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 English Oaks Convalescent & Rehabilitation Hospita during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported that a male CNA attempted to sexually assault him at night, describing that the CNA pulled down his pants, exposed himself, and tried to climb on top of him before the resident pushed him away and called for help. The resident disclosed the allegation to a CNA using a notepad with the word “rape,” and this CNA reported it to an LN, who then notified another nurse, after which the ADM and DON were informed. Although leadership stated that CDPH was notified the same day, they could not provide evidence of the time of notification, and the SOC 341 related to the allegation was not received by CDPH until the following day. The ADM later acknowledged knowing that such allegations must be reported to CDPH within two hours, but the facility could not document that this requirement was met, despite a policy requiring abuse allegations to be reported within federal timeframes.
Improper Beard Net Use in Food Service: An RD observed a dietary relief worker at the tray line with a beard net that did not fully cover facial hair, including the mustache. The RD confirmed the beard net was not worn properly, and another RD stated this was a sanitation issue affecting food quality. The facility dress code policy required facial hair to wear a beard restraint.
Medication Disposal and Delivery Documentation Deficiencies: Pharmaceutical waste bins in medication rooms were observed open with prescription and OTC meds still accessible and not rendered unusable before disposal. Staff confirmed that non-controlled meds were supposed to be crushed or dissolved, documented in the destruction log, and signed by two LNs, but this was not consistently done. In addition, pharmacy delivery manifests and packing slips were not consistently signed, dated, and timed by the receiving nurse when meds were delivered, limiting accurate accountability of received medications.
Staff failed to protect resident dignity when an IP referred to a resident as a “feeder,” signage in another resident’s room identified the resident as a “1:1 feeder,” and a resident’s urinary catheter bag was left uncovered without a privacy cover. The residents had care needs including dysphagia, aspiration precautions, poor oral intake, and 1:1 feeding, and staff interviews confirmed the labeling and uncovered catheter bag were inappropriate and disrespectful.
Staff failed to protect a resident’s privacy during tracheostomy care when an RT performed the procedure with the room door open, allowing visibility from the hallway. Staff also left another resident’s EMR open on a laptop at the nurses’ station, exposing PHI to anyone passing by. The RT, an LPN, and the ADM all acknowledged the privacy and confidentiality lapses, and facility policies required bodily privacy during care and locking/logging off workstations when unattended.
Failure to Follow Constipation Orders: A resident with aphasia, dementia, Alzheimer’s disease, and a G-tube had no BM for 5 days, but ordered constipation meds were not given on time. The MAR showed MOM, Dulcolax, and Fleet enema orders were not followed as directed, and the DON confirmed the bowel care orders were not carried out. The resident’s daughter reported staff only acted after she asked about the last BM, and the care plan identified the resident as at risk for constipation.
Failure to Maintain Ordered Oxygen Therapy: A resident with CHF, hypoxia, acute respiratory failure, and pleural effusion had an order for continuous O2 at 3 L/min via NC. Staff observed the resident in a wheelchair with a portable O2 tank turned off, and the RT confirmed the tank was not on; the resident's O2 saturation rose from 90% to 97% after oxygen was turned on. The resident's care plans called for continuous oxygen and administering oxygen as ordered, but staff did not follow the identified interventions.
A resident admitted under Medicare Part A did not receive the required initial comprehensive visit from a physician; instead, a nurse practitioner performed the assessment and admission orders. Facility staff confirmed that the physician did not personally conduct the initial assessment, which is mandated by federal regulations and facility policy.
A resident with a history of aggressive behavior physically struck another resident, causing injury and distress, after staff failed to provide adequate monitoring and supervision. The aggressive resident was known to require close observation due to behavioral disturbances, but lapses in hourly monitoring and reduced staff presence during lunchtime allowed the incident to occur in an unsupervised hallway.
A resident with hemiplegia and hemiparesis was transferred using a mechanical lift by only one CNA, despite assessment and facility policy requiring two staff for such transfers. The resident slipped from the sling and fell, resulting in a large intramuscular hematoma and fractures. Staff interviews confirmed the failure to follow policy led to the resident's injuries.
A resident with a history of cancer, anxiety disorder, and failure to thrive was found outside in a neighboring parking lot late at night after being unaccounted for in her room. Staff were unable to monitor or ensure her safety during this time, and the resident sustained two skin tears to her right knee. Facility leadership confirmed the incident and acknowledged the risk of more serious injury due to the lack of supervision.
A facility failed to assess a resident's use of a partial denture and hearing aids, leading to staff being unaware of these needs. The resident's partial denture was lost and found cracked, and hearing aids were misplaced, contributing to weight loss and confusion. The facility did not maintain an accurate inventory or care plan for these items, as acknowledged by the DON and Administrator.
A facility failed to implement a comprehensive care plan for a resident's partial denture and hearing aids, leading to staff unawareness and inadequate care. The resident experienced confusion and a 15-pound weight loss. Clinical records did not assess these needs, and the denture was lost and damaged, while hearing aids were misplaced. Staff interviews revealed non-compliance with care planning policies.
A resident with hemiplegia and hemiparesis following a stroke did not receive the ordered RNA therapy for a week, as there was no documentation in the EHR. The facility's policy requires documentation of all services provided, which was not followed, leading to a deficiency in care.
