Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Manzanita Healthcare Center during CMS and state inspections, most recent first.
Carrots Prepared Outside Recipe Requirements: Food was not prepared according to the facility recipe when a staff member cooked carrots for 50 minutes, drained off the juice, and then added lemon juice, melted butter, and seasonings without adding salt. Three residents stated the food was not flavored and tasted bad, and the DS confirmed the recipe called for a 10 to 20 minute cook time and salt as part of the seasoning.
Food items in the walk-in refrigerator were found opened without labels, and several items were expired. The dietary record review also showed missing dishwasher temperature and chlorine monitoring for breakfast and lunch on two days. The DS confirmed the log was incomplete, and a NC stated dietary staff were expected to monitor dishwasher temperature and chlorine levels before each meal.
Infection prevention and control failures occurred when an LN used the same reusable tray for wound care on two residents without sanitizing it between uses, an LN repositioned a resident on EBP without wearing a gown, CNAs entered a resident on neutropenic precautions without the required gown, gloves, and mask or without a gown, and a CNA provided care to a resident with COVID-19 wearing a surgical mask instead of an N95. The IP and DON stated the expected PPE and sanitation practices, and facility policies required sanitizing reusable items between residents and using the appropriate PPE for EBP, neutropenic precautions, and COVID-19 care.
Failure to report alleged resident abuse: two residents were involved in an incident where one resident was verbally aggressive, bumped the other resident with a wheelchair, and attempted to punch him. The DON said the event was reportable and should have been reported, and the ADM stated suspected abuse must be reported within two hours per facility policy.
Psyllium husk powder was not administered in accordance with the manufacturer's instructions for one resident with constipation. An LPN prepared one tsp of the powder with an unmeasured amount of water, even though the canister directed mixing one serving with 8 oz of water. The order did not specify the liquid amount, and the LPN stated she used 100 mL each time because the order was silent on the quantity.
An LPN left prepared medications unattended on top of medication cart D while inside a resident's room administering meds. The DON observed the unsecured bubble packs, liquid med, and powdered med, and the LPN confirmed she forgot to secure them inside the cart after preparing them.
A resident with severe cognitive impairment and total dependence on staff developed multiple pressure injuries after staff failed to implement and document required interventions such as frequent repositioning, use of pressure-relieving devices, and regular skin assessments. Despite repeated indications of skin issues on inspection sheets, nursing staff did not follow up with assessments or communicate findings, and weekly summaries were not completed. The resident's wounds were only discovered upon hospital transfer, and family members were not informed of the injuries.
A resident with DM, psoriasis, severe cognitive impairment, and total dependence for care developed multiple pressure injuries after staff failed to follow the skin integrity care plan. Shower skin inspection sheets repeatedly showed redness and an open area to the posterior buttocks, but nurses did not consistently assess, document, or report the changes, and weekly nursing summaries were not completed. The resident’s orders also lacked documented repositioning and pressure-relieving device orders that were listed in the care plan. The resident was later sent to the hospital, where an unstageable sacral wound and stage II and III ischial pressure injuries were documented, with pain noted.
Multiple rooms were found to have flying insects present on beds, personal belongings, and around residents, causing ongoing disturbance and discomfort. Two residents reported the issue to staff and housekeeping without improvement, and both a nurse and the DON confirmed the infestation in four rooms. A maintenance work order had been submitted but the problem persisted, contrary to the facility's pest control policy.
A resident with moderate cognitive impairment and a history of aggression was punched by another resident with severe cognitive impairment and a pattern of physical aggression, leading to a fall and head injury. The incident was witnessed by staff, and both residents had documented behavioral issues. The event demonstrated a lack of adequate supervision to prevent accidents between residents with known behavioral risks.
The facility failed to maintain proper pharmacy services, as a nurse did not sign the medication control count sheet after administering hydromorphone to a resident, leading to an inaccurate drug count. Additionally, unused or expired controlled drugs were not properly destroyed, as pills were found identifiable in a storage container, contrary to the facility's policy.
A facility experienced a 14.29% medication error rate due to improper administration practices. An LPN crushed ER and DR tablets for a resident, contrary to orders, and omitted a prescribed medication. Another LPN failed to administer a medication due to its unavailability. The DON confirmed these errors, which violated the facility's medication administration policy.
The facility failed to store medications according to manufacturer's specifications and its own policies. A discontinued medication was improperly refrigerated, a probiotic supplement was not refrigerated as required, and a discontinued medication was found on the floor. The DON acknowledged these storage issues, which could lead to medication misuse and errors.
