Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission De La Casa during CMS and state inspections, most recent first.
COVID-19 outbreak control failures in Station AA: staff did not have Transmission-Based Precaution signage or an isolation cart at the unit entrance, PPE use in the hallway was inconsistent, resident room doors were left open, and group activities were held in the hallway with residents seated close together and without masks. The IP confirmed the outbreak was not timely reported to CDPH, and the unit included multiple COVID-positive residents, including one resident transferred to acute care with fever, vomiting, and low O2 saturation.
Unqualified oversight of food and nutrition services: The facility failed to have a qualified, full-time person managing day-to-day dietetic services. The RD stated she handled clinical nutrition only and did not oversee kitchen operations, while the ED and ADS were supervising the kitchen, handling scheduling, vendors, equipment, and staff evaluation despite not meeting the qualification pathways in HSC 1265.4(b). The org chart showed dietary staff reported to the Dietary Services Supervisor, but that role was filled by staff who were not qualified.
Food service staff lacked the competency to perform key sanitation and temperature-monitoring tasks. The ADS incorrectly demonstrated how to test quaternary ammonia sanitizer at the three-compartment sink, first using the test strip improperly and initially reading the solution as 200 ppm before correctly following the strip instructions and obtaining a reading closer to 100 ppm. Cook C also misidentified acceptable thermometer calibration readings in ice water, stating that 28.5 degrees F was acceptable, while the ADS confirmed that 28 degrees F was too low and 33.1 degrees F was not acceptable. Facility policy required thermometers to read 32 degrees F during ice point calibration.
Food storage and sanitation issues were observed in the kitchen, including leftover pork kept in the walk-in cooler instead of being discarded, expired raw turkey loaves left in refrigeration, and a one-door refrigerator holding food and milk above the required temp. Staff also found several tofu containers past their use-by date and 4 of 12 knives in the knife rack with grime. Interviews confirmed the pork should not have been saved, expired items were not being checked daily, and the knife rack should contain only clean utensils.
Failure to Store Perishable Food Brought by Visitors: The facility did not store residents’ personal perishable food brought in by family or visitors. An LVN stated such food had to be consumed or discarded within a short time, and if a resident wanted it later, the family would need to take it home and bring it back. The RD said the facility lacked enough refrigerators for resident food, and the Administrator confirmed the facility did not store personal perishable food. Visitor signage and the facility’s food policy also stated outside food had to be reviewed by nursing and consumed during the visit or discarded.
Unclean Outdoor Waste Collection Area: Surveyors observed the outdoor waste collection area with a compost/organics container leaking dark yellow-brown liquid onto the concrete for about 20 feet, with a strong foul odor and runoff in front of a recyclable items container. The ED acknowledged the area was unclean and needed power washing, and the facility policy required garbage and refuse containers to be maintained in good condition and sanitary condition with lids covered.
A resident with schizophrenia had no care plan for that diagnosis, and multiple residents with bed rails had no person-centered care plans or had care plan interventions that were not carried out. Staff confirmed that several residents had bed rails in place, that quarterly re-evaluations were not completed as planned, and that one resident’s bed rail care plan had been resolved even though continued use remained.
Failure to review and update bed rail care plans quarterly for multiple residents. Surveyors observed bed rails in use for numerous residents with diagnoses including DM, dementia, HF, osteoporosis, Parkinsonism, fractures, anemia, CKD, and hemiplegia. RN and UM interviews confirmed several care plans were initiated but not revised quarterly, and some had not been updated since the original entry or an earlier revision.
A resident with diabetes had BG checks and sliding-scale insulin given before breakfast and earlier than the meal schedule, and the chart lacked documented monitoring for hyperglycemia or hypoglycemia. In addition, three residents had bedrails or positional bars in use without a physician order, including one resident whose prior order had been discontinued and two residents with bilateral bedrails up without an order.
Bed rail use was not properly documented for multiple residents. Staff confirmed that two residents had bed rails in place without a prior entrapment risk evaluation, many residents had no documentation that alternatives were offered or tried before the rails were used, numerous residents did not have quarterly re-evaluations as required by the care plan, and two residents had no consent on file for bed rail use.
PASARR Screening Not Accurately Completed for A resident with Mental Health Diagnoses. The facility failed to complete an accurate PASARR Level I screening for a resident with vascular dementia, MDD, bipolar disorder, and anxiety disorder. The record showed behaviors including verbal and physical aggression, and staff confirmed the only PASARR Level I on file had skipped required sections and no additional screening was completed after the resident remained in the facility beyond 30 days.