The facility failed to maintain sanitary conditions for food storage and handling. Dirty serving scoops were found with clean utensils, and thawed healthshakes were improperly stored. A dish machine pipe lacked an air gap, and ice machines were not cleaned per guidelines, with mold-like spots and debris observed. These issues were acknowledged by the Dietary Services Manager and Plant Operations Director.
A resident's Midodrine medication was not administered according to physician orders, leading to significant medication errors. The medication, intended to manage blood pressure, was either held or given outside the prescribed parameters on multiple occasions, potentially causing adverse effects. The facility's policy on medication administration was not adhered to, resulting in this deficiency.
The facility failed to ensure kitchen staff competency in food and nutrition services, leading to potential contamination risks. A dishwasher was unable to correctly test sanitizer levels, and a Diet Aide did not follow handwashing protocols after handling trash. Additionally, two Diet Aides were not trained in thermometer calibration. These deficiencies were acknowledged by the Dietary Services Manager and Registered Dietitian.
The facility failed to serve meals at a palatable temperature and flavor, affecting 145 residents. Observations revealed discrepancies in recipe adherence and food temperatures, with milk served warmer than policy standards and meals described as bland. Residents reported dissatisfaction with the food quality, and the RD did not conduct test trays to ensure palatability.
The facility failed to maintain the dish machine in safe operating condition, with sanitizer levels exceeding the recommended 50-100 ppm, reaching 200 ppm. The dishwasher was unaware of a water leak and incorrectly believed the sanitizer level was acceptable. The Dietary Services Manager confirmed the incorrect levels, and a vendor technician adjusted the chemicals. The Registered Dietitian expected compliance with manufacturer guidelines, which were not met.
A facility failed to coordinate specialized mental health services for a resident with bipolar disorder and schizophrenia by not responding to the state authority for PASRR Level II needs. The resident's PASRR Level II case was closed due to unresponsiveness, requiring a new Level I Screening to reopen the case. The facility's policy mandates PASRR completion for all residents to determine mental illness and specialized service needs.
Two residents in the facility experienced deficiencies in their care plans. One resident, requiring continuous oxygen therapy, frequently removed his nasal cannula, and the care plan lacked interventions to maintain his oxygen levels. Another resident, with a midline catheter for IV therapy, had a care plan that did not specify necessary maintenance and monitoring, leading to inadequate care. The facility's policies were not adequately followed, resulting in these deficiencies.
A resident in a LTC facility had a peripheral IV inserted by a licensed nurse without a physician order after accidentally dislodging a midline catheter. The resident was receiving IV antibiotics for a hip wound infection. The Assistant Director of Nurses and the medical doctor confirmed there was no physician order or notification regarding the peripheral IV placement, which was against the facility's IV therapy policy.
A resident, admitted with mobility issues and an intact cognitive status, did not receive scheduled showers for over a week while on COVID precautions. Despite being scheduled for showers twice a week, facility records and staff interviews confirmed the absence of showers during this period, contrary to the facility's policy requiring assistance with bathing.
A resident returned from an orthopedic appointment with a sling on her arm but no new orders. The licensed nurse was unable to contact the orthopedist and removed the sling without notifying the resident's primary doctor, contrary to facility policy. The resident experienced swelling and discomfort, and the lack of communication could have delayed necessary care.
A facility failed to monitor a wander guard for a resident with Parkinson's disease, leading to unsupervised wandering. Another resident with COPD and nicotine dependence was not assessed for safe smoking practices in a timely manner, delaying the identification of smoking risks.
A facility failed to monitor the effectiveness of Haldol for a resident with dementia and personality disorder, prescribed for agitation and aggressive behavior. Despite the care plan's requirement for monitoring each shift, the facility did not begin monitoring until mid-September, a month after the resident's admission. This oversight was confirmed by the ADON, highlighting a lapse in following the facility's policy on antipsychotic medication use.
The facility failed to ensure safe medication storage practices, with expired and undated medications found in three of nine medication carts. An expired multi-dose inhaler and a single-dose hydralazine tablet were found, along with an undated Ozempic injection pen. The ADON confirmed that medications should be marked with open and expiration dates, and discharged resident medications should be promptly removed to prevent errors.
A facility failed to properly store and reheat food brought in for a resident, leading to the meal becoming inedible. The resident, with multiple health conditions, received food from family due to dissatisfaction with facility meals. Staff provided inconsistent information about storage and reheating policies, revealing a lack of knowledge and training on the facility's procedures.
The facility failed to maintain infection control practices for two residents. A nurse did not change gloves or perform hand hygiene during wound care for a resident with a gastrostomy tube, contrary to facility policy. Additionally, another resident's urinal was not labeled, risking cross-contamination. These actions did not adhere to the facility's infection prevention standards.
A resident with a history of congestive heart failure, depression, and anxiety experienced a fall, and the facility failed to accurately document the presence of a fall mat. The interdisciplinary team had recommended a fall mat, but records incorrectly indicated it was already in place. This led to potential miscommunication among healthcare providers.