The facility failed to maintain the nutritive value of broccoli by cooking it for over two hours before lunch service, resulting in a mushy texture and potential nutrient loss. Observations showed broccoli was placed in the oven at 9:48 a.m., with lunch service starting at 12:22 p.m. The RD confirmed that overcooking leads to nutrient loss, and the DM's statement contradicted the observed practice. This deficiency could lead to nutrient deficiency for 96 residents.
The facility failed to maintain proper food storage and kitchen cleanliness, risking foodborne illness for 96 residents. Observations included dirty kitchen equipment, wet-stored pans, rusted pipes, a grooved cutting board, improperly sealed bulk containers, and a dusty fan. The Dietary Manager acknowledged these issues.
The facility failed to provide a refrigerator and microwave for resident use, necessary for safe food storage and reheating. Staff interviews revealed that the facility does not store or reheat food for residents, with inconsistent practices regarding how long food can be kept in rooms. The DON confirmed the absence of these facilities, contradicting the facility's policy requiring proper storage of perishable foods.
The facility failed to maintain essential kitchen equipment, including a walk-in freezer with ice build-up, a dish machine not reaching required sanitization temperatures, and a convection oven unable to achieve proper food temperatures. These deficiencies could potentially lead to foodborne illness for the 96 residents consuming facility-prepared meals.
A resident's dignity was compromised when their bilateral buttocks' sides were exposed during a hallway transfer on a shower chair. The resident, diagnosed with panic disorder, was wheeled by a CNA without proper coverage, leading to exposure in front of other residents, staff, and the resident's daughter. The DON acknowledged that the staff should have used a blanket to cover the resident during the transfer.
A resident with speech and language deficits was admitted to the facility, requiring a communication board to express basic needs. During an observation, an LN was unable to find the communication board in the resident's room, which was confirmed by the DON as a necessary tool for communication. The facility's policy emphasizes accommodating residents' limitations to promote communication.
A resident was prescribed divalproex sodium for dementia with behavioral disturbances, despite assessments showing no indicators of psychosis. The resident, who was often confused and sleepy, continued receiving the medication for nearly a year without reassessment for its necessity. Staff interviews confirmed the resident was not a danger to herself or others, and the facility's policy requires psychotropic medications to be prescribed only for specific diagnosed conditions. The facility's MD and consultant pharmacist failed to reassess the medication's use, and the DON could not explain this oversight.
A facility failed to follow infection control practices for three residents. An LPN did not change gloves during wound care for a resident with sepsis, risking cross-contamination. Another resident with a pressure ulcer received treatment without proper hand hygiene, increasing infection risk. A third resident's midline dressing was not changed for nine days, contrary to orders, risking infection. These actions compromised infection prevention efforts.
A resident with moderate cognitive impairment was physically abused by another resident, resulting in a swollen bruise on her face. The incident occurred during an argument about a secret smoking area. The cognitively intact resident admitted to the act, and the injured resident reported feeling unsafe.
Two residents experienced non-functional call lights in their shared bathroom, leading to a deficiency in resident safety and care. Despite being instructed not to use the emergency call light, the system failed to activate the hallway light or alarm. Maintenance and the DON confirmed the malfunction, which contradicted the facility's policy requiring a functional call system at all times.
A resident with schizophrenia and bipolar disorder was administered Invega, an antipsychotic medication, without documented behavior monitoring by the facility staff. The Minimum Data Set Coordinator confirmed the lack of documentation, and the DON acknowledged the oversight. The facility's policy requires monitoring of psychotropic medications, which was not followed.
A resident with dementia and significant memory problems was not assessed for elopement risk, despite being observed wandering alone and unable to return to her room. Facility staff confirmed the resident's high risk for elopement, but no assessment was completed, contrary to the facility's policy on wandering and elopements.
Carrots Prepared Outside Recipe Requirements
Penalty
Summary
Food was not prepared in a manner to maintain nutritive value for a census of 94 residents when the carrots recipe was not followed. During an interview on 4/12/26, Resident 58, Resident 50, and Resident 119 each stated that the food was not flavored and tasted bad. The residents had no memory impairment according to their MDS assessments, and their admission records showed they were admitted in 2025 or 2026. During a concurrent observation and interview in the kitchen on 4/14/26, [NAME] 1 was observed cooking carrots on the stove and stated she had placed only carrots in the pan. Later that morning, [NAME] 1 removed the carrots after cooking them for 50 minutes, drained the carrot juice, and then added a half cup of lemon juice, eight ounces of melted butter, and parsley, garlic, and herb seasoning. [NAME] 1 did not add salt. The facility's recipe for fresh carrots called for a cooking time of 10 to 20 minutes and for margarine, lemon juice, and seasonings such as salt, parsley, and other seasoning to be added after cooking; it also specified one tablespoon of salt for 96 servings. The Dietary Supervisor confirmed the recipe's cooking time, and the Nursing Consultant stated following the recipe was important to help maintain nutritive guideline and diet balance.
