Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Eskaton Village Care Center during CMS and state inspections, most recent first.
A resident with a fractured vertebra and intact cognition reported to an LN that a CNA was being excessively rough during the night shift. The LN did not complete the required abuse reporting paperwork at the time of the allegation, and the SOC 341 abuse report was not faxed to CDPH until the following day, exceeding the facility policy requirement to report alleged abuse within two hours of the allegation.
Care plans were not reviewed or revised as needed for two residents. One resident’s urinary catheter care plan was not updated after the catheter was removed, another resident’s urinary catheter care plan was not revised after discontinuation, and that same resident’s trazodone care plan was not reviewed within the 21-day timeframe noted in the CP. The DON confirmed the records did not show the required review had been completed.
Two residents had urinary catheters discontinued, but their PO and CP documentation was not updated to reflect the change. One resident had a history of cerebral infarction and hemiparesis, and the other had lumbar and thoracic fractures with muscle weakness. LN and the DON confirmed the catheters had been discontinued and that the orders should have been updated, while the care plans still reflected catheter-related needs.
Discontinued medications were found mixed throughout the medication storage area, including in carts, drawers, bins, an insulated bag, and with active IV stock. The DON confirmed the items were discontinued and should have been destroyed, and two reviewed resident orders for Benadryl and hyoscyamine were long discontinued. The CP said staff were expected to keep the storage room free of discontinued meds and destroy them within 90 days.
Food textures, menu items, and resident preferences were not followed for several residents. One resident with multiple texture-modified diet orders was served pureed items despite stating the food was not supposed to be pureed. Another resident on a NAS/low fat diet did not receive the meatloaf or dessert listed on the menu and instead received chicken and brown rice. A resident on a CCHO diet received salmon despite documented dislikes of fish, and another resident did not receive the biscuit listed on the meal ticket. Staff and leadership acknowledged that trays, meal tickets, menus, and preferences were expected to match.
Kitchen sanitation and food handling deficiencies: The ice machine dispenser was observed with black and brown buildup, a kitchen staff member touched the food prep area with soiled gloves after contacting multiple surfaces, ice buildup was present on freezer seals and frames, and wet pans were stored on a ready-to-use rack near the cooking area. The FSM, EC, and DON confirmed these conditions were not expected, and facility policies required clean equipment, proper glove changes, monthly freezer cleaning, and air-dried pans.
A resident received trazodone at bedtime for insomnia, but the order listed depression manifested by insomnia even though the DON confirmed there was no documentation supporting a diagnosis of depression. The LPN and DON also confirmed the resident was not monitored for hours of sleep to assess effectiveness, and the CP agreed the order elements were not accurate.
A resident with pneumonitis, dysphagia, and a GT was NPO and received tube feedings, but the nutritional care plan was not individualized to his needs. The plan included goals for meal intake and interventions such as encouraging oral intake, offering bedtime snacks, and reviewing food preferences, even though the resident stated he could not eat regular food and staff confirmed those interventions were inappropriate for an NPO resident receiving tube feedings.
CP failed to identify and report irregularities during the monthly MRR for a resident receiving trazodone for depression manifested by insomnia. The resident’s chart lacked documentation supporting a clinical diagnosis of depression, and staff confirmed the resident was not monitored for hours of sleep to assess medication efficacy. The DON and CP both acknowledged the order and monitoring documentation were incomplete, but the CP’s review listed no recommendations.
The facility failed to label opened inhalers with open and discard dates for three residents with COPD, as observed by an LPN. The inhalers, stored in a medication cart, lacked necessary labeling, potentially affecting their efficacy. The Interim DON confirmed that medications should have open and discard dates, as per facility policy, to ensure maximum effectiveness.
A staff member failed to follow the recipe and measure ingredients while preparing quiche for 33 residents, potentially affecting the nutritive values of the food. The Executive Chef and Administrator confirmed the expectation to adhere to standardized recipes to meet residents' nutritional needs.
The facility failed to maintain proper food storage and sanitation standards, affecting 33 residents. Unlabeled, expired, and soiled food items were found in the kitchen, along with wet, dirty, and damaged cooking pans. A dirty can-opener and ice machine were observed, and a staff member used soiled gloves on clean surfaces. Ice buildup in freezers was also noted, potentially affecting food quality.
