Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Feather River Care Center during CMS and state inspections, most recent first.
Two residents with heel and foot ulcers received wound care from an LVN who used the same pair of reusable scissors to cut specialized dressings for each resident’s wounds without cleaning or disinfecting the scissors between uses, contrary to facility policy requiring disinfection of multi‑resident equipment after each use; both residents also reported limited assistance with basic hygiene such as showers and access to washcloths for face and hand care.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was subjected to two separate incidents of non-consensual touching by another cognitively intact resident, who was observed rubbing the resident’s side while grunting and later touching the resident’s chest. Staff documented the first event only in the alleged perpetrator’s chart, did not report it as abuse, and did not complete a nursing evaluation or change-in-condition assessment for the victim, despite facility policy requiring immediate protection, assessment, and increased supervision. After the second witnessed incident, nursing staff and the IP confirmed that no full nursing evaluation of the victim was performed. The DON was informed by text of the first incident but directed the RN only to write a progress note, and the Administrator later acknowledged he had not been notified of the first event, that there was no clear plan to keep the two residents apart, and that the alleged perpetrator continued to move unsupervised throughout the unit, including near the victim’s room.
The facility failed to follow its abuse policy when staff reported that a cognitively intact male resident was observed rubbing the side of a severely cognitively impaired female resident while grunting. The RN on duty documented the event only in the male resident’s chart and a communication report, did not assess or document on the female resident, did not initiate a change in condition assessment, and did not report the allegation as abuse to the Admin or required agencies. No specific protective interventions or supervision plan were implemented to keep the male resident away from the female resident, and he continued to move independently in his wheelchair without direct staff supervision. A subsequent incident occurred in which staff witnessed the male resident touching the female resident’s chest area, and the Admin later confirmed the earlier event had not been reported and that there was no solid plan to supervise or separate the residents.
The facility failed to develop and implement individualized smoking safety care plans for four cognitively intact residents known to smoke, despite a policy requiring safe smoking measures to be documented in each care plan and followed in designated smoking areas. Record reviews showed that care plans lacked resident-specific interventions for smoking supervision, designated locations, or safety precautions, even when one resident had documented COPD, substance dependence, and elopement-like behaviors related to smoking, and another had nicotine dependence and mobility issues. Interviews revealed that residents were instructed to go off property to smoke or went outside alone, sometimes over uneven terrain and in cold weather, without staff supervision or a designated smoking area, while an RN and the Administrator confirmed the absence of smoking-related care plan directions or authorized smoking orders.
The facility failed to follow its own smoking and smoke‑free policies, which require a designated smoking area with posted signage and restrict smoking to that area. Four residents who smoke were instead instructed by staff to leave facility property to smoke, with cigarettes stored on the med cart and signed out before departure. One resident was observed independently wheeling across uneven terrain in cold weather to an off‑property location to smoke without staff supervision, and other residents reported propelling themselves in wheelchairs to a public sidewalk or up a hill off the grounds to smoke, sometimes being told to remain out of sight. No designated smoking area or signage existed on or off the property, despite policy requirements and staff and administrator acknowledgment that residents were smoking outside the facility.
Improper Use of Physical Restraint: A resident with metabolic encephalopathy, pneumonia, and COPD was tied upright in a wheelchair with a bed sheet by a CNA, despite having capacity to make his own medical decisions. The DON confirmed the restraint occurred, and the CNA acknowledged she secured the sheet so the resident could not release himself, stating she did it at the resident’s request.
A Licensed Vocational Nurse was found to have an inactive license, which was not identified until a monthly license verification was conducted. The DON confirmed that license checks are usually performed monthly but was not diligent in this instance, resulting in the nurse working with an inactive license until the issue was discovered and the nurse was removed from the schedule.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident with multiple medical conditions was physically struck in the eye by another resident following a verbal altercation, resulting in a bruised eye and discomfort. Staff confirmed the incident as physical abuse, and the facility's policy requiring prevention of abuse was not effectively implemented.
Nursing staff did not promptly recognize or report a significant change in condition for a resident with multiple complex diagnoses, resulting in delayed acute care treatment and eventual hospital transfer. The resident experienced a notably low blood pressure, and despite a physician order to push fluids, there was no timely escalation or evaluation. The DON confirmed that facility policy was not followed, leading to the resident's extended hospital admission and dissatisfaction with care.
A resident who spoke only Hmong and had significant medical needs was not provided with any translation services or communication aids. Staff and family confirmed that the facility had no way to communicate with the resident, resulting in the resident not being properly assessed and her pain not being treated.
A resident with hemiplegia and hemiparesis suffered an injury after slipping in a shower chair, resulting in a cut and visible pain, which was witnessed by staff and family. Despite clear signs of pain, no documentation, physician notification, or pain management interventions were provided, and the event was omitted from the medical record, leaving the resident without pain relief.
A resident with hemiplegia and dysphagia, who communicates only in Hmong, suffered a leg injury after slipping into a shower chair. Nursing staff did not assess, document, or notify the physician about the injury, nor was pain addressed or a care plan updated. Family members and staff confirmed the incident and the resident's pain, but no pain medication was given and the event was not recorded in the medical record.
A resident with a history of aggression and mental health issues, who was not properly assessed or care planned for behavioral health needs, pushed another resident out of her wheelchair while under 1:1 monitoring. The incident occurred despite facility policy requiring assessment and intervention for residents with behaviors that could lead to conflict, and the interdisciplinary team did not address the altercation until several days later.
A resident admitted from another SNF with documented depression, Bipolar II disorder, and prescribed sertraline did not have their PASRR reassessed or validated by facility staff. The previous PASRR inaccurately indicated no serious mental illness or psychotropic medication use, and staff confirmed they did not verify its accuracy, resulting in no behavioral health care plan for the resident.
A resident with a history of depression, Bipolar II disorder, and recent psychological care was admitted without a behavioral health care plan, despite documented aggression, agitation, and suicidal ideation. The facility did not provide mental health appointments or address these needs in the care plan, leading to multiple behavioral incidents, including a resident-to-resident altercation while under 1:1 monitoring.
A resident with a history of psychiatric and behavioral health needs was admitted without proper behavioral health evaluation or services, despite documented diagnoses and prior psychological care. The facility did not reassess or validate previous mental health screenings, failed to develop a behavioral health care plan, and did not arrange mental health appointments. This led to escalating behavioral incidents, including aggression, self-harm, and a resident-to-resident altercation, ultimately resulting in the resident's transfer to a hospital for psychiatric evaluation.
A resident with schizophrenia under a court-appointed conservator had her antipsychotic medication changed without the conservator's knowledge or consent, contrary to facility policy and legal requirements. The conservator was not informed of the risks, benefits, or alternatives to the medication change, and documentation was lacking. This led to a decline in the resident's mental health and subsequent hospital readmission.
A resident with a history of aggressive behavior was involved in an altercation, leading the provider and IDT to recommend 1:1 monitoring. Although a CNA was assigned to monitor the resident, the care plan was not updated to include this intervention, contrary to facility policy. The DON confirmed the care plan should have reflected the 1:1 monitor after the incident.
The facility failed to maintain proper infection control practices, as a CNA wore the same isolation gown while caring for two residents, one with C-diff. Additionally, there was no dedicated cleaning equipment for the C-diff resident's bathroom, and the nurse's station counter was damaged, preventing proper disinfection. These issues were confirmed by staff, highlighting a breach in infection prevention protocols.
