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 Greenfield Care Center Of Fillmore, Llc during CMS and state inspections, most recent first.
A resident on EBP for a Foley catheter and G-tube was observed receiving tube feeding in the dementia care unit activity room with other residents present, and no privacy measures were in place. An LVN and a CNA provided the care in view of others, despite the facility’s dignity policy requiring bodily privacy during treatment procedures.
Unsigned POLST Form: A resident's POLST listed CPR, full treatment, and long-term artificial nutrition, but it was not signed by the resident or the legally recognized decisionmaker. The RN Supervisor acknowledged the missing signatures during record review, and the facility policy required the form to be signed by both the physician and the patient or decisionmaker.
Failure to provide written bed-hold notice at transfer. A resident was sent to the hospital after becoming drowsy, weak, hypoxic, tachycardic, and febrile, and later returned with a kidney infection. The resident’s bed-hold form was signed on admission, but the transfer section was left blank. The RNS stated residents are informed of the bed-hold policy during admission and that nurses send residents to the hospital with a face sheet and med list.
The facility failed to resubmit PASRRs for two residents after changes in their mental health conditions. One resident, admitted with paranoid schizophrenia, later received new diagnoses of anxiety, PTSD, and unspecified psychosis and was started on Zyprexa, but no repeat PASRR was completed. Another resident, admitted with anxiety and unspecified psychosis, later had a care plan update for psychosocial needs related to anxiety and was started on Trazadone, but no new PASRR was initiated. The MDSC acknowledged the repeat PASRRs were not done after the residents’ mental condition changes.
Care Plan Not Revised for Ongoing Dialysis Refusals: A resident who was scheduled for dialysis 3 times weekly repeatedly refused treatments, and the care plan identified risk for complications related to refusing dialysis. During record review and interview, staff could not show that the CP interventions were evaluated or revised despite the ongoing refusals, and the RN supervisor acknowledged the interventions should have been reviewed with the IDT when they were not effective.
Missed Weekly Wound Assessments for Resident With Multiple Pressure Injuries: The facility failed to complete required weekly wound assessments for a resident with a stage 4 pressure ulcer and a right hip skin shear. Documentation was missing for one week for the hip wound and one week for the buttock wound, and both the IP and WN acknowledged the gaps during record review.
Expired meds and supplies were found in the respiratory storage room, station 3 med storage, and multiple treatment carts, including opened probiotics, expired respiratory supplies, single-use items left available for reuse, and treatment products without proper open dates. Staff also found the station 3 med refrigerator out of range, with repeated temperature checks showing abnormal readings and the thermometer later placed in the freezer. The issues involved expired topical meds, irrigation solutions, and single-use supplies that were still accessible for use.
Ice machine not maintained in clean condition: During kitchen observation, a tissue test of the lower stainless steel bin inside the ice machine revealed minimal greyish-black residue, and the DM, MR, and Dietician validated the finding. The MR stated he had cleaned parts of the machine and checked for mineral scale buildup but missed other areas. The manufacturer’s manual and facility P&P both required thorough cleaning of the stainless steel and inside of the machine with attention to specific components.
Staff failed to follow infection control practices when a resident on EBP received tube feeding and another resident on EBP had a blood sugar check without the required gown. Surveyors also found oxygen tubing that had not been changed on schedule for a resident, along with an open saline irrigation bottle and used DeCloggers left available on treatment carts for reuse.
The facility failed to create individualized care plans for three residents, leading to unmet needs. A resident who speaks only Spanish was not provided with an interpreter, another with dementia and fall risks had no care plan for alarm use, and a quadriplegic resident had an inappropriate call light. These oversights were acknowledged by the DON and were not in line with facility policies.
The facility failed to adhere to professional standards in medication administration and documentation, including administering oxygen without a physician's order, not providing Acetylcysteine as scheduled, and failing to follow insulin sliding scale orders for residents with respiratory and diabetic conditions.
The facility failed to follow its policies for sharps disposal, timely replacement of E-Kits, and medication administration. Syringes were improperly disposed of, E-Kits were not replaced within 72 hours, and expired medications were found. Medication nurses administered drugs outside the prescribed time window due to workload issues, and medications were not immediately documented in the MAR.
A facility was found to have a medication error rate of 17.7%, exceeding the acceptable threshold. Errors included an LVN crushing a delayed-release medication, failing to administer prescribed medications, and incorrect dosages of topical treatments. These observations were made during medication passes involving multiple residents.
The facility improperly installed and maintained portable air conditioning units (PACUs) in 12 rooms. Exhaust hoses were duct taped to window frames, making windows inoperable, and air filters were not cleaned as per manufacturer's guidelines. The Maintenance Supervisor was unaware of the correct cleaning frequency and the presence of two filters per unit.