The facility failed to maintain the dryer lint compartments, posing a fire hazard for 33 residents. Laundry staff did not clean the lint compartments at the start of their shift, and the housekeeping supervisor noted missing documentation of lint removal on several occasions. The facility's policy required equipment to be ready for use at all times.
A resident in the facility experienced a deficiency in her living environment due to a broken light switch and a stuck drawer, which hindered her ability to access personal items and maintain independence. Despite her requests for repairs, the issues persisted, impacting her comfort and well-being. Staff confirmed the problems and acknowledged the importance of a homelike environment, as outlined in the facility's policy.
A resident with COPD and dependence on supplemental oxygen did not have a care plan indicating oxygen therapy, despite receiving oxygen at two liters per minute. This was confirmed by a nurse and the IDON, who emphasized the necessity of care plans for meeting residents' needs.
A licensed nurse in an LTC facility prepared a medication for a resident using another resident's medication supply, violating professional standards and facility policy. The resident, admitted with a hip fracture and chronic constipation, had a prescription for polyethylene glycol. The nurse acknowledged the error, and the Interim DON emphasized the importance of following the five rights of medication administration.
A resident with a right femur fracture was not offered or given scheduled showers, despite having the capacity to make healthcare decisions and a care plan indicating the need for assistance with bathing. Observations revealed unkempt and matted hair, and the resident reported not having a shower since her accident. Both a CNA and an LN confirmed the absence of documentation for showers on scheduled dates, contrary to the facility's policy for maintaining personal hygiene.
A resident with paraplegia and dementia fell during a transfer using a mechanical lift when a sling loop broke, resulting in a head injury. The facility's policy required slings to be inspected for damage, but this was not done, leading to the incident. The Director of Staff Development and Interim DON confirmed the sling was not properly inspected.
A resident with paraplegia and dementia received a meal tray that did not match their meal ticket, failing to accommodate their food preferences. The meal tray contained chicken tamales and other items, while the meal ticket indicated a different set of food choices. The Interim DON confirmed the expectation for meal tickets to match meal trays, as per the facility's policy on maintaining food preferences.
A CNA failed to use required PPE when entering an isolation room of a resident with pneumonia, despite clear signage and facility policy. This lapse in infection control practices was confirmed by the Infection Preventionist and Interim Director of Nursing, highlighting a potential risk for cross-contamination among residents.
A resident with chronic kidney disease and no memory impairment was not informed of a change in her medication regimen, specifically the discontinuation of spironolactone, which she had been taking for high blood pressure and fluid retention. This led to worsening leg edema. The DON confirmed that the MD did not discuss the medication change with the resident, violating the facility's policy on Resident Rights.
A resident with chronic pain syndrome and pancreatitis experienced delayed administration of pain medication by an LN, leading to unmanaged pain and feelings of mistreatment. The facility's policy required timely administration, which was not followed.
Delayed Reporting of Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents. The resident had been admitted with a diagnosis of a fractured vertebra and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no memory impairment. According to progress notes, the resident informed a licensed nurse that a certified nursing assistant had been "way too rough" with him during the night shift. The licensed nurse acknowledged during interview that she did not complete the required paperwork to report this allegation when it was made. Record review showed that the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was not faxed to the Department of Public Health until the following morning, as confirmed by the administrator. A fax cover sheet documented successful transmission of the abuse report on that later date. The facility’s policy on Elder and Dependent Adult Suspected Abuse and Reporting required that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but no later than two hours after the allegation is made. The delay in reporting the allegation beyond the two-hour requirement constituted the deficiency.
Care plans not reviewed or revised after catheter removal and trazodone review timeframe
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised in a timely manner for two sampled residents when their urinary catheter care plans were not updated after the catheters were discontinued, and when one resident’s trazodone care plan was not reviewed or revised within the timeframe indicated. Resident 5 was admitted with diagnoses including cerebral infarction and left-sided hemiparesis, had a physician order for a urinary catheter, and the care plan dated 12/14/25 addressed urinary retention and catheter use. Resident 5 later confirmed the catheter had been removed, but the care plan was not updated to reflect that change. Resident 2 was admitted with diagnoses including lumbar and thoracic fractures, muscle weakness, lack of coordination, and weakness, and had a physician order for a urinary catheter with a care plan addressing potential complications related to catheter use. A progress note documented a new order to discontinue the catheter, and Resident 2 later confirmed it had been removed, but the care plan was not revised. Resident 2 also had an order for trazodone 50 mg at bedtime for depression manifested by insomnia, and the care plan dated 2/10/26 identified a goal related to sleep and stated the interdisciplinary team would meet to discuss and review psychoactive medication use within 21 days of admission. During interview and record review, the DON confirmed the care plan indicated the IDT was to review trazodone within 21 days of admission and stated there was no evidence in the medical record that this had been completed. Facility policy stated care plans are reviewed and revised as needed during the weekly summary process, but the records reviewed showed the catheter-related care plans for Resident 5 and Resident 2, and the trazodone care plan for Resident 2, had not been reviewed or revised as indicated.