Food Storage and Dishwasher Monitoring Deficiencies
Penalty
Summary
Food was not stored in a sanitary manner in the facility’s dietary area. During observation in the walk-in refrigerator, opened food items were found without labels, including a pancake waffle syrup, almond extract bottles, a whipped cream bag, and a browning seasoning sauce bottle. Also observed were a lime juice bottle with an expiration date of 4/9/26 and two thickened lemon flavor water containers with best by dates of 12/5/25 and 2/25/26. The staff member present confirmed the opened items were not labeled with an open date and best by or expiration date and stated there should not have been any expired food items. The dishwasher temperature log for April 2026 was reviewed with the Dietary Supervisor, who confirmed there was no temperature and chlorine monitoring for breakfast and lunch on 4/10/26 and 4/11/26. The Dietary Supervisor stated the dishwasher log should have been monitored for each shift daily. A Nursing Consultant stated dietary staff were expected to follow dishwasher monitoring for temperature and chlorine level of 50 to 100 ppm and to monitor it daily before each meal, breakfast, lunch, and dinner. The facility policy titled, Labeling and Dating of Foods, dated 2023, stated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
Infection Prevention and Control Program Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in multiple instances involving resident care and use of personal protective equipment. During wound care for two residents with foot wounds, a licensed nurse used the same reusable tray for both treatments without sanitizing it between residents. The nurse placed wound care supplies on the tray, used it at one resident’s bedside, returned it to the medication cart without sanitizing it, and then used the same tray for the next resident’s wound dressing change. The nurse later confirmed the tray was not sanitized between the two treatments, and the Infection Preventionist and DON stated reusable equipment should be sanitized between residents. The facility also failed to follow enhanced barrier precautions for a resident with a right knee wound. The resident’s record showed enhanced barrier precautions were ordered and the care plan directed their use during high-risk care activities. During observation, an LN assisted the resident with repositioning the right leg and adjusting pillows but did not wear a gown while providing that care. The Infection Preventionist stated staff should follow infection prevention and control practices for resident safety, and the facility’s policy stated enhanced barrier precautions include targeted gown and glove use during high-contact resident care activity. In addition, staff did not use the required PPE for residents on neutropenic precautions and for a resident with COVID-19. One CNA entered a resident’s room on neutropenic precautions without a gown, gloves, or mask, and another CNA entered the same room wearing gloves and a mask but no gown while assisting with oral care and lunch tray setup. The Infection Preventionist stated staff should always wear a mask, gown, and gloves for neutropenic precautions, and the policy listed gloves, gown, and surgical masks. For the resident with COVID-19, a CNA provided ADL care while wearing a surgical mask, gown, and gloves instead of an N95 respirator; the CNA confirmed an N95 should have been used, and the Infection Preventionist stated staff were expected to wear N95, gloves, gown, and face shield or goggles for that care.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure an alleged abuse incident was reported immediately for two residents after an event in which one resident was verbally aggressive and attempted to punch the other resident. Resident 52 was admitted with a diagnosis of bipolar disorder, and Resident 41 was admitted with diagnoses including difficulty walking and generalized muscle weakness; Resident 41’s MDS dated 3/26/26 showed a BIMS score of 15 out of 15. Resident 41 stated that Resident 52 hit him with a wheelchair several times and attempted to punch him. Resident 52’s progress note documented that Resident 52 became verbally aggressive toward Resident 41 after bumping into his chair and tried to punch him. Resident 41 and Resident 52 had been roommates before Resident 41 was moved to a different room. During interviews, CNA 3 stated Resident 52 was upset and was a little aggressive toward Resident 41, and LN 4 stated she heard Resident 52 yelling at Resident 41 and saw that Resident 52 tried to punch him. The DON reviewed the progress note and stated the incident was reportable and should have been reported. The ADM stated alleged abuse or suspected abuse should have been reported to him as abuse coordinator and to officials within two hours. The facility policy stated suspected resident abuse must be reported immediately to the administrator and other officials within two hours of an allegation involving abuse.