A facility failed to ensure an IDT assessed a resident's ability to self-administer medication, leading to the resident having unauthorized access to DuoNeb vials. The resident stated he administered the medication himself, but the LN confirmed he was not allowed to do so. The DON acknowledged that no IDT meeting had occurred to authorize self-administration, contrary to the facility's policy.
The facility did not maintain the most current survey results in the survey results binder accessible to the public. The binder, located at the facility's main entrance, contained outdated survey results, missing updates from August 2024 to February 2025. The DON acknowledged the oversight, which was contrary to the facility's policy requiring the most recent survey documents to be available in a common area.
The facility inaccurately assessed two residents using the MDS, leading to incorrect data reporting to CMS. One resident's language needs were misrepresented, indicating no need for an interpreter despite their primary language being Spanish. Another resident's functional status was inaccurately recorded as having no impairments, despite an OT assessment indicating otherwise. These errors were acknowledged by the MDS Coordinator and DON.
The facility failed to document and maintain medication refrigerator temperatures within the required range. On one occasion, the temperature was recorded below the policy range, and on another, there was no documentation of the temperature, indicating a deficiency in proper storage conditions for drugs and biologicals.
The facility failed to follow its policies for labeling and dating food items, risking foodborne illnesses. Observations revealed bins of rice, beans, and pasta with incomplete date information, and a box of mixed vegetables with non-specific delivery dates. The Kitchen Manager and Dietician acknowledged the labeling issues.
The facility failed to adhere to infection control practices, including improper storage of respiratory equipment for two residents and lack of PPE availability outside rooms with contact precautions. Equipment was not stored in plastic bags as required, and PPE was not accessible before room entry, posing a risk of cross-contamination.
The facility failed to document responses to recurring complaints from residents about untimely call light responses during Resident Council Meetings. In December and January, residents reported long wait times and inadequate assistance, with no documented resolution or communication of outcomes. The assistant director of nursing confirmed the lack of documentation, despite facility policy requiring a response form to track and resolve issues.
A resident, totally dependent on staff for repositioning, developed a new stage 3 pressure ulcer on the right buttock due to the facility's failure to consistently reposition the resident every two hours as required. Despite being at risk for skin breakdown, the resident's care plan was not followed, leading to the deterioration of a stage 2 ulcer to stage 3. Interviews confirmed the lack of consistent repositioning, contrary to the facility's policy.
The facility failed to implement comprehensive RNA care plans for fourteen residents, resulting in missed RNA services and lack of documentation. Interviews and record reviews confirmed that RNA exercises were not provided as ordered, and no replacements were arranged when the assigned RNA was unavailable.
A resident with a history of falls and multiple medical conditions fell and sustained a right distal femur fracture due to the facility's failure to ensure a bed alarm was in place. The facility did not follow its policies on fall risk and injury prevention, nor did it conduct a neurological evaluation following the unwitnessed fall.
A resident admitted with a history of hemi-glossectomy, post tracheostomy, and a left arm grafted site experienced deficiencies in care. The facility failed to follow up on a discharge order for the arm wrap, leading to a delayed wound consultation and graft failure. Sutures were removed without a physician's order, and skin assessments were inadequately documented, missing significant skin damage.
A facility failed to accurately document a resident's tracheostomy site condition, as noted in the Admission Nursing Assessment and skilled charting, which showed redness around the stoma. However, the Respiratory Orders Administration Record indicated no signs of infection during the same period. This discrepancy was acknowledged by the DON, highlighting inaccuracies in the resident's clinical record.
A resident with end-stage Huntington's disease and other conditions exhibited new symptoms of right leg redness and swelling. Despite these observations, the facility failed to develop and implement a comprehensive care plan. The DON confirmed the absence of a care plan during a review of the resident's medical record.
A facility failed to implement a smoking care plan and ensure adequate supervision for a resident with a history of traumatic brain injury and muscle weakness. The resident fell from a wheelchair while smoking unsupervised, resulting in an acute fracture of the left humerus. The care plan and facility policies for fall risk and smoking supervision were not followed.
Failure to Protect Resident Privacy During Tube Feeding
Penalty
Summary
Facility staff failed to maintain privacy and resident dignity for one resident who was on Enhanced Barrier Precautions due to a Foley catheter and G-tube. During an observation in the dementia care unit activity room, an LVN and a CNA were seen providing tube feeding to the resident in the presence of other residents, and no privacy practices were observed during the procedure. The resident’s medical record showed physician orders for EBP related to the Foley catheter and G-tube every shift. The DON stated that infection control practices and dignity must be practiced for all residents, including protecting bodily privacy during treatment procedures. The facility’s Dignity policy stated that staff are to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and treatment procedures.