The facility failed to follow its P&P for one resident with schizophrenia when it did not have an order to monitor behaviors related to the resident's mental illness. The DON stated the resident should have had behavioral monitoring because of the diagnosed mental illness, and the facility policy describes behavioral interventions and evaluation of new or worsening changes in condition.
Inconsistent Fortified Diet System: A resident with a stage 4 pressure ulcer and poor intake was ordered a fortified minced and moist diet, but trayline staff and dietary leadership gave conflicting accounts of what the diet included. The resident’s tray ticket did not reflect fortified milk or whipped topping, and staff alternately described the diet as including butter, fortified milk, Super Cereal, or the Special Nutrition Program. The RD confirmed the diet was ordered because the resident needed more calories for poor intake and wound healing.
Menus were not followed during lunch tray service when one resident received a mixed fruit cup instead of the 1 fresh apple listed on the menu, and another resident received tarter sauce even though the menu called for mayonnaise as the substitution. During tray line observation, kitchen staff and the ADS confirmed the tray items did not match the menu or tray ticket instructions.
Laundry staff failed to keep the dryer lint compartment and lint trap cleaning log routinely maintained. During observation, the dryer lint compartment contained lint fibers, and the ED stated lint traps were to be cleaned every 2 hours. Record review showed multiple missing signatures on the lint trap cleaning log, and both the ED and IP confirmed the entries should have been completed by laundry staff. The facility policy required routine cleaning and documentation to prevent lint accumulation in dryers and exhaust ducts.
Kitchen Fly Infestation and Delayed Pest Response: Staff observed multiple flies in the kitchen, including on food prep items and around prepared food, with a later count of about 152 flies. An ADS reported the flies had been present for about a week and had been reported to the ED, but pest control was not contacted right away because the facility first conducted an internal investigation. The IP was unaware of the issue, and the pest control contract did not include fly treatment as part of routine service.
The facility failed to sanitize a food thermometer between measuring temperatures of different food items, potentially affecting all residents receiving meals. Despite policies requiring sanitation to prevent cross-contamination, a staff member did not follow these procedures, as confirmed by interviews with the Dietary Supervisor, DON, and Administrator.
The facility failed to ensure accurate Level I PASARRs for two residents, leading to deficiencies in reflecting their mental health diagnoses. One resident's PASARR did not include their depression and psychotic disorder, while another's omitted PTSD. Staff interviews confirmed the inaccuracies, emphasizing the importance of accurate PASARRs for proper care and placement.
A facility experienced an 8% medication error rate due to underdosing two residents. An LVN failed to administer the correct dosages of sertraline and memantine, as per physician orders, affecting residents with depression and dementia. The errors were acknowledged by the LVN and confirmed by the RN and DON, highlighting a failure to follow the facility's medication administration policy.
A resident with a high risk for falls and requiring extensive assistance was left unsupervised in her wheelchair, resulting in a fall and fatal subdural hematoma. Despite documented needs for close monitoring, staff failed to provide adequate supervision, leading to the resident's death.
COVID-19 outbreak control failures in Station AA
Penalty
Summary
The facility failed to implement infection prevention and control measures during a COVID-19 outbreak in Station AA, a COVID-19 designated and locked dementia unit. On 8/11/2025, surveyors observed that there was no Transmission-Based Precaution signage posted at the double doors to Station AA and no isolation cart was present before entry into the unit. The infection preventionist confirmed there was no signage at the entrance indicating PPE use prior to entry, and stated visitors were only wearing face masks when entering Station AA and were expected to don gowns, face shields, and gloves only before entering a resident room. The county communicable disease investigator stated that, because of the increasing number of positive residents, positive residents had been transferred to Station AA to contain them. Surveyors observed inconsistent PPE use by staff assigned to Station AA and observed resident room doors left open. Activity aides and restorative staff were seen wearing varying combinations of N95 masks, face shields, and gowns while moving through the hallway, and some staff were observed wearing only N95 masks while passing wandering residents. The infection preventionist stated staff in Station AA should protect themselves by wearing PPE in the hallway, while the activity supervisor stated the aides were not instructed to wear gowns and face shields in the hallway. Multiple resident rooms with Transmission-Based Precaution postings were observed with doors open, including rooms where residents were in bed, asleep, or not in the room. One resident was observed walking out of the room without a face mask, and another resident was seated outside the room while positive for COVID-19. RN staff confirmed residents with COVID-19 infection should be encouraged to wear face masks when out of their rooms and that their doors should remain closed. Group activities were also observed in the hallway in Station AA. Two activity aides provided group activities to three residents seated close together in the hallway, and the residents were without face masks. The activity supervisor stated activities should be provided inside the rooms of residents with COVID-19 infection and that group activities should have been cancelled during the outbreak. The infection preventionist also stated there should be no activities outside resident rooms during the outbreak. The report further states that the facility failed to timely report the COVID-19 outbreak to CDPH; the infection preventionist confirmed the outbreak was not reported, despite multiple residents and staff testing positive across several stations. The outbreak involved numerous residents from Station AA and other stations, and included a resident transferred to an acute care hospital due to fever, vomiting, and low oxygen saturation.