A resident with osteoarthritis experienced severe pain due to the facility's failure to timely order and administer Norco. Despite requests and attempts to contact the physician, a prescription error delayed medication administration. Additionally, the facility ran out of the resident's pain medication, and the reorder process was not completed promptly, leading to further pain management issues.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after becoming aware of the allegation. A resident with a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, reported that a male CNA attempted to have sex with him during the night, pulled down his pants, exposed himself, and tried to climb on top of him. The resident stated he pushed the CNA away, screamed for help, and that his roommate heard the incident. On a later date, the resident identified the alleged perpetrator as a specific CNA. The allegation was first brought forward when the resident showed CNA 1 a notepad with the word “rape” written on it and stated that the male CNA on the night shift was raping him. CNA 1 reported the allegation to LN 3 the same day, and LN 3 stated she immediately notified LN 2. A progress note authored by LN 2 documented that the Administrator and DON were made aware of the allegation that afternoon. The Administrator reported being notified of the allegation that day and stated that CDPH was notified the same day, but she could not provide evidence of the exact time of notification. The DON similarly stated that CDPH was notified that day but could not provide documentation of the time. A SOC 341 form related to the allegation was received by CDPH via email the following day at 1:57 PM. The Administrator later acknowledged awareness that the alleged abuse should have been reported to CDPH within two hours and was unable to provide documentation confirming that this requirement was met, despite the facility’s Abuse Prevention Program policy requiring investigation and reporting of abuse allegations within federally required timeframes.
Improper Beard Net Use in Food Service
Penalty
Summary
The facility failed to ensure kitchen staff followed the required dress code when dietary relief 1 was observed at the tray line with a beard net that did not fully cover his facial hair, including his mustache. During the observation, the registered dietitian verified that the beard net was not properly covering all facial hair and stated it should have covered the mustache. In a later interview, another registered dietitian stated that not wearing a beard net properly was a sanitation issue affecting food quality and that hair could also cause residents to choke. A review of the facility's dress code policy stated that personal hygiene and appropriate dress are an important part of the Food & Nutrition Services Department and that facial hair must wear a beard restraint.
Medication Disposal and Delivery Documentation Deficiencies
Penalty
Summary
Pharmaceutical waste was not consistently rendered unusable before being placed in the medication room waste bins. During observations at the south nurse station and west nurses' station medication rooms, the pharmaceutical waste bins were found open, with prescription and over-the-counter medications visible and accessible by hand retrieval. Licensed nurses confirmed that the facility's process for non-controlled medication disposal included removing resident identification stickers, documenting the medication name and quantity in the non-narcotic medication destruction log, and placing the medications in the pharmaceutical waste bin, with two licensed nurses required to sign the log. The Infection Control Nurse stated that medications should be crushed or dissolved in the approved solution before disposal, and that leaving medications usable and accessible in the medication room posed a potential for diversion. The pharmacy delivery manifests and packing slips were also not consistently completed by licensed nursing staff when medications were received from the pharmacy provider. Review of delivery documents from the south nurses' station showed that several slips were missing required signatures, dates, and times. Licensed nurses confirmed that the receiving nurse was responsible for verifying the medications against the delivery slip for accuracy, documenting receipt, and signing and dating the manifest at the time of delivery. Staff stated that without properly completed delivery slips, the facility could not accurately track missing medications or determine which staff member received the medications and when they were received. Facility staff and the pharmacy consultant described the expected processes for medication disposal and receipt, including use of the approved dissolving solution for non-controlled medications, secure closure of the pharmaceutical waste bin, and signing and dating delivery manifests upon receipt. The DON stated that pharmacy deliveries were primarily received by night shift nurses and that licensed nursing staff were expected to reconcile medications with the delivery slips and sign and date the receipts at the time of delivery. The facility policy reviewed by surveyors stated that medications not returned to the dispensing pharmacy were to be disposed of in accordance with applicable regulations, and that pharmacy services procedures included staff roles and responsibilities during receipt and storage of medications.
Failure to Protect Resident Dignity Through Labeling and Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect when the Infection Preventionist referred to a resident as a “feeder” during a bedside observation and interview. The resident’s care plan showed the resident was at risk for altered nutritional status, had poor oral intake, dysphagia, aspiration precautions, and required 1:1 feeding. The facility’s dignity policy stated residents should be treated with dignity and respect at all times and not labeled or referred to by care needs. The facility also posted signage in another resident’s room and on the resident’s communication board that identified the resident as a “1:1 feeder,” publicly disclosing the resident’s care needs. Staff interviews confirmed the labeling was inappropriate and disrespectful, and the Administrator stated it was not acceptable and not in accordance with facility policy. In a separate observation, a resident’s urinary catheter bag was left uncovered without a privacy cover. A CNA confirmed the bag should have had a privacy cover for dignity purposes, and the DSD stated it was the expectation that urinary catheter bags would be covered to support dignity and self-respect.
Failure to Protect Resident Privacy and Confidential Information
Penalty
Summary
Staff failed to protect Resident 4’s privacy during tracheostomy care. Resident 4 was admitted with diagnoses including dysphagia and aphasia. During a concurrent observation and interview in the resident’s room, the Respiratory Therapist performed tracheostomy care while the bedroom door remained open, allowing visibility into the room from the hallway. The RT confirmed the door stayed open throughout the procedure and stated he should have closed the door or pulled the privacy curtains. The Administrator reviewed the facility’s dignity policy and verified that privacy had not been provided during the treatment. Staff also failed to protect Resident 19’s confidential electronic medical record. During an observation at the nurses’ station unit, an open laptop computer was left on top of a medication cart with Resident 19’s personal and medical information visible to anyone walking by. A Licensed Nurse confirmed she had stepped away from the computer after giving medication and had forgotten to lock the screen. Another nurse stated staff were expected to lock computer screens when walking away, and the Administrator stated it was the expectation that staff log off so resident information could not be seen. The facility policy on computer terminals stated workstations must be protected from public view and may not be left unattended unless the screen is cleared and the user is logged off.