Physician Orders and Care Plans Not Updated After Catheter Discontinuation
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of nursing practice for two sampled residents when physician orders and care plans were not updated after urinary catheters had been discontinued. Resident 5 was admitted with diagnoses including cerebral infarction and left-sided hemiparesis. The resident’s physician order dated 12/14/25 included a urinary catheter, and the care plan dated 12/14/25 noted urinary retention and that a urinary catheter had been inserted. During interview and observation on 3/17/26, Resident 5 confirmed the urinary catheter had been removed, and no drainage bag was observed at the nursing station. Resident 2 was admitted with diagnoses including lumbar and thoracic fractures and muscle weakness. The physician order dated 2/9/26 included a urinary catheter, the care plan dated 2/10/26 addressed potential complications related to urinary catheter use, and a progress note dated 2/11/26 documented a new physician order to discontinue the urinary catheter. During interview on 3/18/26, Resident 2 confirmed the urinary catheter had been removed quite some time ago. During record review with LN 1 and later with the DON, both confirmed that Resident 5’s and Resident 2’s urinary catheters had been discontinued and that the physician orders should have been updated; the DON also acknowledged resident orders should be initiated, updated, or discontinued when received and followed per physician instructions.
Discontinued Medications Left in Medication Storage
Penalty
Summary
The facility failed to ensure discontinued medications were removed from the medication supply and destroyed in a timely manner. During an inspection of the Medication Storage Room with the DON, surveyors observed a three-drawer cart filled with medications, additional medications in a plastic drawer on top of the cart, an orange bucket overflowing with more medications, multiple plastic bins and a soft maroon insulated bag filled with medications on the shelves, and one IV bag of sodium chloride 0.9% with a pharmacy label comingled with the facility's stock of the same IV solution. The DON confirmed these were discontinued medications that needed to be separated from active stock and destroyed, and stated discontinued medications were destroyed every Friday with another nurse as witness, but if a second nurse was unavailable, destruction would be delayed by a week. Two discontinued medications were reviewed in detail. Resident 22 had an order for Benadryl 25 mg, 1/2 tablet every 6 hours as needed, dated 1/22/25 to 8/13/25, and the DON confirmed it had been long discontinued and should have been destroyed. Resident 20 had an order for hyoscyamine 0.125 mg sublingual tablet, 1 tablet twice a day, dated 4/4/25 to 5/28/25, and the DON confirmed that order was discontinued and should have been destroyed. The consultant pharmacist stated he expected the Medication Storage Room to be clean of discontinued medications and that staff were aware discontinued medications were to be destroyed within 90 days. The facility policy stated discontinued medications were to be immediately removed from stock, stored separately from active orders, and kept in a secured, organized medication storage area.