Unqualified oversight of food and nutrition services
Penalty
Summary
The facility failed to have qualified, full-time oversight of Food and Nutrition Services in accordance with State requirements. The deficiency was based on interview and document review showing that the Registered Dietitian did not perform the day-to-day management and supervision of dietetic services described in the job description, and the staff placed in charge of supervising the kitchen were not qualified under California requirements. During an observation and interview, the Environmental Director and the Assistant Dietary Supervisor were found in the supervisor office in the kitchen. The Environmental Director stated she was the kitchen supervisor, but also said she was responsible for Central Supply, Housekeeping, and Maintenance. The Assistant Dietary Supervisor stated she helped supervise the kitchen. The Administrator later stated the Registered Dietitian did not oversee the day-to-day operation of the kitchen and that the Assistant Dietary Supervisor oversaw it, but was not qualified. The Registered Dietitian stated she handled clinical nutrition only and completed a monthly sanitation checklist in the kitchen. The Environmental Director stated she had a supervisor role in the kitchen, including staff scheduling, contacting vendors, ordering equipment, and overseeing needed items, and that she and the Assistant Dietary Supervisor evaluated kitchen staff quality of work. The Administrator also stated the Registered Dietitian was in charge of all Food and Nutrition Services, but later acknowledged that the Assistant Dietary Supervisor and Environmental Director did not meet any of the qualification pathways listed in HSC 1265.4(b). The facility organization chart showed the Dietary Services Supervisor reported to the Registered Dietitian and Administrator, and dietary staff reported to the Dietary Services Supervisor, with handwritten names for the Dietary Supervisor and Registered Dietitian positions.
Food Service Staff Lacked Competency in Sanitizer Testing and Thermometer Calibration
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. During observation and interview in the kitchen, the Assistant Dietary Supervisor (ADS) tested the sanitizing solution used for wiping kitchen surfaces at the three-compartment sink. ADS poured sanitizer from the tube dispenser into a container, used a test strip, and initially dipped and moved the strip in the solution for more than 5 seconds before reading the color chart. ADS stated the strip matched 200 ppm, but when asked to follow the instructions on the test strip container, ADS verbalized that the strip should be dipped for 1 second and then repeated the process, after which the strip color was closer to 100 ppm. ADS stated the vendor would need to be notified. The report also documented that Cook C was unable to accurately identify the acceptable calibration temperature for thermometers in an ice water solution. During observation, Cook C placed four thermometers in ice water and recorded readings of 32, 33.1, 32.4, and 28.5 degrees F. Cook C stated that 32 degrees F or lower was acceptable and identified 33.1 degrees F as unacceptable, but confirmed that 28.5 degrees F was acceptable. When the ADS reviewed the readings, ADS stated that 28 degrees F was too low and required supervisor notification, that 33.1 degrees F was not acceptable, and that 32 degrees F was acceptable. ADS also confirmed not knowing how to calibrate the thermometers. Facility policy titled Calibrating the Thermometer, last revised January 2025, stated thermometers shall register +/- 1 degree F from 0-230 F and described ice point calibration procedures, including placing the probe in ice water, waiting about 30 seconds, and calibrating the thermometer until the dial reads 32 degrees Fahrenheit. The policy also stated that if a thermometer does not permit calibration and the temperature reading exceeds or does not reach temperature accuracy, the thermometer shall be removed from service. ADS stated thermometers are calibrated by cooks every Monday or Tuesday at around 5:30 AM, and the facility census at the time was 151, with 144 residents consuming food prepared in the kitchen.