Failure to Follow Constipation Orders
Penalty
Summary
The facility failed to provide constipation treatment and care according to physician orders for one resident with aphasia, dementia, Alzheimer’s disease, and a gastrostomy tube. The resident was non-verbal. The resident’s bowel elimination record showed no bowel movement from 1/4/26 through 1/8/26, and the MAR showed that the ordered constipation medications were not given from 1/4/26 through 1/7/26. The orders directed staff to give Milk of Magnesia if there was no bowel movement after 3 days, then Dulcolax suppository if there was no result, and then Fleet enema if there was still no result. During interviews and record review, the DON confirmed the resident had no bowel movement for 5 days and that the physician orders were not followed when constipation medications were not given after 3 days without a bowel movement. The resident’s daughter stated she asked staff about the last bowel movement and was told it had been four days earlier, and that this was the only time staff acted on the situation. The care plan identified the resident as at risk for constipation and directed administration of constipation medications as ordered by the physician.
Failure to Maintain Ordered Oxygen Therapy
Penalty
Summary
Resident 2 was admitted and later readmitted with diagnoses including acute respiratory failure with hypoxia, chronic systolic congestive heart failure, and pleural effusion. The resident had an active physician order for oxygen at 3 liters per minute via nasal cannula every shift for hypoxia and shortness of breath, with a goal of maintaining oxygen saturations above 90%. During observation, the resident was seen in bed connected to an oxygen concentrator set at 3 L/min, and the resident stated he routinely received oxygen while in bed and used a portable oxygen tank when in his wheelchair. During a later observation, Resident 2 was seated in a wheelchair in the hallway and connected to a portable oxygen tank that was turned off. The Respiratory Therapist confirmed the tank was not on and measured the resident's oxygen saturation at 90%, which increased to 97% within 30 seconds after oxygen was turned on at 3 L/min. The RT stated he could not determine how long the resident had been without oxygen and said nursing staff were expected to ensure the resident remained on continuous oxygen therapy as ordered, including turning on the portable tank when transferring the resident to the wheelchair. Review of the resident's care plans showed interventions for congestive heart failure and risk for hypoxia that included oxygen via nasal cannula at 3 L continuously and administering oxygen as ordered with oxygen precautions. The LN and DON confirmed the resident had an active order for continuous oxygen and that staff were expected to keep the portable oxygen tank on when the resident was in the wheelchair. The facility policy on oxygen administration also directed staff to verify the order, review the care plan, turn on the oxygen, and observe the resident to ensure oxygen was being tolerated.
Initial Physician Assessment Not Completed for Medicare Part A Admission
Penalty
Summary
The facility failed to ensure that the initial comprehensive visit for a resident admitted under Medicare Part A was completed by a physician, as required by federal regulations. Instead, the initial assessment and admission orders for the resident were performed by a nurse practitioner. This was confirmed through interviews and record reviews with facility staff, including the LN, DON, and Administrator, all of whom acknowledged that the physician did not personally conduct the initial assessment. The facility's own policy and procedure, as well as CMS guidance, specify that the initial comprehensive visit in a skilled nursing facility (SNF) must be performed by a physician and cannot be delegated to a non-physician practitioner. The deficiency was identified for one of three sampled residents, with documentation showing that the nurse practitioner completed the initial assessment and 72-hour charting. Staff interviews further confirmed the importance of the physician's role in establishing a baseline, reviewing and reconciling medications, and developing the plan of care during the initial assessment. The facility is dually certified under Medicare and Medicaid, and the failure to have the physician personally complete the required initial visit was verified by the Administrator.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behavior physically abused another resident. The aggressive resident, who had diagnoses including dementia with agitation and behavioral disturbance, was known by staff to exhibit combative and threatening behaviors, including striking out at staff and other residents. On the day of the incident, the aggressive resident approached another resident in a hallway, struck her on the hand, and attempted to kick her. The assaulted resident, who had normal cognitive function and required assistance with personal care and mobility, sustained a bruised right hand and reported feeling upset, uncomfortable, and unsafe following the incident. Staff interviews and record reviews revealed that the aggressive resident was supposed to be monitored hourly due to his known behaviors and tendency to wander. However, documentation showed that hourly monitoring was not consistently performed or recorded as expected. At the time of the incident, there were fewer staff available due to lunchtime coverage, and no staff were present in the hallway where the abuse occurred. The area where the incident took place was not visible from the nurses' station, further reducing the likelihood of timely staff intervention. Multiple staff members, including nurses and CNAs, confirmed that the aggressive resident required close supervision when out of his room to prevent harm to others. Despite this, the lack of adequate monitoring allowed the resident to approach and harm another resident without immediate staff intervention. The facility's own policy required protection of residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers due to hemiplegia, hemiparesis, and aphasia following a stroke, was transferred using a mechanical lift by a single CNA instead of the required two-person assist. The resident's Minimum Data Set assessment indicated a need for two or more staff members for transfers, and facility policy mandated at least two nursing assistants for safe use of a mechanical lift. Despite these requirements, the CNA attempted the transfer alone, resulting in the resident slipping from the sling and falling to the floor. As a result of this incident, the resident sustained a large intramuscular hematoma to the right pectoralis and minimally displaced fractures of the right proximal tibia and fibula. Interviews with facility staff, including the MDS Coordinator, Licensed Nurse, and DON, confirmed that the resident required two-person assistance and that the CNA did not follow established policy and procedures. The DON acknowledged that the resident's injuries were acquired due to the fall caused by the failure to implement the required two-person assist during the transfer.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was found outside the facility in the parking lot of a neighboring apartment complex at approximately 10:00 p.m. The resident was not in her room at 9:30 p.m., prompting a search of the building, and was located outside around 9:45 p.m. Upon assessment, the resident was found to have two skin tears on her right knee and was unable to recall the events that led to her being outside. The resident's clinical record indicated diagnoses including malignant neoplasm of the kidney, anxiety disorder, and failure to thrive. Staff interviews confirmed that the resident had eloped from the facility and that staff were unable to ensure her safety or monitor her when she was not in the building or accounted for. The administrator acknowledged that the resident was assessed and treated for her injuries after being found outside and stated there was potential for more serious injury due to the lack of supervision while the resident was outside the facility.