A resident frequently entered the rooms of five other residents uninvited, violating their privacy rights. Despite being aware of the issue, the facility staff, including the DON and CNAs, did not implement effective measures to prevent these intrusions. The affected residents, some with cognitive deficits and others cognitively intact, expressed discomfort and dissatisfaction with the situation.
A resident with cognitive intactness and a history of hemiplegia was not provided adequate foot care due to the facility's failure to assess and document the condition of the resident's feet. The LN did not notify the physician or develop a care plan, leading to the resident experiencing discomfort and frustration. Observations showed long, thick, discolored toenails and dry, flaky skin, with no foot care treatments ordered.
A resident with dementia and a history of falls was found unsupervised in a shower room, resulting in a fall due to an unlocked door. The facility failed to provide required one-to-one supervision and did not document the resident's wandering behavior accurately in the MDS assessment, compromising the resident's safety.
A resident admitted with hemiplegia and hemiparesis following a stroke did not receive a necessary follow-up appointment with a vascular surgeon due to the absence of social services staff at the time of admission. The interdisciplinary team failed to ensure the referral was made, despite discharge documents indicating the need for an appointment within a week.
The facility's dietary department was found deficient due to an unlabeled storage bin with sugar and four bins with visible dust and adhesive residue on the lids. The Dietary Manager confirmed these issues, which were against the facility's policies on cleanliness and labeling.
The facility was found non-compliant with regulations limiting resident room capacity to four individuals, as one room contained five beds. Despite adequate privacy and storage, this setup violated standards. The Administrator noted the ongoing waiver renewal request.
A resident in a facility was found without access to a call light, which was not within reach, potentially delaying care. The resident, who had multiple health issues and was dependent on staff for daily activities, was observed yelling for help. The call light was improperly positioned, contrary to the facility's policy, and was confirmed by staff to be inaccessible.
A resident, who was cognitively intact and had multiple medical conditions, experienced a violation of their rights when a staff member was rude and disrespectful during an inquiry about lost clothing. The Maintenance Supervisor yelled at the resident and incorrectly claimed the clothing was not labeled. The facility's policies on resident rights and dignity were not followed, as confirmed by the Administrator and DON.
A resident's needs were not accommodated when a bedside table used for art supplies was removed without consent, leading to frustration and anger. The Maintenance Supervisor took the table for another resident due to a shortage, and the Administrator and DON confirmed the removal was not handled appropriately.
A facility failed to update a resident's care plan to reflect new pain management needs. The resident, with rheumatoid arthritis and other conditions, expressed discomfort due to pain when touched at night. Despite new medication orders for Methotrexate and Prednisone, the care plan was not revised to include these or the resident's specific repositioning preferences. Interviews confirmed the oversight, resulting in unrecognized care needs.
A resident with Rheumatoid Arthritis and spinal stenosis did not receive consistent daily hair care assistance, as required by the facility's policy. Documentation showed inconsistencies in the level of assistance provided, and observations revealed the resident's hair was not properly maintained. The resident expressed dissatisfaction, and a CNA confirmed the lack of appropriate supplies for hair care. The DON acknowledged the need for daily assistance due to the resident's reduced fine motor skills.
The facility failed to protect the dignity and rights of six residents by not responding to call lights and delaying pain medication administration. A resident experienced an argument with an LVN over medication, while another on hospice care faced significant delays in receiving pain relief, increasing her anxiety and pain. Other residents reported long wait times for assistance, particularly during the night shift, leading to feelings of anger, sadness, and fear.
The facility failed to provide timely care for activities of daily living, leaving a resident in a soiled brief for 12 hours due to short-staffing and lack of CNA assignment. Two other residents also reported not being changed regularly, highlighting issues with staffing and communication during shift changes.
Two residents reported feeling unsafe due to the disrespectful behavior of an LVN, who yelled at one resident for requesting pain medication and refused to change another's bandage. The LVN was terminated after multiple complaints and observations of inappropriate conduct, violating the facility's policy on resident rights.
A deficiency occurred when a staff member closed a resident's door and silenced the call light, against facility policy. The resident, with severe cognitive impairment and a history of trauma, was vulnerable to isolation. The LVN involved admitted to closing the door and adjusting the call light system, although she denied disconnecting wires. The DON confirmed an investigation was underway, and the LVN was removed from duty.
A resident with multiple medical conditions was left with soiled dressings and a bloody shirt while eating meals, despite requesting assistance. A CNA informed an LN, who acknowledged the need for dressing changes but had not yet acted. The DON confirmed the dignity issue, stating they were unaware until informed.
A resident was admitted with multiple medical conditions, including sepsis and cellulitis, but the facility failed to obtain necessary physician orders for wound care. The admission records were incomplete, lacking orders for open wounds on the resident's body. Interviews with staff, including the DON and MD, confirmed the oversight, revealing a lack of communication and documentation. Staff admitted to not performing necessary assessments, leading to a delay in care.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with serious health conditions, as required by their policy. The absence of this care plan was confirmed through medical record reviews and staff interviews, indicating that staff lacked necessary information to address the resident's specific needs.
The facility failed to maintain comfortable temperatures in six resident rooms, with temperatures ranging from 82.6 to 90.3 degrees Fahrenheit. A resident with a history of acute myocardial infarction and respiratory failure felt hot and uncomfortable due to the HVAC unit malfunction and circuit overloads caused by portable air conditioners.
The facility failed to maintain comfortable room temperatures, affecting several residents. Despite repairs to the main air conditioning units, room temperatures exceeded the facility's policy range. Residents reported discomfort, and attempts to use swamp coolers and portable air conditioners were ineffective due to improper use and electrical issues. Staff and family members confirmed the ongoing temperature problems, with the HVAC system requiring further repairs.
A resident with multiple health conditions did not receive privacy during a medical procedure. An LVN entered the room to administer medication while the Maintenance Director and a surveyor were present. The LVN exposed the resident's body without using a privacy curtain. The LVN admitted to not considering privacy during the procedure.
A facility failed to ensure accurate resident assessments, as an MDS inaccurately indicated a resident had an indwelling catheter. This was confirmed through staff interviews and record reviews, revealing the resident did not have the catheter, potentially impacting their care.
The facility failed to develop a comprehensive care plan for a resident who frequently removed their clothes. Despite staff acknowledging the behavior, no interventions were documented to manage it, leading to inadequate care and services for the resident's well-being.
A resident with a history of renal disease and muscle weakness exhibited UTI symptoms, including dark and foul-smelling urine, vomiting, and bladder pain. Despite receiving an order for a urinalysis (UA) and urine culture sensitivity test (C&S) on 3/8/2024, the facility failed to collect the UA until 3/10/2024. The delay in testing and lack of documentation potentially delayed the resident's treatment.
Failure to Disinfect Reusable Scissors Between Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policy for cleaning and disinfecting reusable, non‑critical equipment between residents. The written policy dated 1/1/2026 states that multiple‑resident use equipment shall be cleaned after each use. During surveyor observation, an LVN performed wound care on a resident with a left heel pressure ulcer. The LVN used a pair of scissors taken from her pant pocket to cut a special dressing (Calcium Alendronate) for the wound and then returned the uncleaned scissors to her pocket after completing the dressing change. No cleaning or disinfection of the scissors was performed after use on this resident. Shortly afterward, the same LVN performed wound care on the roommate, a resident with a diabetic ulcer on the right foot. The LVN again retrieved the same scissors from her pant pocket and used them to cut the special dressing for the second resident’s wound without having cleaned or disinfected the scissors between uses. The LVN then placed the scissors back into her pocket without cleaning them. In interviews, the first resident reported having heel wounds and receiving only sponge baths twice a week without being routinely offered washcloths for face and hand hygiene, and the second resident reported having a diabetic foot ulcer and needing to ask for basic care items such as washcloths. In a post‑observation interview, the LVN acknowledged forgetting to sterilize the scissors between residents and stated that the standard is to sterilize equipment between residents, and the Infection Preventionist confirmed that the expectation is to disinfect instruments between residents.