Food Storage, Temperature Control, and Utensil Cleanliness Deficiencies
Penalty
Summary
Unused pork leftovers from dinner service were found stored in the walk-in refrigerator on 08/11/2025. Two metal pans covered with foil contained pork labeled with a use-by date of 8-11-25, and the pans were sitting on top of two raw thawing turkey loaves in a larger metal pan labeled with a use-by date of 08/09/2025. During interview, the Assistant Dietary Supervisor stated the pork was leftover from the prior dinner meal and should not have been stored as leftovers, and also confirmed it should not have been stored on top of raw thawing turkey. The Assistant Dietary Supervisor further stated the facility uses a cool down logbook only for egg salad and tuna salad and does not have a cooling process for other foods. A staff member stated the pork had been intended to be thrown away but was instead labeled and placed in the refrigerator because there was not time to discard it. Two raw thawing turkey loaves were also observed in the walk-in refrigerator with a use-by date of 08/09/2025 and a prep date of 08/07/2025. The Assistant Dietary Supervisor confirmed these turkey loaves should have been discarded on 08/09/2025 and stated expired items should not have been in the refrigerator. The same interview also confirmed staff had not been checking for expired items on a daily basis. Facility job descriptions for cooks and diet aides stated they are responsible for disposing of food and waste in accordance with established policies, and the Food Receiving and Storage policy stated refrigerated food, including leftovers, should be labeled, dated, monitored, used by the use-by date, frozen where applicable, or discarded. The one-door refrigerator in the kitchen was observed at 45 F, above the required 41 F or below. Inside were milk cartons, gallons of milk, yogurt, tofu, breakfast meals, and tray line beverages. Several tofu containers had use-by dates of 08/08/2025, and two tofu containers measured 43.6 F and 43.9 F. A staff member stated the tofu had been prepared three days earlier and placed in the refrigerator that day, and confirmed the expired tofu should have been discarded. Later, the Assistant Dietary Supervisor stated 5 gallons of milk had been moved from the walk-in refrigerator to the one-door refrigerator around 6:00 AM, and 4 of the 5 gallons measured above 41 F, with temperatures of 50.0 F, 49.8 F, 49.8 F, and 49.5 F. The facility policy stated refrigerated food temperatures and refrigeration equipment should be monitored daily and at routine intervals during all hours of operation. At the knife station, 4 out of 12 knives were observed with grime on the blades. A staff member and the Assistant Dietary Supervisor both agreed the knives appeared dirty and should be returned to the washer, and both confirmed the knife rack should only contain clean knives. The facility's utensil cleaning policy stated utensils used in food preparation and serving shall be cleaned and disinfected or discarded after each usage.
Failure to Store Perishable Food Brought by Visitors
Penalty
Summary
The facility failed to allow residents to store perishable food brought in by family and other visitors. During an interview, an LVN stated that perishable food brought in for residents was not stored and that residents and families were told the food had to be consumed or discarded within one hour. The LVN also stated that if family brought perishable food in the morning and the resident wanted to eat it later in the day, the family would need to take it home and bring it back later. The RD stated she was aware that food brought by visitors for residents was not stored and had to be discarded within two hours, and said the facility did not have enough refrigerators to store residents’ personal perishable food. An observation at the front desk kiosk showed a visitor sign-in message stating that food brought in must be reviewed by nursing for appropriateness before being given to the resident and that food left with the resident and not consumed during the visit would need to be disposed of if not consumed timely. The Administrator confirmed the facility did not store residents’ personal perishable food. Review of the facility document titled "Bringing in Food for a Resident" showed that all prepared food must be consumed during the visit and that no microwave was available for reheating food from outside.
Unclean Outdoor Waste Collection Area
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the outside waste collection area in an unclean condition. During an observation, a large green metal compost/organics container had the left top cover closed and the right top cover open, with dark yellow-brown liquid streaks running down the container and actively spilling onto the concrete surface for approximately 20 feet, accompanied by a strong foul odor. Runoff from the green container was also seen in front of a white metal recyclable items container with both top covers closed. During interview, the Environmental Director acknowledged the outdoor waste collection area was unclean, required power washing, and that maintaining the area was the facility's responsibility. Review of the facility policy titled Dispose of Garbage and Refuse stated that garbage and refuse containers are to be maintained in good condition, waste is to be properly contained with lids covered, and garbage storage is to be maintained in a sanitary condition to prevent the harborage and feeding of pests.