Failure to Assess Resident's Use of Dentures and Hearing Aids
Penalty
Summary
The facility failed to accurately assess a resident for the use of a partial denture and hearing aids, which led to staff being unaware of the resident's needs. Upon admission, the Licensed Nurse did not assess the resident's use of these items, and the Minimum Data Set (MDS) nurse incorrectly indicated that the resident did not use hearing aids. This lack of assessment resulted in the absence of a care plan for the resident's hearing aids and partial dentures. The resident's partial denture was lost and later found cracked, rendering it unusable for over three weeks, during which the resident experienced weight loss. The resident's hearing aids were also misplaced for a few days. Interviews with staff and family members revealed that the facility did not maintain an accurate inventory of the resident's possessions, and there was no consistent care for the resident's partial denture and hearing aids. The Director of Nursing and Administrator acknowledged that the Licensed Nurse should have reassessed the resident's dental and hearing status, which would have generated appropriate care plans. The facility's policy and procedure for resident assessment and care plan coordination were not followed, as confirmed by the Director of Nursing during a review of the facility's policy.
Failure to Implement Comprehensive Care Plan for Resident's Denture and Hearing Aids
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was in place for a resident, specifically addressing the use of a partial denture and hearing aids. This oversight resulted in the nursing staff's lack of awareness regarding the resident's need for these aids, leading to inadequate care and management of the partial denture and hearing aids. The resident experienced confusion and a significant weight loss of 15 pounds during their stay at the facility. The resident's clinical records, including the Admission Record and the Nursing Admission Data Collection and Baseline Care Plan Tool, did not assess or document the use of a partial denture and hearing aids. Despite the Registered Dietitian noting the presence of dentures in a Nutritional Comprehensive Assessment, the lack of a formal care plan meant that these needs were not systematically addressed. The resident's partial denture was lost and found damaged, and the hearing aids were misplaced for a few days, further complicating the resident's care. Interviews with facility staff, family members, and the resident revealed that the facility did not follow its policies and procedures for comprehensive, person-centered care planning. The Director of Nursing and Administrator acknowledged that the Licensed Nurse should have reassessed the resident's dental and hearing needs, which would have generated the necessary care plans. The failure to reassess and document these needs led to the absence of a care plan that could have mitigated the resident's confusion and weight loss.
Failure to Provide and Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing treatment and services for a resident, identified as Resident 2, who did not receive her ordered RNA therapy for a specific week. Resident 2 was admitted with diagnoses including difficulty in walking, hemiplegia, and hemiparesis following a cerebral infarction affecting the left side. The physician had ordered RNA therapy two times a week for upper extremity active range of motion (AROM) and transfer training, which was later increased to three times a week. However, there was no documentation of RNA services being provided to Resident 2 during the week of September 23rd, as confirmed by the Restorative Nurse Assistants and the Director of Rehabilitation. Interviews and record reviews revealed that the RNA services were not documented in Resident 2's electronic health record (EHR) for the specified week, and there was no paper documentation available either. The Director of Rehabilitation and the Assistant Administrator confirmed the absence of documentation, indicating a lapse in the provision of RNA services. Resident 2 and a family member also stated that RNA services began the following week. The facility's policy on restorative nursing services and documentation requires that all services provided be documented in the resident's medical record, which was not adhered to in this case.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage and handling, as observed during a survey. Dirty serving scoops with green and brown crusted substances were found stored with clean utensils in a cook's undercounter drawer. The Dietary Services Manager (DSM) acknowledged the oversight, noting that the scoops should have been clean and checked by the cooks. Additionally, eleven cases of thawed and soft mighty healthshakes were improperly stored in the walk-in refrigerator, with some past their use-by date. The DSM confirmed the shakes were heavily used in the facility and acknowledged the improper storage. Further inspection revealed a pipe from the dish machine extended directly into a floor sink drain without an air gap, which is a violation of the 2022 Federal FDA Food Code. The DSM and Plant Operations Director (POD) were unaware of this issue, and the POD admitted the pipe needed to be raised. Additionally, two ice machines were not cleaned and maintained according to the manufacturer's instructions. The ice machine in the dining room had small brownish pink spots and black, grayish mold-like spots on the baffle, which the POD acknowledged as missed during cleaning. The main ice machine also had thick debris and buildup inside the ice spout, which the POD admitted could have been scrubbed more thoroughly. The facility's policies and procedures were reviewed, indicating that equipment should be maintained and cleaned regularly. However, the observations during the survey showed that these procedures were not followed, leading to unsanitary conditions that could potentially expose residents to harmful substances. The Registered Dietitian (RD) expressed expectations for the ice machines to be clean, following the manufacturer's guidelines, without any residue or debris.