Psyllium Husk Prepared Without Following Manufacturer Directions
Penalty
Summary
The facility failed to provide services consistent with professional standards of quality for one sampled resident, Resident 104, when psyllium husk powder was not prescribed or administered in accordance with the manufacturer's instructions. Resident 104 was admitted in March 2026 with a diagnosis of constipation with unspecified intestinal obstruction, and her order summary dated 3/27/26 included psyllium husk powder to be given twice daily for constipation. The order did not specify the amount of liquid to be mixed with each teaspoon of powder, as required by the manufacturer's directions. During observation on 4/13/26, a nurse prepared the psyllium husk powder by placing one teaspoon in a small cup and adding an unspecified amount of water before administering it to Resident 104. The resident stated the drink was too sweet. The manufacturer's instructions on the canister directed that one serving be placed into an empty glass and filled with eight ounces of water, then stirred briskly and drunk promptly. During interview and record review, the nurse stated she did not measure the amount of water used and said she used 100 milliliters each time because the order did not specify the quantity. The DON stated nurses must verify orders were accurately written and consult with the doctor or pharmacy consultant when necessary to clarify instructions so specific guidelines were followed.
Unsecured medications left on top of medication cart
Penalty
Summary
The facility failed to ensure medications were properly stored and secured when LN 3 left medications unattended on top of medication cart D during medication pass. During observation, LN 3 was inside a resident's room administering medications while two bubble packs, one bottled liquid medication, and one canister of powdered medication remained unsecured on the cart. The DON observed the situation and acknowledged that the medications were left unsecured while LN 3 was in the resident's room. LN 3 later confirmed she forgot to put the medications away after preparing them and stated she should have secured them inside the cart before entering the resident's room. The facility policy titled Medication Labeling and Storage stated that medications and biologicals are to be stored in accordance with applicable federal and state requirements and maintained in an orderly manner in cabinets, drawers, and carts.
Failure to Prevent and Assess Pressure Injuries
Penalty
Summary
A resident with significant medical conditions, including Type 2 Diabetes, severe cognitive impairment, and complete dependence on staff for activities of daily living, was admitted to the facility and identified as being at risk for developing pressure injuries. The resident's care plan and facility policies required frequent turning and repositioning, use of pressure-relieving devices for both bed and chair, regular skin monitoring, and weekly skin assessments. Despite these documented interventions, the resident's physician orders did not include repositioning protocols or pressure-relieving devices, and these interventions were not consistently implemented or documented by staff. Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) failed to properly assess, document, and communicate changes in the resident's skin condition, despite repeated markings and notations of redness and open areas on the resident's posterior buttocks on shower day skin inspection sheets. The CNAs did not label their observations clearly, and the LNs did not follow up with assessments or notify the Treatment Nurse as required. Weekly Nursing Summaries, which were intended to capture changes in the resident's health status, were not completed for the month during which the pressure injuries developed. The Director of Nursing confirmed that the process for skin assessment and documentation was not followed, and that findings were not entered into the resident's chart or treatment records. As a result of these failures, the resident developed multiple pressure injuries, including an unstageable pressure injury on the sacrum, a stage III pressure injury on the left ischium, and a stage II pressure injury on the right ischium, which were discovered upon transfer to the hospital. The responsible party and family members were not informed of the presence or severity of these wounds, despite the resident's ongoing complaints of pain. The facility's lack of adherence to its own care plans and policies directly led to the development and worsening of these pressure injuries.
Failure to Monitor Skin Changes and Prevent Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and failed to prevent new pressure injuries from developing for a resident admitted with Type 2 DM, psoriasis, severe cognitive impairment, total dependence for many ADLs, and bowel and bladder incontinence. The resident’s care plan identified altered skin integrity and included interventions for monitoring skin breakdown, using pressure relieving devices for the chair and bed, turning and repositioning frequently, and weekly skin checks. The facility’s policy also required weekly risk reassessment, individualized repositioning, and evaluation, reporting, and documentation of skin changes. Record review showed that the resident’s order summary did not include a physician order for frequent repositioning or for a pressure-relieving mattress or chair device, despite those interventions being listed in the care plan and referenced in the facility’s skin prevention policy. The resident’s shower skin inspection sheets documented repeated abnormal findings to the posterior buttocks, including shading, redness, and an open area, but the markings were not consistently labeled with words describing the findings. Nurses signed the sheets, but the interviews showed they did not consistently assess the resident’s skin, document the findings in the chart, or notify the treatment nurse as expected. The record also showed that weekly nursing summary assessments were not completed for the resident during August 2025, despite staff stating these assessments were needed to identify changes in skin condition. The treatment nurse stated the resident should have been repositioned every two hours, had skin integrity checked regularly, and had pressure-relieving devices in place. The resident was later transferred to the hospital, where the emergency department documented an unstageable sacral pressure injury, a stage III left ischial pressure injury, and a stage II right ischial pressure injury, with pain noted. The hospital physician note stated the sacral pressure injury was present on admission.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flying insects in four residents' rooms in Unit C. Observations revealed that insects were seen flying around and landing on residents' beds, personal belongings, pillows, windows, side tables, walls, and curtains. Two residents, both with the mental capacity to make their own decisions, reported ongoing disturbances from the insects, including insects crawling into their noses during sleep and persistent disruption of rest. Both residents stated that the issue had been reported to staff and housekeeping, but no improvement was noted. Staff interviews and record reviews confirmed the ongoing problem. A licensed nurse and the DON both observed and acknowledged the presence of insects in multiple rooms, and the DON confirmed that the issue affected four rooms in Unit C. A maintenance work order had been submitted as a high priority several days prior, specifically noting the presence of moths, but the problem remained unresolved at the time of the survey. The facility's pest control policy required maintaining a pest-free environment, but this was not achieved, as confirmed by staff and documentation.