Unsigned POLST Form
Penalty
Summary
The facility failed to ensure that information regarding a Physician Orders for Life-Sustaining Treatment (POLST) form was provided to Resident 3 or the legally recognized decisionmaker. The POLST, dated 2/11/23, indicated orders for Attempt Resuscitation/CPR, full treatment, and long-term artificial nutrition including feeding tubes. Although the form was marked to show that the information was discussed with the resident and that there was no advance directive, it was signed and dated by the physician only and was not signed by the resident or the resident's sister, who was listed as the legally recognized decisionmaker. During record review, Resident 3's comprehensive MDS dated 1/5/26 showed a BIMS score of 15. In a concurrent interview and record review on 3/18/26, the RN Supervisor reviewed Resident 3's POLST and acknowledged that it was not signed by the resident or the resident's representative. The facility policy titled Physician Orders for Life Sustaining Treatment (POLST) or Request Regarding Resuscitative Measures Form stated that a healthcare provider shall explain the form and medical interventions and procedures offered on the form, and that the form must be signed by a physician and the patient or his/her legally recognized health care decision maker.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written bed-hold information to Resident 37 when the resident was transferred to the hospital. Review of the resident’s Bed Hold Notification, dated 2/3/23, showed the resident signed the document on admission, but the section titled “To be Completed upon Transfer” was left blank. The facility’s policy titled “Bed Hold Notice,” dated 7/2025, stated that the facility shall inform the resident or resident’s representative in writing of the right to exercise the bed-hold provision at the time of admission and at the time of transfer for hospitalization or therapeutic leave. Resident 37’s progress notes dated 10/11/25 documented that the resident was drowsy, had unusual weakness, low oxygen saturation, and an elevated heart rate and temperature, and was transferred to the hospital. Further evaluation at the hospital showed a kidney infection, and the resident was later discharged back to the facility. During interview, the Registered Nurse Supervisor stated that nurses send residents to the hospital with a copy of the face sheet and medication list, and that residents are informed of the bed-hold policy during the admission process, with those records kept in medical records.
Failure to Resubmit PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a PASRR for two sampled residents after changes in their mental health conditions. Resident 5 was admitted with a diagnosis of paranoid schizophrenia and had a level I PASRR completed before admission, with no level II required. After admission, Resident 5 was diagnosed with anxiety, PTSD, and unspecified psychosis, and the order summary showed Zyprexa was started. A repeat PASRR was not resubmitted after these new mental illness diagnoses. Resident 45 was admitted with diagnoses that included anxiety and unspecified psychosis and had a level I PASRR completed before admission, with no level II required. The resident’s care plan was later updated for psychosocial wellbeing problems/needs related to anxiety, and the order summary showed Trazadone was started. A new PASRR was not initiated after the care plan update or after the medication change. During interview, the MDS Coordinator stated PASRRs are resubmitted when there is a significant change in mental status or cognitive decline, but acknowledged that these residents did not have repeat PASRRs after changes in their mental conditions.
Care Plan Not Revised for Ongoing Dialysis Refusals
Penalty
Summary
Facility staff failed to ensure Resident 3’s care plan for noncompliance with dialysis was reviewed, evaluated for effectiveness, and revised when the resident continued to refuse dialysis treatments. Resident 3’s order summary indicated dialysis was scheduled every Tuesday, Thursday, and Saturday, and progress notes documented refusals to go to dialysis on multiple dates, including 12/24/25, 1/3/26, 1/8/26, 1/17/26, 1/20/26, 1/27/26, 2/5/26, 2/28/26, and 3/19/26. The care plan dated 5/15/24 identified that the resident was at risk for complications related to refusing dialysis. During interview and record review, the MDS nurse stated the resident had a pattern of not wanting to go to dialysis but was unable to verbalize or provide documentation showing that the care plan interventions were evaluated and revised based on the ongoing refusals. The registered nurse supervisor stated care plans are reviewed by the MDS nurse and should be reevaluated by the target date, and acknowledged that the resident’s dialysis noncompliance interventions should have been discussed with the IDT and revised if ineffective. The facility policy stated care plans are revised as resident condition changes and when the desired outcome is not met.