Food textures, menu items, and resident preferences were not followed
Penalty
Summary
The facility failed to ensure that resident food textures, menu items, and stated preferences were followed for four sampled residents. Surveyors observed and reviewed records showing that one resident with multiple diet texture orders, including IDDSI Level 7, Level 5, and Level 6, was served a lunch tray that included pureed items even though the resident stated the food was pureed again and that the resident had never been on a pureed diet. The resident also stated that most of the time the food served could not be eaten because it was pureed. A second resident, admitted with a left hemiarthroplasty and major depressive disorder, was ordered a NAS/low fat diet and had a care plan directing diet changes as appropriate and review of food preferences. During observation, the resident’s tray and meal ticket showed chicken and brown rice instead of the meatloaf listed on the menu, and the resident stated the meal did not match what was requested and that dessert had not been received in several days. The DCE confirmed the resident’s disappointment from not receiving the menu item or a dessert item and stated menus and food preferences were expected to be followed. A third resident, with a CCHO diet order and documented dislikes of fish, spinach, broccoli, and pies, was observed receiving salmon and potato chowder, meatloaf, cornbread, and sugar free chocolate pudding. The resident stated she did not eat fish or seafood and that a vegetable item had not been served. A fourth resident, on a regular diet with thin liquids and no memory impairment, had a breakfast meal ticket listing a biscuit, but the biscuit was not on the tray. The resident stated she wanted the biscuit and did not need to lose more weight. The RD, FSM, CNA, and DON all acknowledged that meal tickets, trays, menus, and resident preferences were expected to match, and the facility policy stated food preferences would be maintained in the tray card system.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
Food was not stored and prepared in accordance with professional standards in the main kitchen. During observation, the interior dispenser of the ice machine was found covered with black and brown substances, and the Food Service Manager confirmed the ice machine was dirty and that ice was exposed to the dirty surfaces. The Director of Maintenance stated it was the expectation that the kitchen's contracted technicians completed quarterly full cleaning, including the interior of the ice machine, and the Director of Nursing stated ice machines were expected to be cleaned for infection control reasons and residents' health. The facility policy stated that all equipment shall be kept clean. During another observation, a kitchen staff member wearing single-use gloves touched the food prep area after touching multiple surfaces, including a hot holding food door handle with visible debris, and the staff member confirmed he should have removed his gloves before handling resident food. The Food Service Manager confirmed the handle was soiled and that gloves were expected to be changed after touching dirty surfaces. In addition, ice buildup was observed on the rubber seals, edges, and frames of the freezer doors holding ice cream, and the Executive Chef confirmed the buildup was present and could pose a health risk. Wet cooking and hotel pans were also found stored on the ready-to-use rack next to the cooking area, and the Director of Nursing stated ready-to-use items were expected to be dry to avoid risk of infection to residents. The facility policies for sanitation and cleaning and ware washing stated freezers were to be cleaned monthly and pans were to be air dried.
Unnecessary Psychotropic Medication Use Without Adequate Indication or Monitoring
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medication when the resident received trazodone 50 mg at bedtime for insomnia without adequate indication for use and without adequate monitoring for efficacy. The resident was admitted with diagnoses including multiple lumbar fractures, lower back pain, lack of coordination, and weakness. The physician’s order dated 2/9/26 listed trazodone for “depression manifested by insomnia,” although the Director of Nursing confirmed there was no documentation to support a clinical diagnosis of depression and stated the order had been written that way because Medical Records had advised that trazodone, as an antidepressant, needed a depression diagnosis even though it was being used for insomnia. During record review and interviews, the Licensed Nurse confirmed the resident’s chart documented that the resident was sleeping, but the number of hours slept was not recorded, and agreed that hours of sleep should have been monitored to assess whether the medication was effective for insomnia. The DON also confirmed the resident was not monitored for hours of sleep, and the Consultant Pharmacist agreed that all elements of a prescriber’s order must be accurate and that without a depression assessment the resident could not be diagnosed with depression. The facility policy required residents on psychotropic medications to be monitored for appropriate use and effectiveness and required the physician order to include the diagnosis and specific behavior manifestation to be treated.
Nutritional Care Plan Not Individualized for NPO Resident With Feeding Tube
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for one of 12 sampled residents, Resident 7, because the resident’s nutritional status care plan was not individualized to his specific medical needs. Resident 7’s face sheet showed diagnoses including pneumonitis due to inhalation of food and vomit and gastronomy placement. Records showed Resident 7 was NPO and received tube feedings, and a diet order dated 2/25/26 also indicated NPO status. Resident 7’s care plan dated 1/20/26 stated he required a feeding tube related to oropharyngeal dysphagia and included instructions to check the placement and patency of the feeding tube every shift and before each feeding. However, the nutritional care plan dated 1/22/26 identified him as at risk for altered nutritional status related to pneumonitis, dysphagia, and use of a feeding tube, but its goals and interventions included no significant weight changes, consuming at least 70% of meals daily, offering bedtime snacks, encouraging oral intake, offering food substitutes, and reviewing food preferences. During interviews, Resident 7 stated he received nutrition through his GT tube and could not eat regular food yet, and facility staff confirmed that the oral intake and bedtime snack interventions were inappropriate for a resident who was NPO and receiving tube feedings.