Failure to Provide Adequate Supervision Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of aggression was punched in the stomach by another resident with severe cognitive impairment and a documented pattern of physical aggression. This incident caused the first resident to fall and hit her head on a metal door frame, resulting in a head laceration and visible discoloration on her shoulder. The event was witnessed by a staff member, and documentation confirmed the injury and the circumstances leading to it. Both residents involved had histories of behavioral disturbances, with one resident's care plans noting multiple episodes of physical aggression, agitation, and aggression. Staff interviews confirmed that both residents had previously exhibited aggressive behaviors. The facility's policy emphasized the importance of resident safety and supervision, but the incident demonstrated a failure to provide adequate supervision and prevent accidents between residents with known behavioral risks.
Plan Of Correction
F 689 CORRECTIVE ACTIONS FOR RESIDENTS AFFECTED BY THIS DEFICIENT PRACTICE. Resident #1 and Resident #2 were immediately separated. Two staff members re-directed Resident #2's behavior and stayed with the resident until 911 paramedics arrived. Resident #1 was assessed from head to toe, provided first aid treatment, and staff members stayed with the resident. Both residents were assessed for emotional distress and given reassurance. Both residents were transferred to the hospital for further evaluation and treatment. CORRECTIVE ACTIONS TAKEN TO THOSE RESIDENTS IDENTIFIED THAT HAVE THE POTENTIAL TO BE AFFECTED BY DEFICIENT PRACTICE. All residents with interactions with Resident #2 can be affected by this deficient practice. Upon notification of the incident, the supervisor and all licensed nurses on duty conducted rounds on all residents to determine if they had any interactions with Resident #2, and none were found. No other residents were affected by this deficient practice. SYSTEMIC CHANGES IMPLEMENTED BY FACILITY TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR. The Director of Staff Development (DSD) conducted an in-service with staff on 4/17/25 on Residents' Rights on 04/17/2025. The IDT team will assess and identify residents at least quarterly or as necessary. Residents with challenging behaviors will have their POC updated to include de-escalation techniques and strategies, and the POC will be implemented to provide adequate supervision to prevent accidents. FACILITY'S PLAN TO MONITOR THAT SOLUTIONS ARE SUSTAINED. The Social Services Director (SSD) and/or designee will be the process owner who will monitor the plan of care that is in place and is implemented to ensure all residents are safe and have adequate supervision from staff. Any trends and discrepancies will be brought to the facility's QAPI committee for review and additional guidance or recommendations. DATE CORRECTIVE ACTIONS WILL BE COMPLETED. 04/21/2025
Deficiencies in Controlled Drug Management and Destruction
Penalty
Summary
The facility failed to maintain proper pharmacy services for its residents, specifically in the management of controlled drugs. During an inspection of medication cart A, it was found that the controlled drug count for a resident's hydromorphone was inaccurate. There were 10 tablets in the medication bubble pack, while the controlled drug log indicated there should be 11. A Licensed Nurse admitted to administering the medication earlier and forgetting to sign the medication control count sheet immediately after administration, which is required by the facility's policy. Additionally, the facility did not properly destroy unused or expired controlled drugs according to its policy. During an inspection of the storage area for unused and expired controlled medications, it was discovered that pills were identifiable and not destroyed, despite being placed in a container of liquid. The Director of Nursing acknowledged that the pills were not destroyed as per the facility's policy, which requires medications to be rendered unusable in the presence of a nurse and a witness.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 14.29% error rate during a survey. Licensed Nurse 2 (LN 2) administered medications to Resident 140 incorrectly by crushing extended release (ER) and delayed release (DR) tablets, which were not supposed to be crushed according to the physician's orders and pharmacy labels. This included isosorbide mononitrate ER and pantoprazole DR tablets. Additionally, LN 2 omitted the administration of Resident 140's prescribed amlodipine tablet, which was documented as given in the Medication Administration Record (MAR) but was not observed during the medication pass. Licensed Nurse 3 (LN 3) failed to administer the correct dose of simethicone to Resident 36 due to the unavailability of the medication in the facility. The Director of Nursing (DON) confirmed that the medications were not administered as prescribed and acknowledged the errors. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed, which was not adhered to in these instances.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during inspections. A discontinued medication, cyanocobalamin, was found stored in the refrigerator, contrary to the manufacturer's specifications which required it to be stored at room temperature. The Director of Nursing (DON) acknowledged this discrepancy, confirming that all medications should be stored according to the required temperature range. Additionally, a medication cart inspection revealed that an acidophilus probiotic dietary supplement was stored at room temperature, despite the manufacturer's instructions to refrigerate it after opening. The DON confirmed that medications requiring refrigeration should be stored in a designated refrigerator. Furthermore, a discontinued medication, clonidine, was found stored under the sink on the floor in the medication storage room. The DON acknowledged that this medication was for a discharged resident and should have been given to her for destruction. The facility's policy and procedure indicated that discontinued, outdated, or deteriorated medications should be returned or destroyed as per the dispensing pharmacy's instructions. These findings highlight the facility's failure to adhere to its own medication labeling and storage policy, potentially leading to medication misuse and administration errors.
Deficiency in Maintaining Nutritive Value of Broccoli
Penalty
Summary
The facility failed to maintain the nutritive value of food, specifically broccoli, by cooking it for over two hours prior to the lunch meal service. This was observed on February 4, 2025, when a staff member placed frozen broccoli into a convection oven at 9:48 a.m., and the lunch meal service began at 12:22 p.m. The broccoli served was noted to have a light green color and a soft, limp texture, which was confirmed by five surveyors who tasted the test trays at 1:30 p.m. The Registered Dietitian (RD) confirmed that vegetables should be cooked last to preserve their vitamins and minerals, which are lost when overcooked. The Dietary Manager (DM) stated that broccoli is usually cooked 30 minutes before meal service, contradicting the observed practice. A review of the facility's recipe for seasoned broccoli indicated a cooking time of 10-20 minutes, warning against overcooking to prevent the broccoli from becoming brown and mushy. The report references external sources that support the claim that overcooked broccoli loses nutrients, which are essential for the residents' health. This deficiency had the potential to lead to nutrient deficiency for the 96 residents receiving facility-prepared meals.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as well as kitchen equipment cleanliness, which could potentially lead to foodborne illness for the 96 residents consuming meals prepared by the facility. During an initial kitchen tour, several deficiencies were observed, including dirty baking sheets, a frying pan, a container for scoops, stove knobs, a convention oven, and a mixer. The Dietary Manager (DM) acknowledged these issues, noting that the baking sheets and frying pan were old and needed discarding, and confirmed the presence of food residue on the mixer and other equipment. Additionally, the facility stored ten pans, two frying pans, and a blender while still wet, which could promote bacterial growth. The DM confirmed the wet condition of these items and acknowledged the need for them to be fully dried before storage. Furthermore, the pipes under the three-compartment sink were found rusted and dirty, with the floor and counter in the area showing discoloration and buildup. The DM was unsure of the cause of this buildup and discoloration. Other issues included a yellow cutting board with deep grooves, which could harbor microorganisms, and four bulk storage containers with lids not tightly closed, risking contamination. A fan in the dishwashing area was also found with significant dust buildup. The DM confirmed these observations and acknowledged the potential for contamination due to these deficiencies.