Incomplete Care Planning for Schizophrenia and Bed Rail Use
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for multiple residents with identified needs. Resident 15 had a diagnosis of schizophrenia on the facesheet dated 8/14/25, but during a 8/15/25 review with the DON, no care plan for schizophrenia was found. The DON stated that Resident 15 should have had one. The facility policy titled "Comprehensive Care Plans-Timing" stated that each resident has a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, including the resident representative if applicable. The facility also failed to develop care plans for bed rail use for Residents 22 and 64. Resident 22 was observed on 8/12/25 with two bilateral bedrails attached to the bed, and RN G confirmed on 8/18/25 that no person-centered care plan had been developed and implemented for bedrail use as a positioning device. Resident 64 was observed on 8/12/25 with bilateral bedrails up, and RN G confirmed on 8/18/25 that no person-centered care plan had been developed and implemented for Resident 64's bedrail use, and that one should have been. For Residents 55, 92, 78, 70, 89, 60, and 67, the positioning device care plans included an intervention to re-evaluate resident safety and use of bed rails quarterly, but this was not implemented. Resident 55's latest bed rail use assessment was dated 6/18/2021, and MDSN K confirmed the quarterly re-assessment had not been done. Resident 60's latest assessment was dated 12/5/2024, and there was no documentation that alternatives were offered or attempted prior to bed rail use. Resident 67's latest assessment was dated 11/11/2024, Resident 70's was dated 1/29/2025, Resident 89's was dated 12/9/2024, Resident 78's was dated 4/10/2024, and Resident 92's was dated 9/27/2024; in each case, MDSN K confirmed the quarterly re-evaluation intervention was not implemented. For Resident 136, the positioning device care plan was initiated on 7/16/2024 and resolved on 4/15/2025, but MDSN K stated there should have been a care plan developed related to continued bed rail use.
Failure to Review and Update Bed Rail Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans for siderails or bed rails were reviewed and updated quarterly for multiple residents. The report identified 19 of 29 sampled residents as affected, including residents whose care plans for bed rails were either not revised after initiation or had not been updated for multiple quarters. The facility’s policy titled "Comprehensive Care Plan-Timing," revised 1/25, stated that each resident has a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team including the resident and resident representative, if applicable. For several residents, the record showed bed rails in use and an order or care plan entry allowing bilateral positioning bars or similar positioning devices to promote independence with bed mobility and transfer. Examples included residents with diagnoses such as diabetes, dementia, heart failure, osteoporosis, Parkinsonism, fractures, anemia, hypertension, chronic kidney disease, and hemiplegia following cerebral infarction. During observations on 8/12/25, surveyors saw two bed rails attached to the beds of residents including Resident 31, 38, 4, 59, 96, 54, 97, 109, 110, 11, 138, 142, 145, 151, 150, 26, 81, 62, and 141. During interviews and record reviews with RN G and UM E, staff confirmed that multiple residents’ bed rail care plans had been initiated on various dates but were not revised quarterly, and in some cases had not been revised since the original initiation or since an earlier revision. Staff specifically acknowledged that quarterly care plan reviews were not completed for residents including 31, 38, 4, 59, 96, 54, 97, 109, 110, 11, 138, 142, 145, 151, 150, 26, 81, 62, and 141. The report states these failures had the potential to result in residents not receiving the interventions necessary to maintain their highest level of well-being.
Improper BG Timing and Unordered Bedrail Use
Penalty
Summary
Resident 116, who was admitted with diagnoses including choledocholithiasis, pneumonia, and diabetes, had blood glucose testing performed before breakfast and insulin administration at times that were earlier than the meal schedule. The resident’s MDS indicated intact cognitive skills for daily decision making. The resident stated staff woke her at 5:00 a.m. for a finger stick even though breakfast was at 7:30 a.m., and the LVN stated blood sugar checks for sliding scale insulin were done before meals, with breakfast checks around 6:30 a.m. and insulin given then, not 15 minutes before breakfast. The medical record showed orders for multiple diabetes medications, including Alogliptin, Lantus, Metformin, and regular insulin per sliding scale. Review of blood glucose documentation showed multiple morning checks performed before 6:30 a.m., including several readings done between about 5:33 a.m. and 5:58 a.m. RN G stated blood glucose checks should not be done that early and that checks and insulin should be prior to a meal. The chart also contained no indication that the resident was monitored for hyperglycemia or hypoglycemia, and RN G stated monitoring should have been present. For Residents 130, 22, and 64, bedrails or positional bars were observed in use on their beds, but no physician order was found for the use of the bedrails. Resident 130 had one bed rail attached to the bed, Resident 22 had bilateral bedrails, and Resident 64 had bilateral bedrails up. For Resident 22, the order summary showed a prior order for bilateral positioning bars had been discontinued. RN G and the Unit Manager confirmed there was no physician order on file for the bedrails for these residents. The facility policy on physician orders stated that orders must be complete and accurate and verified by Medical Records.