Medication Administration Error
Penalty
Summary
The facility failed to protect a resident from significant medication errors when Midodrine, a medication used to manage blood pressure, was not administered according to physician orders. The resident, who had a history of aphasia following a cerebral infarction, was prescribed Midodrine to be given three times a day via PEG-Tube for hypotension, with specific instructions to hold the medication if the systolic blood pressure exceeded 130. However, the medication was either held or administered outside of these parameters on multiple occasions in August and September 2024. The Assistant Director of Nursing confirmed that the medication was not administered correctly, with instances of Midodrine being held when it should have been given, and vice versa. This included specific dates where the medication was either held or administered incorrectly, potentially leading to adverse effects such as hypotension or hypertension. The facility's policy on administering medications, which mandates that medications be given safely and timely as prescribed, was not followed, resulting in this deficiency.
Deficiencies in Kitchen Staff Competency and Sanitation Practices
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. During an observation, a dishwasher (DSW) was unable to correctly test the dish machine sanitizer or identify the safe temperatures and sanitizer levels for the 3-compartment sink. The DSW incorrectly recorded the sanitizer level as 200 ppm, which was too high, and did not know the correct temperature levels for the 3-compartment sink. The Dietary Services Manager (DSM) acknowledged these errors and stated that the correct sanitizer level should be 50-100 ppm. Additionally, a Diet Aide (DA) failed to wash his hands after disposing of trash outside on two occasions, which is a violation of proper food safety and sanitation practices. The DA admitted that he should have washed his hands and worn a disposable apron to prevent cross-contamination. The DSM confirmed that the DA did not follow the correct procedures, which could lead to contamination. Furthermore, two Diet Aides were unable to demonstrate how to calibrate a thermometer correctly. One DA stated she had never been trained on this procedure, while another DA recalled some information from a previous job but was unsure of the correct process. The DSM acknowledged that the DAs should know how to calibrate a thermometer correctly. The Registered Dietitian (RD) expected the kitchen staff to perform these tasks correctly and stated that monthly in-services and quarterly kitchen sanitation checks were conducted, but some staff members did not attend the relevant training sessions.
Deficiency in Meal Temperature and Flavor
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature and flavor, as per their policy, affecting 145 out of 155 residents. During a kitchen observation, it was noted that the cook was unsure if the regular recipe for pasta with garlic and herbs was fully followed, and the pureed chicken cacciatore sauce did not match the regular version, potentially altering the flavor. During a trayline service observation, test trays revealed that the milk was served at 52 degrees Fahrenheit, which was warmer than the facility's policy of 41 degrees Fahrenheit. The pureed salad was described as watery and bland, and the pureed chicken cacciatore lacked flavor until the sauce was added. The regular meal pasta was also found to be buttery and bland due to missing garlic and herb seasoning. During a resident council meeting, multiple residents anonymously reported that the food was not tasty, often served cold, and was bland and overcooked. The Registered Dietitian (RD) admitted to not conducting test trays to check food temperatures and palatability, although she personally liked the facility food. The RD acknowledged that the food should be served at an appealing temperature to encourage residents to eat. The facility's policies emphasized the importance of serving meals at appropriate temperatures and using approved recipes to ensure nutritional needs are met, but these were not adhered to, leading to the deficiency.
Dish Machine Sanitizer Levels Exceeded Safe Limits
Penalty
Summary
The facility failed to maintain the dish machine in safe operating condition, as observed during a kitchen tour. The dish machine sanitizer exceeded safe levels, with test strips showing a dark purple color indicating 200 parts per million (ppm), which is above the recommended 50-100 ppm. The dishwasher was unaware of the water leak beneath the machine and incorrectly believed the sanitizer level was acceptable. The dish machine sanitizer testing log consistently recorded 200 ppm from September 1 through 17, which was initialed by the dishwasher. The Dietary Services Manager (DSM) acknowledged the incorrect sanitizer levels and the water leak, confirming that the appropriate level should be 50-100 ppm. A vendor technician adjusted the chemical levels to the correct range, noting that excessive chemicals could contaminate dishes and food. The Registered Dietitian (RD) expected the dish machine to function according to manufacturer guidelines, which were not met. The facility's policies required proper maintenance and regular checks of the dish machine, which were not adhered to, leading to the deficiency.
Failure to Coordinate Specialized Mental Health Services
Penalty
Summary
The facility failed to ensure coordination of specialized mental health services for a resident with serious mental illness diagnoses, including bipolar disorder and schizophrenia. The deficiency occurred when the facility did not respond to the state-designated authority for further PASRR Level II needs, which is a tool used to ensure residents with certain mental illnesses receive the necessary care in the most appropriate setting. The resident was admitted in August 2024, and the PASRR Level II letter dated 8/21/24 indicated that facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. As a result of the facility's inaction, the PASRR Level II case was closed, and the facility was required to resubmit a new Level I Screening to reopen the case. The Minimum Data Set Case Manager (MDSCM) confirmed that the PASRR Level II was closed due to the agency's inability to contact anyone at the facility. A new PASRR Level I screening was completed on 9/18/24, which indicated the resident had serious mental illness diagnoses and required a PASRR Level II Screening. The facility's policy on PASRR indicated that all residents entering the facility should have a PASRR completed to determine if they are mentally ill and whether they need specialized services.