Missed Weekly Wound Assessments for Resident With Multiple Pressure Injuries
Penalty
Summary
The facility failed to ensure timely weekly wound assessments were completed for one resident with multiple wounds. Resident 7, a male admitted with diagnoses including acute respiratory failure with hypoxia, a stage 4 sacral pressure ulcer, abnormal blood chemistry, diarrhea, fever, pain, and hyperlipidemia, had weekly wound assessments documented for the right hip skin shear on 2/18/26, 3/3/26, and 3/10/26, but there was no weekly wound assessment documented for the week of 2/25/26. For the left buttock stage 4 pressure injury, weekly wound assessments were documented on 2/10/26, 2/17/26, 2/24/26, and 3/10/26, but there was no weekly wound assessment documented for the week of 3/3/26. During a concurrent interview and record review, the Infection Preventionist and the Wound Nurse both acknowledged that the weekly wound assessments were not initiated for the right hip wound during the week of 2/25/26 and for the left buttock wound during the week of 3/3/26. The facility policy stated that wound assessment data such as wound bed color, size, drainage, odor, and pain were to be documented weekly by the wound nurse or designee.
Expired Medications, Improperly Labeled Supplies, and Out-of-Range Medication Refrigerator
Penalty
Summary
Expired medications and supplies were found in multiple storage areas and treatment carts, and several items were available for use despite being past their expiration dates or beyond their allowed open-use period. In the respiratory storage room, a box of acetaminophen suppositories and an opened bottle of acidophilus probiotic were found expired inside the refrigerator, and multiple respiratory supplies were also expired, including a non-rebreathing mask, sterile water for irrigation, an enteral feeding syringe, a female catheter adapter, a full suction kit, disposable exhalation ports, a nasal oxygen cannula, flex trach adaptors, an airway adapter, tubing, and a tracheostomy tray. In the station 3 medication storage room, two opened bottles of acidophilus probiotic and a box of pen needles were also found expired. Treatment cart inspections showed additional expired or improperly handled items. On Treatment Cart 1, a single-use skin barrier ointment, a half-empty bottle of normal saline labeled not to reuse, and an opened hydrogel that was past its open-date period were present. On the sub-acute unit treatment cart, two opened Santyl ointments, an ammonium lactate cream, and silver sulfadiazine were available without an open date recorded, and a partially empty 100 mL normal saline irrigation bottle remained available for use after opening. On station 3 treatment cart, zinc oxide ointment was opened, a ViaLok vial access device was expired, two ammonium lactate lotions were expired and no longer matched the facility census, a one-time use normal saline irrigation bottle was present, and two DeCloggers showed signs of prior use and contamination even though the instructions for use stated they were single-use only. The station 3 medication refrigerator temperature was also found outside the acceptable range during multiple observations. The temperature was first observed at 56 F, then later at 46 F, and later the thermometer was found inside the freezer at 24 F. The refrigerator temperature log for March showed temperatures between 37 F and 40 F for earlier dates, but the temperature was not recorded on 3/18/26. Staff acknowledged the out-of-range temperatures and the improper placement of the thermometer, and the refrigerator remained outside the acceptable range during later checks.
Ice machine not maintained in clean condition
Penalty
Summary
The facility failed to maintain the ice machine in a clean and safe operating condition. During an observation and inspection of the ice machine in the kitchen on 03/18/26 at 2:36 pm, a white tissue test was performed on the lower stainless steel bin inside the machine. After wiping the base of the bin, the tissue contained a minimal amount of greyish-black residue, and repeating the procedure further back into the bin also showed minimal greyish residue. The Dietary Manager, Maintenance Representative, and Dietician validated the findings. During interview, the Maintenance Representative stated he had cleaned the parts of the ice machine and inspected water flow where mineral scale or limescale build up occurs, but said he must have missed cleaning the other parts of the ice machine. Review of the Ice-O-Matic Service and Installation Manual dated 01/14 showed that stainless steel should be cleaned thoroughly once a week, and review of the facility's Ice Machine Cleaning Procedure stated that the inside of the machine should be cleaned with a sanitizing agent per the manufacturer's instructions and that special attention should be paid to the door molding and lid of the machine.