Failure to Protect Resident From Repeated Sexual Contact and to Follow Abuse Policy
Penalty
Summary
The facility failed to protect a resident from sexual abuse and to follow its own abuse, neglect, and exploitation policy after two separate incidents of non-consensual touching by another resident. The policy defined abuse to include certain resident-to-resident altercations and required immediate protection of the alleged victim, examination for injury or psychosocial harm, increased supervision, and emotional support. Despite this, after staff observed one resident sitting next to another and rubbing her side while grunting, the nurse documented the event only in the alleged perpetrator’s chart and did not report it as abuse, did not complete a nursing evaluation or change-in-condition assessment for the alleged victim, and did not initiate protective interventions as outlined in the policy. The alleged victim, Resident 1, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, and her most recent MDS showed severely impaired cognition with a BIMS score of 5. The alleged perpetrator, Resident 2, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with intact cognition and a BIMS score of 14. Staff documented that on one date Resident 2 was seen touching Resident 1’s side and grunting, and on a later date staff witnessed Resident 2 touching Resident 1’s chest area. The second incident was recorded in an IDT note, but nursing staff confirmed that Resident 1 was not given a full nursing evaluation after this incident, and the Infection Preventionist also confirmed that Resident 1 was not evaluated by nursing staff after the second event. Multiple staff interviews confirmed that the facility did not implement its abuse policy to protect Resident 1 after either incident. The LVN and RN involved acknowledged that no full evaluation of Resident 1 was completed after the second incident, and one RN stated he was unaware he should have done so per policy. Another RN stated she did not feel compelled to report the first incident as abuse because she had not personally witnessed it and only wrote a progress note in Resident 2’s chart after being told to do so, with no documentation for Resident 1. The Administrator reported he was not informed of the first incident, confirmed there was no solid plan to keep Resident 2 away from Resident 1, and acknowledged that Resident 2 continued to move throughout the facility in his wheelchair without direct supervision, including to the area outside Resident 1’s room, while no specific protective measures were in place for Resident 1.
Failure to Report and Protect After Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse and to protect a resident after staff observed inappropriate physical contact between two residents. Facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours when abuse is involved. The policy also required immediate protective measures for alleged victims, such as increased supervision and emotional support. Despite this, an RN documented on 12/20/25 that staff reported a cognitively intact male resident sitting next to a severely cognitively impaired female resident, touching her side and grunting, and only noted to monitor behavior. Resident 1, the alleged victim, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, with a recent MDS showing severely impaired cognition (BIMS score of 5). Resident 2, the alleged perpetrator, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with an intact cognition (BIMS score of 14). On 12/20/25, RN A documented in Resident 2’s progress notes and the facility communication report that staff saw Resident 2 rubbing Resident 1’s side while grunting, and that the residents were separated. However, RN A did not complete a nursing evaluation, did not document in Resident 1’s record, did not initiate a change in condition assessment, and did not report the allegation as abuse per facility policy, stating she did not feel compelled to report because she had not personally witnessed the interaction and that she only entered a progress note as directed. On 12/22/25, a subsequent incident occurred in which staff witnessed Resident 2 touching Resident 1’s chest area, as documented in an IDT note dated 12/23/25. During observation on 12/23/25, Resident 1, in bed, could not recall the incidents but stated that something had happened that was not good. Resident 2 was observed ambulating independently in his wheelchair without direct staff supervision, including to the area outside Resident 1’s room. In an interview, the Administrator stated he was unaware of the 12/20/25 incident because nursing staff failed to notify him, confirmed the incident was not reported per facility policy, and acknowledged that no solid plan or specific interventions were implemented to supervise Resident 2 or keep him away from Resident 1, despite knowing that Resident 2 moved throughout the facility in his wheelchair without supervision. The Administrator also confirmed that the 12/20/25 incident could have led to the escalation and the 12/22/25 incident.
Failure to Develop Individualized Smoking Safety Care Plans for Smoking Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, measurable care plans addressing smoking safety for four cognitively intact residents known by the facility to smoke. The facility’s own “Resident Smoking - Smoke-Free Facility” policy required that any resident deemed safe to smoke, with or without supervision, do so only in designated smoking areas in accordance with the resident’s care plan, and that all safe smoking measures be documented in the care plan and communicated to staff, visitors, and volunteers. Despite this, record reviews on 12/19/25 showed that the care plans and physician orders for Residents 1, 2, and 3 lacked documented, individualized interventions for safe smoking practices, including supervision requirements, designated smoking areas, or other smoking-related safety measures. Resident 4’s care plan addressed smoking cessation only and did not contain interventions or physician orders for safe smoking practices. Resident 1 was admitted with COPD, tobacco use, alcohol abuse, ataxia following cerebral infarction, and psychoactive substance dependence with intoxication delirium, and had a BIMs score of 15, indicating intact cognition. An IDT progress note dated 12/17/25 documented that, despite education, this resident continued to smoke on facility grounds, had been observed smoking near hazardous areas, and was sneaking out multiple times during the day and night. The note also documented refusal of nicotine patch therapy and stated the care plan was to be updated to reflect elopement risk, substance use behaviors, and refusal of nicotine replacement therapy; however, the care plan dated 11/26/25 did not indicate elopement risk or any safe smoking plan. Resident 2, with schizoaffective disorder, muscle weakness, and frontal lobe/executive function deficit and a BIMs score of 15, also had no safe smoking plan in the care plan dated 12/12/25. In interview, this resident reported smoking cigarettes and stated he had been told he must go off the property to smoke because smoking was not allowed, and expressed feeling that staff did not care about him or what he wanted. Resident 3, admitted with pleural effusion, malnutrition, nicotine dependence, difficulty walking, and kidney disease and a BIMs score of 14, had a care plan dated 11/19/25 that did not address safe smoking. In interview, this resident reported going outside alone to smoke 1–2 times a day, leaving oxygen in the room, and stated he had been signed off by physical therapy as safe to go outside independently, but wished he did not have to go so far to smoke. Resident 4, admitted with diabetes, COPD, muscle weakness, and difficulty walking and a BIMs score of 15, had no care plan or physician orders authorizing or directing safe cigarette smoking practices. During concurrent interview and record review, RN A confirmed the absence of such documentation, stated awareness of the non-smoking policy, and reported that she believed residents went around the corner of the building to smoke but that she had not supervised residents while smoking. Observation showed Resident 4 independently wheeling himself across uneven terrain in cold weather to an off-property area to smoke, without staff supervision or redirection, and this location was not a designated smoking area. The Administrator confirmed awareness that these four residents smoked, acknowledged there was no designated smoking area at that time, and confirmed that none of the four residents had individualized cigarette smoking safety care plans addressing supervision, location, or safety measures.
