o pain or discomfort and this time" 5/25/2025 1528 - Nurses Note "Stated they felt safe at this time" 5/25/2025 2145 - Asked if he is okay "Yes, I am happy here. I feel good. I am okay" 5/26/2025 0618 - Welfare Check "Client has not made any statements of distress or feeling unsafe" 5/26/2025 1407 - Welfare Check "No noted issues or statements of feeling unsafe" 5/27/2025 0939 - IDT Note "Did not wish to discuss the incident further... Did not report feeling unsafe through the weekend... Did not express any s/s of distress... will be discontinued from welfare checks due to not expressing feeling unsafe" 5/28/2025 1722 - IDT Note "Ombudsman met with Resident 58... Resident denied feeling unsafe and had no concerns at the time of the interview" Facility will continue to provide Elder and Dependent Adult Abuse education as part of the new hire orientation for newly hired staff. Facility will continue to provide Elder and Dependent Adult Abuse in-service education to staff through the year as part of the facility's annual educational calendar. Facility DSD began providing in-services to staff on 6/4/2025, including guidelines and expectations of maintaining a facility free of abuse and neglect. As part of the facility admission process, the Admission Coordinator will screen for residents with a history of abuse or assaultive behavior towards others. Further issues regarding Resident Abuse will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Administrator, Director of Nursing, DSD, Medical Director, department heads, leadership team, nursing staff, and all departments shall be responsible to monitor for ongoing compliance.
Client Elopement Due to Malfunctioning Door and Staff Oversight
Penalty
Summary
The facility failed to ensure the safety and security of a client, identified as Client 1, who eloped from the facility due to a malfunctioning security door locking system. The incident occurred when the magnetic lock on the south door intermittently malfunctioned, allowing Client 1 to exit the facility without detection. The facility's Administrator confirmed that the door could only be opened with a key, but the malfunction allowed Client 1 to push open the door and walk into the front lobby, leading to her elopement. The Temporary-Office Assistant (TOA), who was unfamiliar with the residents, did not recognize Client 1 as a client when she passed through the front lobby and exited the facility. The TOA, who had started working in August, mistook Client 1 for an employee due to the time of day when staff were coming and going. This lack of recognition contributed to the failure to prevent Client 1's elopement. Additionally, Program Staff (PS) observed Client 1 outside the facility but did not inquire about her presence or take action to ensure her safety. PS assumed that another staff member was accompanying Client 1 on an outing and did not verify this assumption. As a result, Client 1's whereabouts were unknown for eight hours, during which she was at risk for injury and exposure to cold weather.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, Resident 84, who had a history of impulsive and aggressive behavior. On June 12, 2024, Resident 84 struck Resident 82 in the face multiple times, causing bleeding injuries. This incident occurred after Resident 84 accused Resident 82 of spitting on them, which Resident 82 denied. The facility's investigation confirmed the incident, and it was noted that Resident 84's conservator was seeking a more suitable facility due to Resident 84's behavior. Earlier, on May 22, 2024, Resident 84 was involved in another incident where they placed their hands around Resident 3's throat while Resident 3 was reclined in a chair. This incident was witnessed by staff, who intervened and separated the residents. Resident 84 later claimed not to remember the incident and showed a lack of insight into their behavior during a telepsychiatry session. Despite being on welfare checks every 15 minutes for aggressive behavior, Resident 84's actions were unpredictable and sporadic. Both incidents highlight the facility's failure to adequately assess and manage Resident 84's aggressive tendencies, despite having a policy in place for abuse prevention. The facility's interdisciplinary team was expected to identify residents needing treatment planning to prevent such occurrences, but the incidents with Residents 82 and 3 indicate a lapse in effectively implementing these measures.
Failure to Label and Date Opened Food Products
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling and dating food containers and product bags after opening. During an observation and interview, it was found that multiple packages in the freezer, including frozen breaded fish, frozen french toast, frozen hashbrowns, and frozen fried eggs, were open and unlabeled. A staff member admitted to opening and using some of these items without labeling them. Additionally, in the walk-in refrigerator, a package of fresh pepperoni and a bag of peeled garlic cloves were also found open and unlabeled. The Food Service Supervisor confirmed that these products should have been labeled with an open date once the packaging was opened.
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What surveyors actually found near you
We read the 67 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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Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Care At Shasta | 0.5 mi | ★★★★★ | 19 | 0 |
| Copper Ridge Care Center | 1.1 mi | ★★★★★ | 15 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 2.2 mi | ★★★★★ | 8 | 0 |
| Redding Post Acute | 2.4 mi | ★★★★★ | 16 | 0 |
| Quartz Hill Post Acute | 3.5 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 July 2026) and official state health department websites.