Infection Control Failures With PPE, Oxygen Tubing, and Single-Use Supplies
Penalty
Summary
Infection prevention and control practices were not followed when staff failed to use the required enhanced barrier precautions for residents receiving high-contact care. Resident 1 had orders dated 02/18/26 for enhanced barrier precautions due to a Foley catheter and G-tube every shift, and during an observation on 03/18/2026, an LVN and a CNA were providing tube feeding in the activity room while wearing gloves but not the appropriate protective equipment. During interviews, staff stated they would normally bring the resident back to the room and wear appropriate PPE, and the DON stated that infection control practices and dignity must be practiced for all residents. Resident 2 was also observed during a blood sugar check without a gown while on enhanced barrier precautions. The LVN performing the check stated only gloves were required because the blood sugar check was not a high-contact care process. The Infection Control Nurse later stated that any direct contact with a resident on enhanced barrier precautions requires a mask, gloves, and gown. Additional infection control issues were identified with resident equipment and supplies. Resident 25’s oxygen tubing was observed labeled 3/4 on 03/17/26, and later labeled 3/18 on 03/20/26; staff stated oxygen tubing is changed weekly, and RN 3 and RT 1 acknowledged the tubing had not been changed in a timely manner. Surveyors also found a partially empty 100 mL normal saline irrigation bottle in a treatment cart with an open date of 3/18/26, and open one-time-use supplies including two DeCloggers with signs of prior use or contamination. Staff acknowledged the saline bottle and DeCloggers should not have been available for reuse, and the DeClogger IFU stated it should be disposed of after a single use.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for three residents, leading to unmet needs. Resident 35, whose preferred language is Spanish, was not provided with a Spanish-speaking interpreter for communication with healthcare staff, despite expressing a desire for one. The MDS Coordinator confirmed the absence of a care plan addressing this communication need, and the Director of Nursing acknowledged the oversight. Resident 11, who has dementia and a history of repeated falls, was observed with tab alarms on his wheelchair and bed. However, there was no documented care plan addressing the use of these alarms. The Director of Nursing confirmed the lack of a care plan for the alarms, which is contrary to the facility's policy on managing falls and fall risks. Resident 47, who is quadriplegic and has multiple medical conditions, was found with a push button call light that was not within reach and inappropriate for his condition. The Director of Nursing acknowledged that a more suitable call light, such as a pad alarm, should have been assessed and provided during the admission process. This oversight was not in line with the facility's policy on ensuring accessible call lights for residents.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to meet professional standards of quality care in several instances, as observed through a combination of interviews, record reviews, and direct observations. One significant deficiency involved the administration of supplemental oxygen to a resident without a physician's order. The resident, who was admitted with COVID-19 and an acute cough, was observed receiving oxygen therapy, yet there was no documented physician order for this treatment. This oversight was acknowledged by the Assistant Director of Nursing during a review of the resident's medication records. Another deficiency was noted in the administration of Acetylcysteine for a resident with acute and chronic respiratory failure. The resident reported not receiving the medication as scheduled, and the respiratory therapist confirmed that the medication was unavailable due to a delay in pharmacy delivery. Additionally, the therapist admitted to documenting the administration of the medication at a time different from when it was actually given, to avoid alert flags in the medical record system. This practice was contrary to the facility's policy, which requires medications to be administered and documented according to the physician's orders. Furthermore, the facility failed to administer insulin according to the physician's sliding scale orders for a resident with type 2 diabetes. The resident's medication administration records showed multiple instances where insulin was either not given or administered outside the prescribed time frame. The Assistant Director of Nursing confirmed these discrepancies, which were not reported to the physician as required by the facility's policy. These failures in medication administration and documentation highlight significant lapses in adhering to professional standards and physician orders, potentially impacting resident care and safety.
Pharmaceutical Services Deficiencies in Medication Management
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding pharmaceutical services, leading to several deficiencies. During an inspection of the medication storage room on Unit 3, it was found that sharps waste was not disposed of according to the facility's policy. Specifically, syringes with needles attached were improperly placed in non-controlled waste containers that were open and not sealed. The facility's Infection Prevention Nurse confirmed that this was against the policy, which requires used syringes and needles to be disposed of in puncture-resistant containers with lids. Additionally, the facility did not replace Emergency Drug supplies (E-Kits) within the required timeframe. An Antibiotic E-Kit had been opened and not replaced for eight days, and a Narcotic E-Kit had been opened for twelve days without replacement, both exceeding the 72-hour replacement policy. Furthermore, expired medications were found in the Director of Nursing's medication storage room, including Ceftazidime vials that were eight months past their expiration date. The facility also failed to administer medications in accordance with its policies. Medication nurses were administering medications outside the prescribed time window due to workload issues, such as handling admissions and resident falls, which led to early medication passes. This practice was contrary to the policy that requires medications to be administered within one hour of the scheduled time. Additionally, medications were not immediately documented in the Medication Administration Record (MAR) after administration, as nurses were entering data after completing their rounds to avoid system flags for early administration entries.
High Medication Error Rate Observed
Penalty
Summary
The facility was found to have a medication error rate of 17.7%, significantly exceeding the acceptable threshold of 5%. This was determined through observations of medication passes conducted by two LVNs, where 8 errors were identified out of 45 opportunities. One notable error involved an LVN administering Divalproex DR 250 mg to a resident by crushing the tablet, despite the manufacturer's instructions indicating that the delayed-release formulation should be swallowed whole. This alteration in the medication's delivery method constituted a medication error. Additional errors were observed during medication passes involving other residents. One LVN failed to administer five prescribed medications to a resident, as confirmed during an interview where the nurse could not recall giving these medications. Another error involved the incorrect administration of Testosterone Gel and Diclofenac Sodium cream to a resident, where the dosage did not match the physician's orders. These errors contributed to the high medication error rate observed at the facility.