Failure to Implement Smoking Policy and Provide Designated Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own smoking policies, which require that residents deemed safe to smoke may do so only in designated smoking areas, at designated times, and in accordance with their individualized care plans. The facility’s smoke-free policy also states that smoking, including e‑cigarettes, is prohibited in all areas except a designated smoking area, and that a designated smoking area sign will be prominently posted. Surveyors reviewed these policies and then observed that there was no designated smoking area or signage on or off facility property. The Administrator acknowledged awareness that four residents smoke outside the facility and confirmed that the facility was not following its smoke-free policy because no designated smoking area had been established. Surveyors identified four residents as smokers. A RN reported that the facility is a non‑smoking facility and that residents who smoke are instructed to leave the property to do so, with their cigarettes stored in the medication cart and signed out on a log before they leave. One resident was observed independently wheeling himself in a wheelchair across uneven terrain in cold weather to an off‑property location to smoke, without staff supervision or redirection, and this location was not identified as a designated smoking area. Another resident stated he obtains cigarettes from nursing staff and is instructed to go to the public sidewalk along the street to smoke and to remain out of sight while smoking. A third resident reported he smokes twice per day and must propel himself in his wheelchair up a hill and off facility grounds to smoke, having been informed the facility is non‑smoking and that residents must go off grounds. A smoking assessment for another resident documented that the resident smokes, does not follow the non‑smoking policy, was determined able to smoke independently, and had been educated on the facility’s smoking policies and risks, yet the facility still lacked a designated smoking area as required by its own policies.
Improper Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident remained free from physical restraint when a CNA tied the resident upright in a wheelchair with a bed sheet. The facility policy titled, Restraint Free Environment, stated that physical restraints are prohibited for discipline or staff convenience and are limited to circumstances in which medical symptoms warrant their use; it also stated that falls do not constitute a medical symptom that warrants physical restraints. Resident 1 was admitted with diagnoses including metabolic encephalopathy, pneumonia, and COPD, and had a physician order dated 11/10/25 indicating capacity to make his own medical decisions. The DON stated the facility confirmed that CNA B restrained the resident on 11/16/25 by tying him to his chair with a sheet, and CNA B confirmed she secured the sheet with a knot at the back of the chair so the resident could not release himself. CNA B stated she did this at the resident’s request and acknowledged she should have refused.
Failure to Ensure LVN Maintained Active License
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) maintained a current and active license in accordance with state law. A review of the Board of Vocational Nursing and Psychiatric Technicians licensure report showed that the LVN's license was inactive, meaning the licensee was not permitted to practice in California, even though the license had not yet expired. The facility's policy required verification of licensure status through the appropriate agency and assigned responsibility for maintaining valid licensure to the Human Resources Director or designee, as well as to the licensed employee. Interviews with the Administrator and Director of Nursing (DON) confirmed that the LVN's license became inactive toward the end of August and that this was discovered during a routine monthly license lookup. The DON acknowledged that license reviews are typically conducted at the end of each month but admitted to not being on top of the process in this instance. The LVN was subsequently removed from the work schedule after the inactive status was identified.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the right eye with a closed fist. The incident occurred after the first resident, who has multiple medical conditions including multiple sclerosis, dementia, and depression, asked the second resident to stop talking loudly and to leave the room. The first resident admitted to possibly yelling due to being hard of hearing, after which the second resident, who also has several medical and psychiatric diagnoses including bipolar disorder and depression, reacted by hitting him. The altercation resulted in the first resident sustaining a bruised right eye and experiencing discomfort for several days. Staff interviews confirmed that yelling was heard from the room, and by the time staff arrived, the physical altercation had already taken place. The resident who was struck was sent to the hospital for evaluation of his injury. Both the DON and the facility administrator confirmed that the incident constituted physical abuse. The facility's policy on abuse, neglect, and exploitation requires the prevention of such incidents, but in this case, the policy was not effectively implemented to protect the resident from harm.
Failure to Recognize and Report Change in Condition Resulting in Delay of Care
Penalty
Summary
Nursing staff failed to recognize and report a significant change in condition for one of eight sampled residents, who had multiple complex medical diagnoses including atrial fibrillation, aortic valve disorder, bilateral pneumonia, COPD, and several mental health conditions. The resident was cognitively intact and responsible for their own care decisions. On the date in question, the resident's blood pressure was recorded at a significantly low level (82/64 mmHg), with documentation noting the abnormal value but lacking details such as multiple measurements or the resident's position during assessment. Although there was a physician order to push fluids, there was no documentation indicating that the resident was sent for further evaluation at that time. Later that evening, police were called to the facility, and after discussions with the resident and their daughter, the resident requested to be sent to the hospital due to concerns about a possible allergic reaction. The medical director was notified, and EMS was called to transfer the resident. The Director of Nursing confirmed that the facility's policy for notification of changes in condition was not followed, and acknowledged that the resident experienced a delay in care and should have been sent to the hospital earlier. The resident was subsequently admitted to a local hospital for an extended period and expressed dissatisfaction with the care received at the facility.
Failure to Provide Translation for Non-English Speaking Resident
Penalty
Summary
The facility failed to accommodate the communication needs of a resident who spoke only Hmong and was her own representative. The resident was admitted with hemiplegia, hemiparesis following a cerebral infarction, and dysphagia. Record review indicated that the resident had a communication deficit due to a language barrier, and the care plan noted that social services provided a picture binder for communication, with an intention to provide a communication board. However, during multiple interviews with staff, family members, and direct observation, it was confirmed that the facility did not provide any means of translation or communication aids for the resident. Staff, including the DON, CNAs, and a nurse, all stated that there was no way to translate or communicate with the resident, and family members confirmed that the only attempts at translation involved asking family to assist. No communication boards or picture aids were found in the resident's room, and the resident was rarely or never understood according to the MDS assessment. As a result, the resident was not properly assessed and her pain was not treated.
Failure to Address and Treat Resident Pain After Shower Chair Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, and dysphagia, who only spoke Hmong, experienced an accident while in a shower chair. The resident slipped and became stuck in the chair, resulting in a cut and visible injury to the right thigh. Multiple staff, including CNAs and nurses, witnessed the incident and observed the resident expressing pain both verbally and through facial grimacing. Family members also confirmed that the resident complained of pain following the incident. Despite clear evidence of injury and pain, there was a complete lack of documentation or follow-up in the resident's medical record. No accident or injury was recorded in the electronic medical record, and there were no notes from social workers, no physician consultation, no psychosocial follow-up, and no updates to the care plan. The Medication Administration Record showed no administration of new pain medication after the incident, and pain scores were recorded as zero each day, despite staff and family reports of pain. Interviews with staff revealed that the incident was known to the Director of Nursing and other nursing staff, but no one documented the event or addressed the resident's pain. The facility's pain management policy required recognition and evaluation of pain, especially after significant changes in condition, but these steps were omitted. The resident suffered without any pain relief or appropriate clinical response following the injury.
Failure to Assess, Document, and Treat Resident Injury Following Shower Chair Accident
Penalty
Summary
Nursing staff failed to assess, document, and respond appropriately when a resident with hemiplegia, hemiparesis, and dysphagia experienced an accident while being transferred in a shower chair. The resident, who only speaks Hmong and is rarely understood, slipped into the opening of the shower chair, resulting in her right leg being caught and sustaining a cut on her right thigh. Despite the resident expressing pain verbally and through facial grimacing, there was no documentation of the incident or injury in the medical record, and no pain assessment or treatment was provided. Interviews with staff revealed that the CNA present during the incident observed the injury and pain but did not document the event. The DON and assigned nurses were either unaware of the incident or could not recall details, and no one completed a change in condition assessment or notified the physician as required by facility policy. The Medication Administration Record showed no pain medication was administered, and pain scores were recorded as zero following the incident. Additionally, the care plan was not updated to address the accident or injury. Family members confirmed being informed of the accident and noted the resident's complaints of pain. Observations days after the incident revealed visible scabbing and injury to the resident's right thigh. The Infection Preventionist acknowledged that the accident and injury were not addressed by nursing staff or the facility, indicating a failure to ensure staff had the competencies and skills necessary to provide appropriate care and documentation for the resident.