Lack of Resident Food Storage and Reheating Facilities
Penalty
Summary
The facility failed to provide a refrigerator and microwave for resident use, which is necessary for the safe storage and reheating of food brought by family and visitors. Interviews with staff, including Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs), revealed that the facility does not have the means to store or reheat food for residents. CNA 1 mentioned that outside food is checked against the diet order before being given to residents, and any leftover food is discarded if not consumed within two hours. However, CNA 2 stated that residents could keep food in their rooms for up to 24 hours before it is discarded, indicating inconsistency in practice. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that there has never been a refrigerator or microwave available for residents. The facility's policy on foods brought by family or visitors, dated March 2022, specifies that perishable foods should be stored in resealable containers with tightly fitting lids in a refrigerator, and potentially hazardous foods left out for more than two hours should be discarded. The lack of proper storage and reheating facilities potentially limits residents' food options and enjoyment of favorite foods, as well as possibly contributing to weight loss.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which could potentially lead to foodborne illness for the 96 residents consuming meals prepared by the facility. The walk-in freezer was observed with significant ice build-up on the ceiling, walls, and fan unit, indicating potential temperature fluctuations. Despite maintenance efforts to remove the ice, the issue persisted, with high condensation and poor visibility noted during subsequent observations. The Environmental Services Director acknowledged the ice build-up, and the Registered Dietitian confirmed that such conditions could affect food quality and cause freezer burn. The dish machine used for sanitizing dishes was not reaching the required minimum temperatures for both the wash and rinse cycles. During multiple observations, the wash temperature gauge did not exceed 140 F, and the rinse temperature gauge failed to reach 180 F, as required by the facility's sanitization policy. The Dietary Manager confirmed the temperature discrepancies and indicated that the dish machine repair company would be contacted to address the issue. Additionally, the convection oven was not achieving the desired food temperature for pork entrees, which were found to be below the required 165 F before meal service. Despite attempts to reheat the pork in the convection oven, the temperatures remained insufficient until the pork was transferred to the stove. The Dietary Manager and staff confirmed the temperature issues, and it was noted that a repair company was called to fix the convection oven after the dinner meal service.
Resident Dignity Compromised During Hallway Transfer
Penalty
Summary
The facility failed to maintain respect and dignity for a resident when the resident's bilateral buttocks' sides were exposed in the hallway during a transfer. This incident involved a resident who was admitted to the facility with a diagnosis of panic disorder. During an observation and interview, it was noted that a Certified Nursing Assistant (CNA) was wheeling the resident on a shower chair in the hallway, and the resident's gown did not cover their bilateral buttocks' sides, exposing them to other residents, staff members, and the resident's daughter. The resident's daughter expressed concern about the respect and dignity issue due to the exposure. The Director of Nursing (DON) acknowledged that staff should have covered the resident with a blanket during the transfer to prevent exposure.
Failure to Provide Communication Board for Resident with Speech Deficits
Penalty
Summary
The facility failed to provide an appropriate communication method for a resident with speech and language deficits, identified as Resident 70. Upon admission in 2024, Resident 70 was noted to have these deficits, necessitating the use of a communication board to express basic needs. During an observation and interview, it was found that Licensed Nurse 7 (LN 7) was unable to locate a communication board in Resident 70's room, which hindered effective communication. LN 7 confirmed the absence of the communication board, which should have been available to assist Resident 70. The Director of Nursing (DON) also acknowledged that the communication board should have been present in the resident's room to facilitate communication. The facility's policy on accommodating individual needs emphasizes the importance of promoting communication by accommodating residents' physical or sensory limitations.
Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to keep a resident free from unnecessary psychotropic medication, specifically divalproex sodium, which was prescribed for an inadequate indication. The resident, a 78-year-old individual with diagnoses including worsening disease of the nervous system, anxiety, depression, and dementia with behavioral disturbance, was receiving divalproex sodium for dementia with behavioral disturbances manifested by hallucination. However, the resident's assessments indicated severely impaired cognition without indicators of psychosis, such as hallucinations or delusions. The resident's care plan noted a risk for falls and injury, and observations revealed the resident was often confused and sleepy, taking extended time to consume meals due to drowsiness. Interviews with staff, including a home health aide and a CNA, confirmed the resident was not a danger to herself or others and did not exhibit combative or hallucinatory behavior. Despite this, the resident continued to receive divalproex sodium over a period of almost a year, with no reassessment for its necessity or appropriateness for treating dementia. The facility's policy on psychotropic medication use requires that such medications are only prescribed when necessary to treat a specific diagnosed condition. However, the facility's MD and consultant pharmacist did not reassess the resident for the unnecessary use of divalproex sodium, which is not FDA-approved for treating dementia. The Director of Nursing was unable to explain why this reassessment had not occurred, highlighting a failure in adhering to the facility's policy and procedure regarding psychotropic medication use.