CP Failed to Report Irregularities in Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review for one resident receiving trazodone. The resident was admitted with diagnoses including multiple lumbar fractures, lower back pain, lack of coordination, and weakness. A physician’s order dated 2/9/26 directed trazodone 50 mg at bedtime for depression manifested by insomnia, and staff later reviewed the order and the resident’s chart during interviews and record review. During the review, the Licensed Nurse stated trazodone was being used for depression and insomnia and confirmed the chart documented that the resident was sleeping, but the number of hours slept was not documented. The nurse stated hours of sleep would be useful to assess whether the medication was working and said she would normally expect to see a monitoring parameter for hours of sleep when a medication is given for sleep. The DON reviewed the order and confirmed there was no documentation supporting a clinical diagnosis of depression, and stated the order should not have read for depression without a clinical diagnosis. The DON also confirmed the resident was not monitored for hours of sleep, although that should have been done to assess the efficacy of the medication. The CP later stated that all elements of a prescriber’s order must be accurate and that without a depression assessment the resident could not be diagnosed with depression. However, the CP’s medication regimen review listing showed no recommendations for this resident, and he did not identify or report that there was no documentation supporting depression or that the resident was not being adequately monitored for trazodone efficacy. The CP further stated he did not typically evaluate the diagnostic criteria used by a physician to diagnose a resident for new psychotropic medication orders and instead reviewed the list of diagnoses in the medical record to confirm a diagnosis was listed for the medication ordered.
Failure to Label and Store Medications Properly
Penalty
Summary
The facility failed to properly store medications for three residents, each diagnosed with chronic obstructive pulmonary disease (COPD), by not labeling opened inhalers with open and discard dates. This deficiency was identified during an observation and interview with a licensed nurse, who confirmed that the inhalers for three residents were stored without the necessary labeling in the medication cart. The inhalers included fluticasone furoate, umeclidinium, and vilanterol for one resident, fluticasone and salmeterol for another, and fluticasone furoate for the third resident. Each of these medications has specific discard timelines after opening, which were not adhered to, potentially affecting their efficacy. The Interim Director of Nursing acknowledged that medications should have open and discard dates to ensure they are administered effectively. The facility's policy, titled 'Medication Administration General Guidelines,' mandates that nurses place a 'date opened' sticker on medications, especially those with shortened end-of-use dating, to maintain medication purity and potency. The failure to follow this policy could result in medications being used beyond their effective period, thereby reducing their potential to treat the residents' respiratory conditions.
Failure to Follow Recipe and Measure Ingredients for Quiche
Penalty
Summary
The facility failed to ensure the nutritive values of food were conserved during preparation for a census of 33 residents. This deficiency occurred when a staff member, identified as [NAME] 1, prepared quiche without measuring the ingredients and not following the recipe. During an observation and interview, [NAME] 1 was seen mixing ingredients for quiche without measuring the amounts of liquid eggs and heavy cream, and confirmed that she did not follow the recipe. She also stated she was unable to determine the exact number of servings to be prepared. The facility's recipe for quiche specified precise measurements for ingredients to prepare 180 servings, which [NAME] 1 did not adhere to. The Executive Chef confirmed that the recipe should have been followed with correct measurements to maintain the nutritive values of the food. The Administrator also stated that the expectation was for the recipe to be followed to ensure the nutritional needs of the residents were met. The facility's policies on menus and recipes, as well as food preparation and safety, require standardized recipes to be used and ingredients to be measured based on diet counts from the computerized tray card system.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards, affecting a census of 33 residents. Unlabeled, expired, incorrectly dated, and soiled food items were found in the main kitchen's ready-to-cook area. The Executive Chef confirmed these issues, and the Administrator acknowledged that such items were unsafe and could cause foodborne illnesses. Additionally, wet, dirty, and damaged cooking pans were stored on the ready-to-use rack, which the Administrator stated could become sources of food contamination. A dirty can-opener was found attached to the kitchen counter, ready for use, and the Administrator confirmed that dirty equipment could lead to food contamination and illnesses. The interior dispenser of the ice machine in the Skilled Nursing Facility kitchen was observed to have black, brown, and white substances on its surfaces, which the Dietary Manager and Director of Environmental Services confirmed needed immediate cleaning to prevent contamination of the ice. Furthermore, a kitchen staff member was observed touching clean food preparation surfaces with soiled gloves, which the Administrator stated could cause cross-contamination. Ice buildup was found on the edges and frames of entry doors and on food boxes inside the walk-in freezers in both the Skilled Nursing Facility and main kitchens. The Executive Chef confirmed that the walk-in freezer door was not closing properly due to ice buildup, which could affect the quality of food stored inside. The Administrator expected kitchen staff to report such issues to maintenance routinely, as ice buildup could interfere with door closing and potentially compromise food quality.