Failure to Protect Resident from Abuse Due to Inadequate Behavioral Assessment and Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another out of her wheelchair, resulting in the latter falling to the floor. The facility's policy requires the identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect. However, the admission team did not identify that the resident who committed the abuse had Bipolar II disorder or that he had been receiving psychological care at his previous facility. There were no behavioral health care plans in his record, nor were any mental health appointments provided to him after admission. The resident had a history of aggression, agitation, and suicidal ideation, as documented in multiple progress notes, and was placed on 1:1 monitoring after expressing self-harm and aggressive behaviors. Despite being under continuous 1:1 monitoring, the resident was able to approach another resident in the hallway and push her out of her wheelchair. The interdisciplinary team did not meet to discuss the altercation until six days after the event. The resident who was pushed had severe cognitive impairment and was significantly dependent on caregivers. The Director of Nursing confirmed gaps in the identification and care planning for the resident with behavioral health needs, as well as a lack of awareness of his mental health status and history upon admission.
Failure to Validate PASRR Accuracy for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident who was admitted from another skilled nursing facility. Upon admission, the staff did not validate or reassess the PASRR that had been completed at the previous facility, despite the resident having documented diagnoses of depression and Bipolar II disorder, as well as being prescribed sertraline, a psychotropic medication. The PASRR from the prior facility indicated no diagnosed or suspected serious mental illness and no psychotropic medication use, which was inconsistent with the resident's medical record and ongoing treatment. Interviews with facility staff, including the DON and Social Services Director, confirmed that the admission team did not reassess or validate the PASRR upon the resident's admission. The staff relied on the previous PASRR without verifying its accuracy, resulting in the absence of a behavioral health care plan for the resident, despite clear evidence of mental health diagnoses and treatment in the resident's record.
Failure to Develop and Implement Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the mental health and behavioral needs of a resident with a history of depression and Bipolar II disorder. Upon admission, the resident's records indicated diagnoses of stroke, depression, and Bipolar II disorder, as well as recent participation in multiple psychology appointments at a previous facility. The Minimum Data Set (MDS) assessment identified moderate cognitive impairment and mild depression, but these findings were not incorporated into a behavioral health care plan. Despite documented episodes of aggression, agitation, and suicidal ideation, there was no care plan in place to address the resident's mental health needs. The resident exhibited threatening behavior toward staff, self-harm, and made multiple statements about wanting to end his life. The facility's Social Services Director and Director of Nursing confirmed that no behavioral health care plan was developed, and the resident did not receive mental health appointments after admission. The Social Services Director also acknowledged being behind on developing the resident's plan of care. While under 1:1 monitoring due to suicidal ideation, the resident was able to initiate a physical altercation with another resident, resulting in harm. The lack of a comprehensive care plan addressing the resident's behavioral and mental health needs contributed to these incidents, as the facility did not follow its own policy requiring measurable objectives and timeframes for all identified needs.
Failure to Provide Behavioral Health Services Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a history of psychiatric and behavioral health needs received appropriate behavioral health evaluation and services upon admission. The resident was transferred from another skilled nursing facility with diagnoses including stroke and depression, and had a documented history of Bipolar II disorder and recent psychology appointments. However, upon admission, the facility did not validate or reassess the previous PASRR, which had not identified serious mental illness or psychotropic medication use, nor did they recognize the resident's ongoing mental health needs as indicated in the transfer records and initial assessments. Despite the resident's moderate cognitive impairment and mild depression identified on the MDS and PHQ-9, there was no behavioral health care plan developed, and no mental health appointments were provided after admission. The DON confirmed that the admission team did not identify the resident's Bipolar II disorder or prior psychological care, and the Social Services Director stated that the PASRR from the previous facility was not validated for accuracy. The lack of behavioral health interventions and follow-up contributed to the resident's escalating behavioral symptoms, including aggression, threats of self-harm, and agitation. These unaddressed behavioral health needs culminated in multiple incidents, including threats to staff, self-injurious behavior, and a resident-to-resident altercation where the resident shoved another resident out of a wheelchair. The situation escalated to the point where the resident required 1:1 monitoring and was ultimately transferred to the hospital for psychiatric evaluation after repeated self-harm attempts and aggressive behavior, despite being under continuous observation.
Failure to Obtain Conservator Consent for Antipsychotic Medication Change
Penalty
Summary
The facility failed to inform the court-appointed conservator of a resident with schizophrenia about the risks, benefits, and alternatives to a proposed medication change, as required by both facility policy and the resident's legal status. The resident, who was under an LPS conservatorship due to a serious mental illness and inability to make medical decisions, was admitted to the facility while receiving Clozapine for schizophrenia. Shortly after admission, Clozapine was placed on hold for an unknown reason, and the resident was instead prescribed Paliperidone. The informed consent form for Paliperidone was signed by the resident and staff, but not by the conservator, who was the legally authorized decision-maker. Facility records and interviews confirmed that the conservator was not notified or consulted prior to the medication change or discontinuation of Clozapine. Staff interviews revealed uncertainty about why the medication was held and acknowledged that the conservator's consent was not obtained, despite the resident's long-standing conservatorship and the facility's own policies requiring such notification and consent for psychotropic medication changes. The conservator was only made aware of the situation after the resident's mental health had deteriorated. As a result of the lack of communication and failure to obtain proper consent, the resident experienced a decline in mental health status, necessitating hospital readmission for treatment of schizophrenia. Documentation did not provide a rationale for the medication change, nor did it show that the conservator was informed or involved in the decision-making process, as required by both policy and legal mandate.
Failure to Update Care Plan with 1:1 Monitor After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to update the care plan for a resident with a history of aggressive behavior following an incident in which the resident struck another resident. Despite the provider's recommendation and the Interdisciplinary Team's (IDT) decision to implement a 1:1 monitor after the incident, this intervention was not added to the resident's care plan. The care plan continued to list previous interventions such as allowing the resident to express concerns, approaching calmly, and consulting psychiatry as needed, but did not reflect the new 1:1 monitoring requirement. Record reviews and staff interviews confirmed that the 1:1 monitor was being implemented in practice, as a CNA was assigned to monitor the resident, but this intervention was not documented in the care plan as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated during the IDT meeting and confirmed that the omission was not in line with facility expectations or policy, which requires care plan revisions upon a change in resident status.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by several deficiencies in infection prevention and control practices. A Certified Nurse Assistant (CNA) was observed wearing the same isolation gown while providing care to two residents, one of whom was diagnosed with Clostridium difficile (C-diff), a highly contagious bacterium. The CNA admitted to not changing the gown between caring for the two residents, which was confirmed by the Infection Preventionist and the Director of Staff Development, both acknowledging the potential for cross-contamination. Additionally, the facility lacked dedicated cleaning equipment for the bathroom of the resident with C-diff, as confirmed by the Maintenance Director and housekeeping staff, who were unaware of the requirement for dedicated equipment. Furthermore, the facility's nurse's station counter was found to be in disrepair, with chipped plastic laminate exposing porous wood, making it impossible to properly disinfect. This was confirmed by both a housekeeper and the Infection Preventionist, who acknowledged that the damaged areas could not be adequately disinfected. These observations highlight the facility's failure to adhere to its own policies and procedures regarding infection control, thereby increasing the risk of infection transmission among residents.