Infection Control Failures in Wound Care and Dressing Changes
Penalty
Summary
The facility failed to adhere to infection control practices during wound care treatment for three residents. Licensed Nurse 6 (LN 6) did not change gloves during the wound care treatment for Resident 441, who was admitted with a diagnosis of sepsis and had a left buttock wound. LN 6 placed trash bags next to the wound and touched the soiled dressing in the trash bag before touching the wound dressing without changing gloves or performing hand hygiene. This was confirmed by LN 6, who acknowledged the risk of cross-contamination and potential wound infection. For Resident 69, who was admitted with severe sepsis and had a stage three pressure ulcer on her tailbone, LN 6 failed to follow proper handwashing and glove-changing procedures. LN 6 used gloved hands to wash the unclean pressure ulcer and then applied medicated cream and dressing covers without changing the contaminated gloves. LN 6 admitted awareness of the need to change gloves and wash hands when moving from a contaminated to a clean body site, acknowledging the increased risk of infection due to improper hand hygiene. Resident 290, admitted with multiple diagnoses including sepsis and acute kidney failure, had a midline dressing on the left upper arm that was soiled and not changed for nine days. The dressing, dated 1/25/25, showed dark-colored drainage around the insertion site. Despite an order to change the dressing weekly or as needed if soiled, the dressing was not changed on the seventh day as required. Licensed Nurse 8 confirmed the oversight, and the Director of Nursing acknowledged the failure to follow the physician's order and facility policy, which could lead to a central line-associated bloodstream infection.
Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck her in the face. Resident 1, who was admitted with an irregular heartbeat and had a moderately impaired cognitive function, reported feeling unsafe after being hit by Resident 2. Resident 2, who was cognitively intact and admitted with spinal stenosis, admitted to slapping Resident 1 during an argument about a secret smoking area. The incident resulted in Resident 1 sustaining a swollen bruise on her face. The incident was documented in an SBAR Summary, which noted the physical injuries sustained by Resident 1. Interviews with the Assistant Director of Nursing and the Social Services Director confirmed that Resident 2 admitted to the act and did not deny the incident. The Social Services Director also observed the physical injuries on Resident 1 two days after the incident. The failure to prevent this incident resulted in Resident 1 feeling unsafe in the facility.
Non-Functional Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning call light system for two residents, leading to a deficiency in ensuring resident safety and care needs. Resident 3, who was admitted with a fracture of the right femur and had a BIMS score indicating cognitive intactness, reported that the call lights in their room were not working on the first night. Similarly, Resident 4, admitted with a rib fracture and a BIMS score indicating moderate cognitive impairment, also experienced non-functional call lights. Both residents were instructed by staff not to use the emergency call light in the bathroom, as it would render the room call lights inoperative. During an inspection, it was confirmed that the emergency bathroom call light did not activate the hallway light or alarm, as observed by the maintenance staff and the Director of Nursing. The facility's policy mandates that each resident should have a functional call system at all times, especially in toileting and bathing areas. The maintenance staff acknowledged the malfunction and recognized the urgency of the issue, while the Director of Nursing confirmed the expectation for the call light system to be operational to ensure residents' needs are promptly addressed.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide care according to accepted standards of quality for a resident who was prescribed an antipsychotic medication, Invega, for schizophrenia. The resident was admitted with diagnoses including schizophrenia and bipolar disorder. Despite the administration of the medication by a nurse from a psychiatric clinic, there was no documented behavior monitoring by the facility staff to assess the effectiveness and side effects of the medication. During a review of the resident's records, it was confirmed by the Minimum Data Set Coordinator that the antipsychotic medication was administered, but there was no documentation of behavior monitoring. The Director of Nursing acknowledged that the medication order should have included proper monitoring for targeted behavior and side effects. The facility's policy on psychotropic medication use requires that such medications be clinically indicated and monitored, which was not adhered to in this case.
Failure to Assess High-Risk Resident for Elopement
Penalty
Summary
The facility failed to assess a resident at high risk for elopement, which increased the risk of the resident wandering unsafely. The resident, admitted in May 2024 with unspecified dementia and behavioral disturbances, had a BIMS score of 4 out of 15, indicating significant memory problems. Despite being able to transfer and ambulate independently with a walker, the resident was observed wandering alone in the hallways without a walker and unable to return to her room without assistance. The resident also exhibited behaviors of wandering and expressed confusion, wanting to go outside to park her car. Interviews with facility staff, including the MDS Coordinator, Social Services Director, and Director of Nursing, confirmed that the resident was at high risk for elopement and should have been assessed properly. However, there was no record of an elopement assessment being completed for the resident. The facility's policy on wandering and elopements, revised in March 2019, requires identifying residents at risk for unsafe wandering and including strategies and interventions in their care plan to maintain safety, which was not adhered to in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 729 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sacramento Post-acute | 0.5 mi | ★★★★★ | 16 | 0 |
| College Oak Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 14 | 1 |
| American River Center | 2 mi | ★★★★★ | 12 | 0 |
| Eskaton Village Care Center | 2.1 mi | ★★★★★ | 13 | 0 |
| Whitney Oaks Care Center | 2.6 mi | ★★★★★ | 6 | 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.