Failure to Maintain Dryer Lint Compartments
Penalty
Summary
The facility failed to safely operate the dryer for a census of 33 residents due to improper maintenance of the lint compartment. During an observation and interview with the laundry staff, it was found that the lint compartments of the dryers contained two thick layers of lint, which were not cleaned at the beginning of the shift. The laundry staff confirmed this oversight. Further review with the housekeeping supervisor revealed that the lint compartment log indicated an expectation for staff to clean the lint compartment every two hours. However, there was missing documentation of lint removal on seven occasions during the evenings in January 2025. The facility's policy required equipment to be ready for use at all times, and the failure to clean the lint compartment decreased the facility's potential to prevent a fire hazard.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 248, due to a broken light switch behind her bed and a non-operational drawer where the switch was kept. This issue was observed during a visit, where it was noted that the resident could not access the light switch or her personal items without assistance, as the drawer was stuck. The resident expressed that this situation was bothersome and had requested staff to fix the light and drawer multiple times. Further observations and interviews with facility staff, including a Licensed Nurse and the Director of Environmental Services, confirmed the issues with the light switch and drawer. The staff acknowledged the importance of the resident's ability to access her personal items and maintain independence, as well as the need for a comfortable and welcoming environment. The facility's policy on providing a safe environment was reviewed, which emphasized maintaining mechanical and electrical equipment in safe operating condition, highlighting the deficiency in this case.
Failure to Develop Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as Resident 148, who was receiving oxygen therapy. Resident 148 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. During an observation, the resident was seen receiving oxygen at two liters per minute via nasal cannula. However, a review of the resident's care plan revealed that it did not include any information about the oxygen therapy. This omission was confirmed by Licensed Nurse 4, who acknowledged the absence of an oxygen care plan in the clinical record. The Interim Director of Nursing also stated that all residents should have care plans to ensure their care needs are met. The facility's policy requires that a care plan be initiated upon admission to address the resident's immediate care needs.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to provide services according to professional standards of quality when a licensed nurse prepared a medication for a resident using another resident's medication supply. This incident involved a resident who was admitted to the facility with a right hip fracture and chronic constipation. The resident had a prescription order for polyethylene glycol to be administered once daily. During an observation, the licensed nurse was seen preparing the medication from a bag labeled with a different resident's name, which she confirmed was incorrect and acknowledged should have been taken from the facility's medication stock. The Interim Director of Nursing stated that the expectation was for nurses to follow the five rights of medication administration to prevent potential adverse effects from incorrect medication administration. The facility's policy and procedure on medication administration clearly indicated that medications supplied for one resident should never be administered to another. This failure to adhere to the policy decreased the facility's potential to safely administer medications to residents.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for Resident 248, who was not offered or given showers as scheduled. Resident 248 was admitted with a right femur fracture and had the capacity to understand choices and make healthcare decisions. Her care plan indicated she needed assistance with bathing and personal hygiene, with showers scheduled twice a week. However, during an observation and interview, Resident 248 reported not having had a shower since her accident and expressed a desire for one. Her appearance, with unkempt and matted hair, suggested a lack of personal hygiene care. Certified Nursing Assistant 1 and Licensed Nurse 1 both reviewed Resident 248's records and confirmed the absence of documentation indicating that showers were offered, refused, or given on the scheduled dates. The facility's policy required that residents unable to perform activities of daily living receive necessary services to maintain grooming and personal hygiene. The lack of adherence to this policy for Resident 248 was evident, as she was not provided the scheduled showers, potentially impacting her cleanliness and psychosocial well-being.