Resident Privacy Violations Due to Uninvited Room Entries
Penalty
Summary
The facility failed to protect the privacy rights of five residents when another resident, identified as Resident 20, entered their rooms uninvited. This behavior was confirmed through interviews with the affected residents and staff members. Resident 33, who has severe cognitive deficits, reported that Resident 20 frequently entered her room and rummaged through her belongings. Similarly, Resident 18, who is cognitively intact, expressed discomfort with Resident 20's uninvited visits, which occurred several times a month. The Director of Nursing and other staff members acknowledged that Resident 20 often wandered into other residents' rooms, which was recognized as a residents' rights issue. Interviews with other residents, including Resident 22, Resident 8, and Resident 5, revealed similar experiences of Resident 20 entering their rooms and attempting to go through their belongings. These residents, who were cognitively intact, expressed their dissatisfaction with these intrusions. The facility's policy on resident rights emphasizes the importance of personal privacy, which includes accommodations. Despite this policy, the facility did not effectively prevent Resident 20 from infringing on the privacy of other residents. Staff members, including CNAs, confirmed that Resident 20's behavior was a known issue, yet no effective measures were in place to prevent these privacy violations.
Failure to Provide Adequate Foot Care for a Resident
Penalty
Summary
The facility failed to provide adequate foot care and treatment for one resident, identified as Resident 201, due to a lack of proper assessment and communication. The Licensed Nurse (LN) did not accurately assess the condition of Resident 201's feet upon admission, nor was a care plan developed within the required 48 hours. The resident, who was cognitively intact and capable of making decisions, expressed discomfort and frustration over the lack of communication regarding foot care. Observations revealed that the resident's toenails were long, thick, and discolored, and the skin on the feet was dry, flaky, and discolored, with a cluster of brown growths on the ankle. The Director of Nursing (DON) was not informed of the resident's foot condition, and the physician was not notified, which should have been done according to the facility's policies and procedures. The LN confirmed that no foot care treatments were ordered, and the admission assessment did not accurately describe the resident's foot condition. The failure to assess and document the resident's foot condition and to notify the physician led to the absence of a care plan, which was a requirement as per the facility's policies.
Failure to Supervise Resident Leads to Unsupervised Fall
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 20, who was at risk for wandering and elopement. The resident, who had a history of dementia, agitation, and falls, was found unsupervised in the shower room, resulting in a fall. The shower room door, which was supposed to be locked to prevent access by wandering residents, was left unlocked, allowing the resident to enter and fall. This incident was not isolated, as the resident had previously fallen in the same shower room, prompting the installation of a keypad lock that was not utilized properly. Additionally, the facility did not adhere to the care plan for Resident 20, which required one-to-one supervision every 30 minutes and 15-minute observations as needed. There was no documentation to confirm that these supervision measures were consistently implemented. The Director of Nursing acknowledged the lack of consistent documentation and monitoring, which contributed to the resident's unsupervised wandering and subsequent fall. Furthermore, the resident's wandering behavior was not accurately captured in the Minimum Data Set (MDS) assessment. Despite staff observations and reports of the resident's wandering tendencies, the MDS Nurse incorrectly coded the resident's behavior as not exhibiting wandering. This oversight in documentation and assessment further highlights the facility's failure to provide adequate supervision and care for the resident, increasing the risk of accidents and compromising the resident's safety.
Failure to Arrange Follow-Up Appointment for Resident
Penalty
Summary
The facility failed to provide medically-related social services to a newly admitted resident, identified as Resident 201, who required a follow-up appointment with a vascular surgeon. The resident, who had been admitted with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, was cognitively intact and responsible for their own decisions. The facility's policy required the social worker to perform an initial assessment and document the resident's needs, but this was not done. The discharge documents from the hospital indicated the need for a follow-up appointment with a vascular surgeon within a week, but there was no documentation in the medical record to support that this referral had been made. During interviews and record reviews, it was confirmed that the social services staff was not present at the time of the resident's admission, and the interdisciplinary team (IDT) was responsible for ensuring the appointment was made. However, the IDT failed to ensure the referral was completed. The Director of Nursing confirmed the oversight, acknowledging that the responsibility fell on the IDT in the absence of the social services staff. This failure had the potential to negatively impact the resident's health status, as the necessary follow-up with a vascular surgeon was not arranged.
Deficiency in Dietary Department Cleanliness and Labeling
Penalty
Summary
The facility failed to maintain a clean and orderly environment in the dietary department, as observed during a survey. Specifically, there was an unlabeled storage bin containing a white granulated substance, later identified as sugar, which lacked proper labeling. Additionally, four storage bins containing sugar, chocolate chips, flour, and rice had lids with visible dust, scratches, and adhesive tape residue. These observations were made during an interview with the Dietary Manager, who acknowledged that the bins should have been labeled and clean, as per the facility's policies on ingredient bins and labeling and dating of foods.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure that all resident bedrooms accommodated no more than four residents, as required by regulations. During an initial tour of the facility, it was observed that one room contained five beds, which is a violation of the standard. Despite the room providing a reasonable amount of privacy and adequate storage space, the presence of five residents in a single room did not comply with the regulatory requirements. The Administrator acknowledged the situation and mentioned the continuation of a waiver renewal request.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a working call system was accessible to a resident, identified as Resident 4, which had the potential to delay care and endanger the resident's health and safety. The facility's policy and procedure on call lights required that call lights be placed within reach of residents to allow them to call for assistance. However, during an observation, Resident 4 was found yelling for help because the call light was not within reach. The call light was hanging through the lower portion of the bedrail, below the mattress level, making it inaccessible to the resident. A Certified Nursing Assistant (CNA) confirmed that the resident needed the call light clipped to the blanket to be able to feel or see it. Further observations revealed that the call light cord was located near the foot of the bed, between the mattress and footboard, and hanging down to the ground, which was not within reach of Resident 4. The Director of Staff Development (DSD) and the Director of Nursing (DON) reviewed the resident's care plan, which indicated that the call light should be kept within reach. Despite this, the call light was not positioned appropriately, leading to the deficiency. Resident 4 had a history of chronic obstructive pulmonary disease, multiple fractures, and a history of falling, and was totally dependent on staff for activities of daily living, making the accessibility of the call light crucial for their safety and care.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during an interaction with a staff member. The incident involved a resident who was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). The resident had a history of rheumatoid arthritis, spinal stenosis, adult failure to thrive, gastroenteritis, colitis, and a history of falling. The deficiency occurred when the resident inquired about lost clothing and was met with a rude and disrespectful response from the Maintenance Supervisor (MS). The MS reportedly yelled at the resident, telling them not to ask about the lost pants again and incorrectly stated that the pants were not labeled, despite the resident's assertion that they were. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and addressing grievances promptly. However, during interviews, both the Administrator and the Director of Nursing (DON) confirmed that the resident's rights were violated due to the MS's disrespectful behavior. The incident caused the resident to feel angry and had the potential to result in emotional stress and other negative outcomes. The report highlights the failure of the facility to adhere to its own policies regarding the treatment of residents with dignity and respect.