Improper Installation and Maintenance of PACUs
Penalty
Summary
The facility failed to ensure the proper installation and maintenance of portable air conditioning units (PACUs) in 12 rooms. Observations revealed that the exhaust hoses of the PACUs were duct taped to window frames, rendering the windows inoperable. The slider kits provided with the PACUs were too short for the facility's window size, leading to the use of cardboard to fill gaps and duct tape to secure the installation. This improper installation could prevent windows from being opened in emergencies, such as a fire. Additionally, the facility did not adhere to the manufacturer's guidelines for cleaning the air filters of the PACUs. The Maintenance Supervisor (MS) admitted to cleaning the air filters every three months, contrary to the manufacturer's instructions, which required cleaning every two weeks. The MS was unaware that each PACU had two filters and lacked documentation or a tracking method for filter maintenance. This oversight could lead to poor air quality due to dust accumulation, affecting the performance of the air conditioning units.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) assessed a resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate. This deficiency was identified for one of the twenty sampled residents, referred to as Resident 51. During an observation and interview, it was found that Resident 51 had two vials of DuoNeb, a medication used for breathing treatments, in his drawer and stated that he administered the medication himself. However, the Licensed Nurse (LN 1) confirmed that the resident was not allowed to self-administer the medication, indicating a lapse in the facility's protocol. The Director of Nursing (DON) confirmed that an IDT meeting is required to authorize a resident to self-administer medications, along with a physician's order. It was acknowledged that no such meeting had taken place for Resident 51. The facility's policy and procedure on self-administration of medications, revised in February 2021, mandates that the IDT assess each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administration. The failure to conduct this assessment for Resident 51 led to the resident having unauthorized access to medication, which could result in incorrect medication administration.
Failure to Update Survey Results Binder
Penalty
Summary
The facility failed to maintain the most current survey results in the survey results binder accessible to the public. During an observation and interview with the Director of Nursing (DON) at the facility's main entrance, it was found that the most recent survey results available in the binder were from May 22, 2024. The binder lacked survey results from August 8, 2024, through February 19, 2025. The DON acknowledged that the survey results binder was not up-to-date. According to the facility's policy and procedure titled 'Survey Results, Examination of,' a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, and state-approved plans of correction for noted deficiencies, should be maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room hallway.
Inaccurate MDS Assessments for Language and Functional Status
Penalty
Summary
The facility failed to accurately assess two residents using the Minimum Data Set (MDS), leading to the reporting of inaccurate data to the Centers for Medicare & Medicaid Services (CMS). Resident 35's language assessment was incorrect, as the MDS indicated no need for an interpreter, despite the resident's primary language being Spanish and their expressed desire for an interpreter to discuss their care plan. This discrepancy was acknowledged by both the MDS Coordinator and the Director of Nursing during interviews. Resident 39's functional status assessment was also inaccurate. The MDS coded no impairment in the resident's upper and lower extremities, contrary to an occupational therapist's assessment indicating impairments. This error was similarly acknowledged by the MDS Coordinator and the Director of Nursing. The facility's policy requires the interdisciplinary team to gather accurate data for the MDS, but this was not adhered to in these cases.
Medication Refrigerator Temperature Documentation Deficiency
Penalty
Summary
The facility failed to ensure that the medication refrigerator temperatures were documented and maintained within the required range as per the facility's policy. During an inspection of the medication refrigerator temperature logs for station 3, it was found that on December 4, 2024, the refrigerator temperature was recorded at 35 degrees Fahrenheit, which is below the facility's policy range of 36 to 46 degrees Fahrenheit. Additionally, on February 19, 2025, there was no documentation of the refrigerator temperature, leaving the facility unable to verify the actual temperature on that date. This lack of documentation and deviation from the required temperature range constitutes a deficiency in maintaining proper storage conditions for drugs and biologicals.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to adhere to its policies and procedures for labeling and dating food items, which could potentially lead to foodborne illnesses. During an observation, it was noted that six large bins containing various food items such as rice, pinto beans, and split peas had different dates but lacked information on the received date, opened date, or expiry date. Additionally, a bin labeled pasta had a date of 9/18/24 but did not indicate an expiry or open date, and contained two packs of pasta with different dates. A box containing mixed vegetables and beans had labeled delivery dates that were not specific to the packaged produce. In an interview, the Kitchen Manager and Dietician acknowledged that the labeling was not specific and should include the expiry date and/or opened date. A review of the facility's Policies and Procedures on labeling and dating foods indicated that newly opened food items should be closed and labeled with an open date and used by date according to storage guidelines.