Resident Injury Due to Sling Malfunction
Penalty
Summary
The facility failed to ensure safety measures were in place for a resident, identified as Resident 15, who fell during a transfer and sustained a blunt head injury and a scalp abrasion. Resident 15, who was admitted to the facility in 2019 with a diagnosis of paraplegia and dementia, was assessed to have a moderate fall risk. During a transfer using a mechanical lift, one of the loops from the sling broke, causing Resident 15 to fall to the floor and hit his head. The incident was witnessed by a Certified Nursing Assistant (CNA), who confirmed that there was no written expiration date on the sling during inspection. The facility's policy required slings to be maintained in appropriate condition, documented with an in-use start date, and inspected prior to each use for any signs of damage. However, the sling used for Resident 15's transfer was not properly inspected, leading to the malfunction. The Director of Staff Development and Interim Director of Nursing confirmed the fall was due to a broken sling and acknowledged that staff should have inspected the sling to ensure it was intact and not expired. The facility's Fall Prevention Program policy stated that residents should be provided an environment that maximizes safety, which was not adhered to in this case.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were accommodated, as evidenced by a discrepancy between the meal ticket and the meal tray provided to the resident. The resident, who was admitted to the facility in 2019 with a diagnosis of paraplegia and dementia, was observed to have received a meal tray containing chicken tamales with green sauce, refried beans, extra sauce, orange juice, milk, and water. However, the meal ticket for the same meal indicated that the resident should have received potato soup, chicken supreme, herbed quinoa, green peas, garlic bread, coffee, whole milk, orange juice, apple juice, cranberry juice, and margarine with extra gravy sauce. During an interview, the Interim Director of Nursing confirmed that the expectation was for the meal ticket to reflect the food choices on the meal tray. The facility's policy on Nutritional Care, Screening, and Assessment, dated February 9, 2017, stated that food preferences should be maintained in the tray card system. This failure to match the meal tray with the meal ticket had the potential to negatively impact the resident's nutritional status.
Inadequate Use of PPE in Isolation Room
Penalty
Summary
The facility failed to maintain proper infection control practices for a census of 33 residents when a Certified Nursing Assistant (CNA 3) did not use the required personal protective equipment (PPE) in an isolation room. Resident 31, who was admitted in 2023 with a diagnosis of pneumonia, was placed in a contact isolation room. Despite a sign on the door indicating the need for gown and gloves, CNA 3 entered the room and collected a meal tray without wearing the necessary PPE. Interviews with the Infection Preventionist (IP) and the Interim Director of Nursing (IDON) confirmed that the expectation was for staff to wear gown and gloves when entering isolation rooms to prevent cross-contamination. The facility's policy, dated June 24, 2024, also required staff to wear appropriate PPE, including gloves and gowns, when entering such rooms. The failure to adhere to these protocols had the potential to increase the spread of infection among residents.
Resident Not Informed of Medication Change
Penalty
Summary
The facility failed to uphold the rights of a resident by discontinuing a medication without informing her, thereby preventing her from participating in her own care planning. The resident, who was her own responsible party and had no memory impairment, was admitted with diagnoses including aftercare following joint replacement surgery and Stage 3 chronic kidney disease. She had been taking spironolactone and hydrochlorothiazide-spironolactone for high blood pressure and fluid retention for at least two years. However, after her admission, the spironolactone 50 mg tablets were discontinued without her knowledge, leading to worsening leg edema. The Director of Nursing confirmed that it was expected for the MD to explain any medication changes to the resident or responsible party, which did not occur in this case. The facility's policy on Resident Rights, which aligns with federal and state laws, was not followed as there was no documentation of the MD discussing the medication change with the resident. This oversight resulted in the resident being unaware of the medication change and feeling that her rights were violated.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to manage a resident's pain timely when a Licensed Nurse (LN) delayed the administration of breakthrough pain medication. The resident, who had chronic pain syndrome, chronic pancreatitis, and low blood oxygen, reported feeling ignored and mistreated due to the delays. The Interim Director of Nursing (IDON) confirmed that the resident was upset and complained about the LN making excuses for the delayed administration, stating she was busy or that the resident was not her only patient. The resident's former roommate corroborated the delays, noting that the LN claimed a two-hour leeway to administer the medication, which led to the resident being in pain and unsure when to request her medication. Review of the resident's Medication Administration Record (MAR) showed that the resident consistently reported high pain levels and received Norco every four hours for pain control. However, there were significant delays in administration when the LN was on duty, with gaps of up to 6 hours and 40 minutes between doses. The facility's policy stipulated that medications should be administered as prescribed, and the IDON verified that the LN should have administered the medication as quickly as possible when requested. The failure to do so resulted in the resident experiencing unmanaged pain and feeling mistreated.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 721 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitney Oaks Care Center | 0.5 mi | ★★★★★ | 6 | 0 |
| American River Center | 0.5 mi | ★★★★★ | 12 | 0 |
| Mission Carmichael Healthcare Center | 0.6 mi | ★★★★★ | 1 | 0 |
| College Oak Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 14 | 1 |
| Sacramento Post-acute | 1.9 mi | ★★★★★ | 16 | 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.