Deficiencies in Resident Care Plans for Oxygen and IV Therapy
Penalty
Summary
The facility failed to provide a resident-centered care plan for two residents, leading to deficiencies in their care. Resident 76, who was admitted with conditions including hepatic encephalopathy, COPD, CHF, and anxiety disorder, required continuous oxygen therapy. However, the care plan did not include interventions to ensure his oxygen levels remained above 90%. Observations revealed that Resident 76 frequently removed his nasal cannula, and staff were not consistently monitoring or reminding him to wear it, resulting in his oxygen saturation dropping below the desired level. Resident 104, admitted with an infection and inflammatory reaction due to a hip prosthesis, required intravenous therapy through a midline catheter. The care plan for Resident 104 was not specific to the midline catheter, lacking details on maintenance, dressing changes, and signs of complications. This oversight was evident when Resident 104 accidentally pulled out her midline catheter, and the care plan did not provide guidance on managing such incidents or the specific care required for her IV access. The facility's policies on oxygen administration and care planning were not adequately followed, as evidenced by the lack of specific interventions and monitoring for both residents. The Assistant Director of Nurses acknowledged the deficiencies in the care plans, noting the absence of necessary interventions and monitoring for Resident 76's oxygen therapy and the lack of specificity in Resident 104's IV therapy care plan.
Peripheral IV Inserted Without Physician Order
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident when a licensed nurse inserted a peripheral IV without a physician order. The resident was admitted with a diagnosis of infection and inflammatory reaction due to an internal left hip prosthesis and a surgical complication. The resident was receiving intravenous antibiotics for a hip wound dehiscence. On a specific date, the resident accidentally pulled out her midline catheter, and the licensed nurse inserted a peripheral IV cannula in the right arm without obtaining a physician order. The Assistant Director of Nurses confirmed that there was no physician order for the peripheral line and no nursing progress note indicating that the resident's medical doctor was informed about the dislodgement of the midline catheter. The medical doctor also confirmed that there was no record of being notified about the need for a peripheral line and did not place an order for it. The facility's policy on IV therapy requires verbal consent for placement and specifies that peripheral catheters are for short-term therapies, typically less than one week.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to provide weekly showers to a resident, identified as Resident 48, as per their preference and schedule. Resident 48, who was admitted in March 2022 with diagnoses including abnormalities of gait and mobility, had an intact cognitive status with a BIMS score of 15. The resident required substantial assistance for personal hygiene and preferred showers over bed baths. Despite being on COVID precautions since early September, the resident expressed concern about not receiving showers, with the last shower documented over a week prior to the interview. The facility's records and interviews with staff, including the Director of Staff Development and a Certified Nursing Assistant, confirmed that Resident 48 was scheduled for showers twice a week but did not receive them between early and mid-September. The Assistant Director of Nursing acknowledged that showers should have been provided according to the schedule, even for residents on COVID precautions, emphasizing the importance of showers for hygiene and infection prevention. The facility's policy required staff to assist residents with bathing as necessary, but documentation showed that showers were not provided as scheduled during the specified period.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to meet professional standards of care for a resident who returned from an orthopedic appointment with a sling on her right arm but without new medical orders. The licensed nurse attempted to contact the orthopedist for further instructions but did not receive a response. Consequently, the sling was removed from the resident's arm due to the absence of a formal order. This action was taken without notifying the resident's primary medical doctor, which was against the facility's policy for handling changes in a resident's condition. The resident, who had been readmitted to the facility earlier in the year, reported significant swelling, limited movement, and discomfort in her right arm. The facility's Assistant Director of Nurses confirmed that there was no documentation indicating that the primary medical doctor had been informed of the situation, which could have led to delayed care. The facility's policy requires prompt notification of the attending physician in the event of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Monitor Wander Guard and Timely Smoking Assessment
Penalty
Summary
The facility failed to implement measures to minimize accidents for two residents, leading to potential safety risks. Resident 122, diagnosed with Parkinson's disease and at high risk for elopement, was not properly monitored with a wander guard device. Despite being identified as having impulsive behavior and poor safety awareness, the wander guard was not consistently checked for placement and functionality. On one occasion, Resident 122 was observed outside the facility without staff knowledge, and it was noted that the resident was not wearing the wander guard wristband. The facility's policy required monitoring of residents at risk for elopement, but this was not adhered to, increasing the risk of unsupervised wandering. Additionally, Resident 296, who was admitted with COPD and nicotine dependence, was not assessed for safe smoking practices in a timely manner. The Smoking Risk assessment was completed 12 days after admission, which delayed the identification of the resident's smoking habits and potential risks, especially given the resident's dependence on supplemental oxygen. The facility's policy required an evaluation upon admission to determine smoking status and ability to smoke safely, but this was not conducted promptly, potentially putting the resident and others at risk.