Infection Control Deficiencies in Equipment Storage and PPE Availability
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. In Resident 4's room, a nebulizer with an attached nose mask and tubing was left exposed on a nightstand, contrary to the facility's policy that requires such equipment to be stored in a plastic bag with the resident's name when not in use. The assistant director of nursing confirmed that the nebulizer mask was not stored appropriately. Resident 4 had multiple diagnoses, including gastrostomy, dysphagia, type 2 diabetes mellitus, and hemiplegia. In Resident 27's room, oxygen tubing was found wrapped around a portable oxygen tank without a label or date, and it was not stored in a plastic bag as required by the facility's policy. The licensed nurse acknowledged the oversight. Resident 27 had acute and chronic respiratory failure, pseudomonas, chronic obstructive pulmonary disease, and a tracheostomy. Additionally, in the sub-acute unit, contact precaution signs were posted outside certain rooms, but no personal protective equipment (PPE) was available outside the rooms for use before entry, as required by the facility's Enhanced Barrier Precautions Policy.
Failure to Address Resident Council Complaints on Call Light Response
Penalty
Summary
The facility failed to document its response and resolution to recurring complaints raised by residents during Resident Council Meetings regarding the untimely answering of call lights. In December 2024, residents expressed concerns about long wait times for call lights to be answered, with reports of waits up to an hour and lights being turned off during the night shift. In January 2025, similar complaints were raised, including instances where staff attended to residents who did not use the call light and a resident having to hold her bladder longer due to delayed assistance. During a review of the Resident Council meeting minutes for December 2024 and January 2025, it was found that there was no documentation indicating that the issues raised were addressed or resolved, nor was there any record of informing residents of the outcomes. The assistant director of nursing confirmed that the minutes did not reflect any actions taken to address the concerns. The facility's policy and procedure on Resident Council, revised in November 2023, requires the use of a Resident Council Response Form to track issues and their resolution, which was not adhered to in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident who was totally dependent on staff for all activities of daily living, including repositioning, resulting in the development of a new stage 3 pressure ulcer on the resident's right buttock. The resident, who had a history of respiratory failure, tracheostomy, quadriplegia, epilepsy, and diabetes, was admitted with a stage 3 pressure ulcer on the sacrococcyx but no other pressure ulcers. However, a subsequent medical record indicated the development of a stage 2 pressure ulcer on the right hip, which later deteriorated to a stage 3 ulcer. The care plan for the resident, dated shortly after admission, identified the resident as being at risk for skin breakdown and specified that the resident should be turned and repositioned every two hours. Despite this, there was no evidence in the records that the resident was repositioned as required throughout August, and there were missing documentation for September and October. Interviews with the wound care nurse and a registered nurse confirmed that the resident was not consistently repositioned every two hours, as per the facility's policy and procedure for the prevention of pressure ulcers.
Failure to Implement Comprehensive RNA Care Plans
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for fourteen residents regarding the Restorative Nursing Assistant (RNA) program. The deficiency was identified through observation, interview, and record review, revealing that the RNA exercises were not provided as ordered for the residents. This failure was particularly evident for Resident 1, who reported that RNA exercises had not been provided since the RNA went on vacation. The review of Resident 1's RNA Flow Sheet confirmed the absence of documentation for the RNA services from 05/09/2024 to 05/21/2024, despite physician orders indicating the need for these services three times a week. Similar deficiencies were found for other residents, including Residents 4 through 16. Each resident had specific physician orders for RNA programs to maintain or improve their physical function, such as ambulation with a walker, assisted active range of motion (AAROM), and passive range of motion (PROM). However, the RNA Flow Sheets for these residents showed no evidence of the required RNA services being provided during the specified dates. For instance, Resident 4's RNA Flow Sheet lacked documentation of RNA services from 05/07/2024 to 05/21/2024, and Resident 5's RNA Flow Sheet showed no RNA services from 05/09/2024 to 05/21/2024. Interviews with facility staff, including the Director of Staff Development Assistant (DSDA) and the Director of Nurses (DON), confirmed the lack of RNA services and documentation. The DSDA mentioned that a Certified Nursing Assistant (CNA) trained as an RNA was reassigned to CNA duties on several dates, and no replacement was arranged to continue the RNA program. The facility's policies and procedures emphasized the importance of the Restorative Program in maintaining residents' optimal physical, mental, and psychological functioning, but these were not adhered to, leading to the identified deficiencies.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, resulting in an avoidable accident and injury. The resident, who had a history of falling, unspecified dementia, hemiplegia, hemiparesis, muscle weakness, and epilepsy, was supposed to have a bed alarm as part of their fall prevention strategy. However, during an observation, it was noted that the resident did not have a bed alarm in place. The resident fell and sustained a right distal femur fracture. Interviews with staff confirmed that the bed alarm was not in use at the time of the fall, and the facility's policy on fall risk and injury prevention was not followed. The resident's care plan, which included interventions such as frequent visual checks and the use of a bed alarm, was not adhered to. The facility's policy on neurological evaluations following an unwitnessed fall was also not followed. The administrator acknowledged that the bed alarm was not in use and that the facility's policies and procedures were not followed, leading to the resident's fall and subsequent injury.