Failure to Accommodate Resident's Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident when a second bedside table, used for storing art supplies, was removed from her room without her consent. This action was taken by the Maintenance Supervisor, who stated that the table was needed for another resident due to a shortage of bedside tables. The removal of the table led to the resident feeling frustrated and angry, as it violated her right to have her specific needs accommodated. Interviews with the resident, the Administrator, and the Director of Nursing confirmed that the resident required two separate tables, one for eating and another for her art supplies. The Administrator acknowledged that the Maintenance Supervisor should have asked the resident before removing the table and suggested that an alternative could have been provided. The Director of Nursing confirmed that the manner in which the table was removed, without proper communication or explanation, was not appropriate.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to revise and update the care plan for a resident to reflect current individual needs for pain management. The resident, who was admitted with conditions including rheumatoid arthritis, spinal stenosis, and a history of falling, expressed discomfort due to pain in her knees when touched during the night. Despite the resident's request for specific repositioning to avoid pain, the care plan was not updated to include these preferences or the new pain management interventions. The resident's medical record indicated new orders for Methotrexate and Prednisone to manage rheumatoid arthritis, but these were not incorporated into the care plan. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed that the care plan had not been revised to include the new medications and interventions for pain management, leading to the resident's care needs going unrecognized.
Inconsistent Hair Care Assistance for Resident
Penalty
Summary
The facility failed to provide daily hair care for a resident, leading to a deficiency in maintaining the resident's personal hygiene and dignity. The resident, who was admitted with conditions such as Rheumatoid Arthritis and spinal stenosis, required assistance with activities of daily living, including hair care. Despite the facility's policy to provide necessary services for grooming and personal hygiene, the documentation showed inconsistencies in the assistance provided to the resident. Over two months, there were several days where no assistance or inadequate assistance was documented, and the resident's hair care needs were not consistently met. Observations and interviews revealed that the resident's hair was not properly maintained, with matted tangles observed, and the resident expressed dissatisfaction with the hair care provided. The resident mentioned that staff did not have the time to assist daily, and the CNA confirmed the lack of appropriate supplies for hair care. The Director of Nursing acknowledged the resident's need for assistance due to reduced fine motor skills and confirmed the necessity for daily help with hair care.
Failure to Safeguard Resident Dignity and Timely Care
Penalty
Summary
The facility failed to protect the rights of six residents by not safeguarding their dignity and respect. Nursing staff ignored call lights and calls for assistance, and failed to administer pain medications in a timely manner. This led to residents feeling angry, sad, scared, and experiencing increased anxiety and pain. The facility's policies on resident rights, pain management, and medication administration were not adhered to, resulting in these deficiencies. Resident 1 experienced an argument with an LVN over medication administration, where the LVN insisted on giving two teal-colored tablets of Meloxicam, which the resident believed was incorrect. The resident felt angry and frustrated, and reported long delays in call light responses. Resident 2, who is on hospice care, reported a significant delay in receiving pain medication, which exacerbated her anxiety and pain. She described an interaction with the LVN where her request for pain medication was dismissed, leading to further distress. Other residents also reported delays in call light responses and inadequate care. Resident 3 mentioned that call lights sometimes take at least half an hour to be answered. Resident 4 expressed concerns about the night staff's responsiveness, stating it took an hour to have her briefs changed. Resident 5 and his wife reported issues with catheter care during the night shift, and Resident 6 had to assist his roommate due to the lack of staff response. These incidents highlight a pattern of neglect and inadequate care during the night shift, contributing to the residents' dissatisfaction and distress.
Failure to Provide Timely Care for Activities of Daily Living
Penalty
Summary
The facility failed to provide timely care and assistance for activities of daily living, specifically in changing soiled briefs for three residents. Resident 1, who was admitted for heart and kidney failure, anxiety disorder, diabetes, and severe obesity, reported being left in a soiled brief for approximately 12 hours. This occurred because the CNA was unavailable, and the nurses, citing short-staffing, did not return to assist. Resident 4, who required substantial assistance due to diabetes, malnutrition, osteomyelitis, COPD, and a history of stroke, reported not being changed at night unless a specific CNA was on duty. Resident 5, with a foot amputation and infection, also reported not receiving timely assistance, with family members having to request help during visits. The facility's policy on activities of daily living emphasizes the need for care based on comprehensive assessments and resident needs. However, the failure to assign a temporary CNA to specific rooms on a day when staff called off contributed to the neglect of Resident 1. The Director of Staff Development acknowledged the oversight in assigning duties, which may have led to the deficiency. The lack of adequate staffing and communication during shift changes resulted in residents not receiving necessary care, potentially leading to negative health outcomes and loss of dignity.
Disrespectful Behavior by LVN A Violates Resident Rights
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination, as evidenced by the actions of LVN A towards two residents. Resident 1, who was admitted for chronic obstructive lung disease, anxiety, and depression, reported feeling unsafe after LVN A yelled at her for requesting pain medication. LVN A was observed arguing with Resident 1 and administering medication in a disrespectful manner, which was corroborated by CNA C. Resident 1 expressed relief when informed that LVN A would no longer be her nurse. Resident 2, admitted for heart failure and bipolar disorder, also reported feeling unsafe due to LVN A's behavior. The resident recounted an incident where LVN A refused to change her bandage and was rude during a phone call with her son. Resident 2 expressed fear of potential harm from LVN A, who was accused of making racially insensitive remarks. The Director of Nursing confirmed that LVN A had been terminated for arguing with and yelling at Resident 2, which violated the resident's rights. Additional interviews revealed that LVN A had a history of inappropriate behavior towards residents, including demanding respect before administering medication. A local community advocate noted similar complaints about LVN A from other residents. The facility's Employee Handbook emphasizes the importance of treating residents with respect and addressing their needs promptly, which LVN A failed to uphold, leading to the reported deficiencies.
Resident Isolation and Call Light Tampering
Penalty
Summary
A deficiency was identified when a staff member at the facility closed the room door of a resident and silenced the resident's call light, contrary to the facility's policy. The resident, who was admitted for respiratory failure, worsening brain disease, anxiety, and difficulty communicating, had a history of being fearful of confinement due to trauma from a local wildfire disaster. The resident's care plan specifically indicated that the room door should remain open for her comfort. Despite this, the Licensed Vocational Nurse (LVN) involved admitted to closing the door and adjusting the call light system, although she denied disconnecting any wires. Interviews revealed that the LVN had previously threatened to shut the door to quiet the resident and had made changes to the call light system. A Certified Nursing Assistant (CNA) witnessed the LVN's actions and reported that the resident was particularly vulnerable due to her paranoia and fear of being left alone. The Maintenance Director confirmed that the call light system had been tampered with, as two wires were found disconnected, although he did not receive a report from the LVN as claimed. The Director of Nursing (DON) acknowledged the ongoing investigation and confirmed that the LVN had been taken off duty.
Resident Dignity Compromised Due to Unchanged Dressings
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect while eating meals. The resident, who was admitted with multiple medical conditions including sepsis, cellulitis, and severe obesity, was observed with dark, dried, red stains on his shirt, which he identified as blood from unchanged dressings. Despite the resident's request for assistance, no staff had attended to his needs, leading to his frustration. A Certified Nursing Assistant (CNA) reported the issue to a Licensed Nurse (LN), who acknowledged the need to change the resident's dressings but had not yet done so. The Director of Nursing (DON) confirmed that the resident should not have been served meals with soiled dressings and a dirty shirt, acknowledging the situation as a dignity problem. The DON stated that they were unaware of the issue until it was brought to their attention.