Failure to Monitor Antipsychotic Medication Effectiveness
Penalty
Summary
The facility failed to ensure safe medication use for a resident on antipsychotic medication, specifically Haldol, by not monitoring its effectiveness. The resident, who was admitted in August 2024 with diagnoses including dementia and personality disorder, was prescribed Haldol for agitation manifested by aggressive behavior. However, the facility did not monitor the resident's aggressive behavior as an indication for Haldol use until mid-September 2024, despite the care plan requiring monitoring each shift. The Assistant Director of Nursing confirmed that behavior monitoring for Haldol was not conducted in August 2024 and only began in September 2024. The facility's policy on antipsychotic medication use required staff to observe, document, and report the effectiveness of interventions, including antipsychotic medications, to the attending physician. This lapse in monitoring placed the resident at risk for inadequate symptom relief and/or adverse effects from the use of the antipsychotic medication.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage practices in three of nine medication carts. An expired multi-dose inhaler, Wilexa Inhub, was found in the medication cart for a resident, with the date indicating it should have been discarded a month after opening. The licensed nurse confirmed the medication was not discarded as per the manufacturer's instructions. Additionally, a multi-dose injection pen of Ozempic was found without a date opened label, which is necessary to determine its expiration. The Assistant Director of Nursing confirmed that medications should be marked with the open date and expiration date to ensure effectiveness. Furthermore, a single-dose package of hydralazine, a blood pressure medication, was found expired and stored in the medication cart for a discharged resident. The medication was not stored with other resident medications, and the licensed nurse was unsure why it was in the drawer. The Assistant Director of Nursing stated that medications for discharged residents should be removed from the cart within a day or two to prevent the risk of administering the wrong medication. The facility's policies on medication storage and disposal were not adhered to, contributing to these deficiencies.
Failure to Store and Reheat Resident's Outside Food
Penalty
Summary
The facility failed to ensure that food brought in from outside for Resident 85 was stored and reheated according to regulatory standards and facility policy. Resident 85, who was admitted with diagnoses including congestive heart failure, type 2 diabetes, iron deficiency anemia, and vitamin D deficiency, expressed dissatisfaction with the facility's food due to its saltiness. As a result, her granddaughter occasionally brought her meals from a nearby steak restaurant. On one occasion, the resident received a meal that included steak, mashed potatoes, and a dinner roll, but was informed by the nursing staff that they could not store or reheat her food, leading to it becoming cold and soggy after sitting out for several hours. Interviews with various nursing staff revealed inconsistencies and a lack of knowledge regarding the facility's policy on storing and reheating food brought in from outside. Licensed nurses provided conflicting information about the storage duration and reheating procedures, with some stating that food could not be stored due to lack of space, while others were unaware of the reheating policy. The Assistant Director of Nursing acknowledged the need for staff training on the policy, which required perishable foods to be labeled and stored appropriately, and reheated by kitchen staff, though specific reheating guidelines were unclear. The facility's policy indicated that discussions about outside food should be documented, and perishable foods discarded after an appropriate time, but these procedures were not followed in this instance.
Infection Control Deficiencies in Wound Care and Urinal Labeling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. For Resident 56, a licensed nurse did not change gloves or perform hand hygiene during wound care. The nurse administered medication via a gastrostomy tube and changed the dressing on the stoma site without changing gloves or washing hands between handling soiled and clean dressings. This was contrary to the facility's policy, which requires hand hygiene and glove changes during dressing changes to prevent infection. The Assistant Director of Nurses confirmed that the standard of care was not maintained, putting the resident at risk of infection. For Resident 246, the facility failed to label the resident's urinal with a name or room number. During an observation, a certified nursing assistant confirmed that the urinal was unlabeled, which could lead to the risk of infection if used by another resident. The facility's infection prevention and control program policy emphasizes the importance of labeling personal items to prevent the transmission of infections. The lack of labeling was identified as a failure to adhere to these infection control standards.
Documentation Errors in Fall Incident
Penalty
Summary
The facility failed to ensure the medical record accurately reflected a fall incident for a resident. Licensed staff did not document whether the resident's fall mat was present when the resident fell out of bed. The interdisciplinary team had recommended the use of a fall mat for the resident, but the care plan and other records incorrectly indicated that this intervention was already in place. This discrepancy in documentation had the potential to cause miscommunication and confusion among healthcare providers regarding the resident's fall. The resident was admitted to the facility in 2021 with diagnoses including congestive heart failure, depression, and anxiety. On the day of the incident, a licensed nurse was called to assess the resident after a fall and found the resident sitting on the floor next to the bed. The bed was in the lowest position, and the call light was within reach. During interviews, both the Director of Nursing and the licensed nurses involved acknowledged the documentation errors regarding the presence of the fall mat.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident diagnosed with osteoarthritis, leading to the resident experiencing severe pain. The resident was admitted in May 2024 and requested Norco for pain relief on May 18, 2024, as Tylenol was ineffective. Despite multiple attempts to contact the physician, including faxing and calling, the prescription was not corrected in a timely manner due to an error in the date, delaying the administration of the medication until May 20, 2024. Further issues arose when the resident's pain medication ran out on July 4, 2024, and the facility did not have the medication available. The nursing staff failed to reorder the medication in a timely manner, and the physician's order was not signed until July 5, 2024. The Director of Nurses acknowledged that medications should be reordered when there are approximately seven doses left, and urgent needs should be addressed within an hour. The facility's policy required medications to be reordered at least three days before the last dose to ensure availability.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vintage Faire Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Almond Vista Healthcare | 1.1 mi | ★★★★★ | 2 | 0 |
| Garden City Healthcare Center | 1.9 mi | ★★★★★ | 19 | 0 |
| Modesto Post Acute Center | 3 mi | ★★★★★ | 17 | 0 |
| Valley Skilled Nursing Center | 3 mi | ★★★★★ | 3 | 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.