Bed Rail Use Lacked Required Assessment, Alternatives, Re-evaluation, and Consent
Penalty
Summary
The facility failed to ensure proper use of bed rails for 38 of 114 residents. Two residents had bed rails in use without a Bedrail Use and Entrapment Risk Evaluation completed before the rails were used. For one resident, one bed rail was observed attached to the bed, and the Unit Manager confirmed there was no evaluation in the record. For another resident, two bed rails were observed attached to the bed, and the RN confirmed there was no evaluation in the record. The facility also failed to document that alternatives were offered and/or attempted before bed rail use for 20 residents. In multiple record reviews, the RN or UM confirmed that the Bedrail Use and Entrapment Risk Evaluation did not show alternatives had been offered or attempted prior to bed rail use. For some residents, bed rails were observed in place during room observations, including residents with one or two rails upright on the bed. For several residents, the record review specifically showed that the evaluation form did not indicate prior alternatives, and in one case the previously attempted alternatives section was not checked. The facility further failed to complete quarterly re-evaluations of bed rail safety and use for 35 residents as indicated in the care plan. For multiple residents, the last bed rail evaluation was months or years earlier, and staff confirmed there were no more recent updates. In several cases, the MDS nurse stated the assessment should have been completed quarterly or with a significant change in condition. The facility also failed to obtain consent for bed rail use for two residents; staff confirmed there was no consent on file for one resident and no consent obtained prior to bed rail use for another resident.
PASARR Screening Not Accurately Completed for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a PASARR screening was accurately completed for one resident with diagnoses including vascular dementia, adult failure to thrive, major depressive disorder, bipolar disorder, and anxiety disorder. The resident’s record showed an admission record dated 8/18/2025, an order for Depakote Sprinkles for bipolar disorder manifested by physical aggression, and an August 2025 MAR documenting behaviors including crying episodes, verbal aggression, physical aggression such as hitting and scratching staff, refusal to be changed, and throwing objects when upset. Review of the resident’s PASARR Level I screening dated 6/15/2020 showed the resident was negative for serious mental illness and did not need a Level II evaluation, but sections 18.a through 18.d were skipped. RN G confirmed the resident had originally been admitted on 8/4/2019 and was later re-admitted, and stated the skipped sections were left blank because the resident had stayed in the facility more than 30 days. RN G also confirmed there was no other PASARR Level I screening completed for the resident except the one dated 6/15/2020, and stated another Level I screening should have been completed on day 31 after admission. The DON confirmed the resident had bipolar disorder and behaviors, and also confirmed another PASARR Level I screening should have been completed since the resident stayed more than 30 days upon admission.
Failure to Monitor Behaviors for Resident With Schizophrenia
Penalty
Summary
The facility failed to follow its Policy & Procedure titled, Dignity and Respect Psychoactive Medications, for one of 30 sampled residents, Resident 15, when it did not monitor her for behaviors related to her diagnosed mental illness. Resident 15's facesheet dated 8/14/25 showed a diagnosis of schizophrenia dated 2/9/23. During a concurrent interview and record review on 8/15/25 at 3:56 p.m., the DON stated that Resident 15 should have an order for behavioral monitoring because she has a diagnosed mental illness. Review of the facility's P&P titled, Dignity and Respect Psychoactive Medications, dated 2025, indicated that behavioral interventions are individualized, nonpharmacological approaches provided as part of a supportive psychosocial environment and that the facility ensures resident behaviors and circumstances warranting evaluation include a new or worsening change in condition.