Failure to Follow Physician Orders and Conduct Accurate Skin Assessments
Penalty
Summary
The facility failed to ensure nursing professional standards of care for a resident who was admitted with a history of hemi-glossectomy, post tracheostomy, and a left arm grafted site. Upon admission, the facility did not follow up with the admitting physician regarding the discharge order for the left arm wrap, which was supposed to be maintained and replaced in an outpatient clinic. This oversight led to a delay in wound consultation and eventually resulted in the failure of the skin graft, as noted by the wound doctor. Additionally, the facility did not obtain a physician's order for the removal of sutures from the resident's post-tracheostomy site. The respiratory therapist removed the sutures based on a signal from nursing staff without verifying the presence of a physician's order, which was against the facility's policy requiring written approval from the attending physician for such procedures. Furthermore, the facility did not conduct accurate skin assessments upon the resident's admission. The clinical records lacked detailed documentation of the resident's skin condition, particularly the sacro coccyx area, which was later found to have significant moisture-associated skin damage at the hospital. The absence of comprehensive skin integrity assessments and documentation contributed to the oversight of the resident's skin condition.
Inaccurate Documentation of Tracheostomy Site
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's tracheostomy site skin condition, which could lead to unmanaged skin conditions and delayed treatment. The facility's policy on surgical wound care requires assessment of surgical wound sites for signs of infection, such as skin irritation, swelling, redness, and drainage. However, the Admission Nursing Assessment noted redness around the tracheostomy stoma upon admission, and subsequent skilled charting consistently indicated redness at the stoma site. Despite this, the Respiratory Orders Administration Record showed no signs of infection from the trach site during the same period. This discrepancy in documentation was acknowledged by the Director of Nursing during an interview, highlighting the inaccuracy in the resident's clinical record. The failure to accurately document the resident's condition could potentially lead to unmanaged skin conditions and delayed treatment.
Failure to Develop and Implement Care Plan for New Symptoms
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a new onset of right leg redness and swelling requiring medical treatment. The resident, who was admitted with diagnoses including end-stage Huntington's disease, severe depression, dementia, and muscle wasting, exhibited symptoms of redness, swelling, and warmth in the right leg as noted in the Nursing Progress Notes dated 4/3/24. Despite these observations, the facility did not create or implement a care plan to address these new symptoms. During an interview with the Director of Nursing (DON) and a concurrent review of the resident's medical record on 4/16/24, the DON acknowledged the new symptoms and confirmed that no care plan had been developed or implemented. The facility's policy and procedure on care planning, dated June 2012, mandates that a plan of care should be formulated based on a comprehensive assessment of the resident within 7 days of admission and updated as needed. The failure to create a care plan for the resident's new symptoms had the potential for the resident's care needs to go unmet.
Failure to Implement Smoking Care Plan and Supervision
Penalty
Summary
The facility failed to implement the interventions of a smoking care plan and ensure adequate supervision and assistance for a resident. This resident, who had a history of traumatic brain injury, generalized muscle weakness, and flaccid hemiplegia, was found smoking by himself off the facility premises. The resident fell from his wheelchair while attempting to step up on a curb, resulting in an acute fracture of the left humerus. The resident's care plan included multiple interventions for fall risk and smoking supervision, but these were not followed, leading to the incident. During the incident, the resident was found face down with a soft helmet on, and the wheelchair was off to the side. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident should have been supervised while smoking, as per the care plan. The facility's policy and procedure for managing falls and fall risk were also not followed, as the resident was not in a supervised area when the fall occurred. The clinical records and interviews with staff highlighted the lack of adherence to the care plan and facility policies, contributing to the resident's injury.
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.
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What surveyors actually found near you
We read the 308 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fillmore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Paula Post Acute Center | 9.6 mi | ★★★★★ | 0 | 0 |
| Oakview Skilled Nursing | 11.6 mi | ★★★★★ | 2 | 0 |
| St. John's Hospital Camarillo D/p Snf | 12 mi | ★★★★★ | 0 | 0 |
| Alta Healthcare Center Of Camarillo | 12.2 mi | ★★★★★ | 0 | 0 |
| Thousand Oaks Post Acute, Llc | 12.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.