Failure to Obtain Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to obtain physician orders for wound care upon the admission of a resident, identified as Resident 2, who was admitted with multiple medical conditions including sepsis, cellulitis, and Bullous Pemphigoid. The admission records were incomplete, lacking necessary wound care orders for open areas on the resident's chest, upper right arm, abdomen, and both lower legs. This oversight was confirmed during a review of the resident's medical records and interviews with facility staff, including the Director of Nursing (DON) and the Medical Director (MD). Interviews with staff revealed that the admission process was not followed, and there was a lack of communication and documentation regarding the resident's condition. The DON confirmed that no wound assessments or measurements were completed, and the MD acknowledged the issue of incomplete admission orders. Staff members, including a Licensed Nurse and a Registered Nurse, admitted to not performing necessary assessments or obtaining verbal reports, citing busyness and oversight as reasons for the lapse in care. This resulted in a delay in addressing the resident's wound care needs.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours for a resident, identified as Resident 2, which is a requirement according to the facility's policy dated February 2023. This policy mandates that a baseline care plan should be created and implemented within 48 hours of a resident's admission to ensure effective and person-centered care. The absence of this care plan was confirmed during a review of Resident 2's medical records, which showed no baseline care plan was developed, despite the resident being admitted with multiple serious health conditions including sepsis, cellulitis, high blood pressure, Bullous Pemphigoid, and severe obesity. Interviews conducted with facility staff further confirmed the deficiency. A Licensed Nurse acknowledged the lack of a baseline care plan in the medical record, which meant staff did not have the necessary information to address Resident 2's specific needs. Additionally, the Director of Nursing confirmed that no admission records, including the baseline care plan, were completed for Resident 2. This oversight had the potential to result in unmet individual needs and negative clinical outcomes for the resident.
Facility Fails to Maintain Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable temperature levels in six resident rooms, leading to discomfort for residents, including one who felt hot and sweaty. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit, but temperatures in the affected rooms ranged from 82.6 to 90.3 degrees Fahrenheit. The issue arose when the HVAC unit stopped working due to an old transformer, and the use of portable air conditioners (P-ACs) caused circuit overloads, tripping the breaker and affecting the oxygen supply for one resident. Resident 1, who had a history of acute myocardial infarction, acute respiratory failure, and chronic kidney disease, was particularly affected. The resident's room temperature was recorded at 85 degrees Fahrenheit, and despite the use of fans and a portable oxygen tank, the resident expressed feeling hot and uncomfortable. The facility was unable to move the resident to a cooler room due to full occupancy, and the DON had to manage the P-AC usage by alternating between rooms to prevent circuit overloads.
Facility Fails to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for six out of 21 resident rooms sampled, potentially affecting 11 residents. The main air conditioning units on the roof were not functioning, and although they were repaired, the room temperatures remained above the facility's policy range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperatures in some rooms reached as high as 84.2 degrees Fahrenheit, which was acknowledged by the Maintenance Director as too hot. Residents expressed discomfort due to the high temperatures, with one resident stating difficulty in breathing and another feeling hot and sweaty. The facility attempted to mitigate the issue by using swamp coolers and portable air conditioners, but these were not effective. The swamp coolers were not used according to the manufacturer's instructions, as there was inadequate airflow in the hallways, and some portable air conditioners could not be used due to electrical issues. Interviews with staff and family members confirmed the ongoing temperature issues, with complaints from residents about the heat. The Maintenance Director noted that the HVAC system had ductwork issues, allowing cold air to escape and hot air to enter, which required further repairs. The facility's failure to maintain a comfortable environment compromised the residents' right to a safe and homelike setting.
Failure to Provide Privacy During Medical Treatment
Penalty
Summary
The facility failed to ensure the right to personal privacy for a resident during medical treatment. The incident involved a resident with multiple diagnoses, including lung disease, diabetes, heart disease, blindness, and bipolar disorder. During an observation, the Maintenance Director and a surveyor were present in the resident's room discussing a maintenance issue when an LVN entered to administer medication. The LVN did not provide privacy for the resident, as she lifted the resident's gown and exposed her bra, abdomen, and briefs without pulling the privacy curtain. The LVN acknowledged during an interview that she failed to provide privacy and admitted it did not cross her mind.
Inaccurate Resident Assessment in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's current status for one of five sampled residents. Specifically, the admission Minimum Data Set (MDS) for a resident dated 3/3/2024 inaccurately indicated that the resident was admitted with an indwelling catheter. This discrepancy was identified during a review of the resident's clinical record and confirmed through observations and interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON). The CNA confirmed that the resident did not have an indwelling catheter and was able to urinate normally, which was further corroborated by the DON who acknowledged the inaccuracy in the MDS assessment. The resident in question had a medical history that included arthritis, end-stage renal disease, dependence on renal dialysis, and muscle weakness. The resident was initially admitted to the facility and later readmitted after a hospital transfer for uncontrolled high blood pressure. Despite these conditions, the MDS inaccurately documented the presence of an indwelling catheter, which was not observed during a physical examination of the resident. This inaccuracy in the resident's assessment had the potential to impact the care and treatments provided to meet the resident's individual needs.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for a resident exhibiting behavior issues, specifically the constant removal of clothes. The resident, who had diagnoses including arthritis, end-stage renal disease, and muscle weakness, was observed sitting on the bed covered only by a blanket and a ripped incontinence brief. The resident expressed confusion about the whereabouts of his clothes and stated he was cold. Staff members acknowledged the resident's behavior but did not have a care plan in place to address it, instead opting to let the resident remain unclothed as he would remove any clothes put on him. During interviews, the Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) confirmed that the resident frequently removed his clothes and that no care plan had been developed to manage this behavior. The ADON admitted that such behavior should have been care planned, and the staff were expected to cover the resident and ensure privacy. However, the care plans reviewed did not include any interventions or strategies to address the resident's specific behavior, leading to a failure in providing necessary care and services to maintain the resident's well-being.
Failure to Provide Timely Urinalysis for Resident with UTI Symptoms
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident exhibiting symptoms of a urinary tract infection (UTI). The resident, who had a history of arthritis, end-stage renal disease, and muscle weakness, was readmitted to the facility after a hospital transfer for uncontrolled high blood pressure. On 3/8/2024, the resident showed signs of a UTI, including dark and foul-smelling urine, vomiting, and bladder pain. The Licensed Nurse (LN) notified the Medical Doctor (MD) and received an order for a urinalysis (UA) and urine culture sensitivity test (C&S). However, the UA and C&S were not ordered or documented in the resident's medical record as required. The Assistant Director of Nursing (ADON) confirmed that the UA was not collected until 3/10/2024, three days after the initial symptoms were reported. The UA report, received on 3/11/2024, confirmed the presence of a UTI. The ADON admitted that there was no documentation explaining why the UA was not collected on 3/8/2024 and acknowledged that staff failed to document whether the UA was collected. This delay in testing and documentation had the potential to delay the resident's treatment and could lead to further complications.
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 112 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Oroville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oroville Hospital Post-acute Center | 0 mi | ★★★★★ | 23 | 0 |
| Country Crest Post-acute | 1.3 mi | ★★★★★ | 17 | 0 |
| Gridley Post Acute | 12.6 mi | ★★★★★ | 2 | 0 |
| River Valley Care Center | 18.2 mi | ★★★★★ | 1 | 0 |
| California Park Post Acute | 20.8 mi | ★★★★★ | 5 | 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 August 2026) and official state health department websites.