Inconsistent Fortified Diet System
Penalty
Summary
The facility failed to have a system for physician-prescribed fortified diets for a resident who was ordered a fortified minced and moist diet. Resident 3 had diagnoses including a stage 4 pressure ulcer and was admitted with poor intake and wound concerns. The resident’s fortified diet order was entered on 6/15/25, but the trayline process did not consistently provide the same fortified items, and staff gave conflicting explanations about what the fortified diet was supposed to include. During lunch trayline observation, Resident 3’s tray ticket showed a Minced & Moist fortified regular portion diet with coffee, juice, and 2% milk, but no butter was placed on the tray. A dietary staff member stated fortified diets should receive butter, while the Assistant Dietary Supervisor later stated fortified diets were supposed to receive fortified milk, whipped topping on dessert, and extra butter, and acknowledged that fortified milk and whipped topping were not added to the tray ticket. The Registered Dietitian stated she recommended fortified diets but was not familiar with the fortified menu and did not know how many extra calories the diet provided. Further interviews showed inconsistent and conflicting descriptions of the fortified diet. One cook stated she added butter to fortified breakfast items, while the Assistant Dietary Supervisor later stated the Special Nutrition Program was the standard for fortified diets and that fortified diets always received Super Cereal and fortified milk for breakfast and fortified milk for lunch and dinner, but did not receive extra butter. The Registered Dietitian confirmed Resident 3 had poor intake, averaging 54 percent initially and later 32 percent after hospital readmission, and that the fortified diet was recommended because the resident needed more calories for poor intake and wound healing.
Menus Not Followed During Lunch Tray Service
Penalty
Summary
Menus were not followed during lunch service when Resident 163 received a mixed fruit cup instead of the 1 fresh apple listed on the daily menu spreadsheet for the Liberal House Renal meal. During a concurrent observation, interview, and record review in the kitchen during tray line, the diet aide initially stated the mixed fruit cup was appropriate, then reviewed the menu spreadsheet and removed a pink colored juice from the tray and replaced it with apple juice. The ADS later confirmed that Resident 163 should have received 1 fresh apple, not the mixed fruit cup. The resident’s lunch tray ticket identified a Vegetarian Renal and Regular Portion meal, and the menu spreadsheet for the Liberal House Renal diet listed 1 fresh apple as the dessert option. Menus were also not followed for Resident 143, whose lunch tray contained tarter sauce even though the menu spreadsheet for the Easy to Chew (EC7) meal indicated mayonnaise 1 Tbsp was to be substituted for tarter sauce. During observation of the tray line, staff identified that Resident 143 had tarter sauce and mayonnaise on the tray, and confirmed that tarter sauce should not have been included. The resident’s lunch tray ticket identified an Easy to Chew (EC7) Small Portion meal, and the facility policy stated that menus are developed and prepared to meet resident choices including nutritional, religious, cultural, and ethnic needs while using established national guidelines.
Laundry Dryer Lint Maintenance and Documentation Deficiency
Penalty
Summary
The facility failed to ensure that a dryer lint filter compartment and lint trap cleaning log were routinely maintained. During a concurrent observation and interview with the environmental director in the linen room, one of the clothes dryer’s lint compartments contained laundry lint fibers from the tumble drying of clothing and linen. The environmental director stated that lint traps were supposed to be cleaned every two hours. During record review, the environmental director reviewed the facility’s laundry lint trap cleaning log and confirmed that it was missing signatures on multiple entries, including 8/1/25 at 10:00 p.m., 8/7/25 at 3:00 p.m., 8/9/25 at 1:00 p.m., 7:00 p.m., and 10:00 p.m., 8/10/25 at 7:00 p.m., 8/11/25 at 5:00 a.m., 8/13/25 at 3:00 p.m. and 5:00 p.m., and 8/15/25 at 1:00 p.m. The infection preventionist also confirmed that the missing signatures on the lint trap cleaning log should have been completed by laundry staff. The facility policy stated that laundry equipment was to be maintained in a safe and sanitary condition and that lint accumulation in clothes dryers and exhaust ducts presents a fire hazard and must be prevented through routine cleaning and documentation.
Kitchen Fly Infestation and Delayed Pest Response
Penalty
Summary
The facility failed to ensure the kitchen was free from flies. During an observation in the kitchen, multiple flies were seen throughout the area, including flies landing on a can of spray used for coating pans, on the foil covering a pan containing a pureed entree, and flying around a pan of cake. A later fly count in the kitchen identified approximately 152 flies. An Assistant Dietary Supervisor reported that flies had been present in the kitchen for about 1 week and had already been reported to the Environmental Director. The Environmental Director confirmed being informed of the fly issue and stated that the pest control company was called, but the facility chose to conduct an internal investigation before contacting pest control. The Environmental Director also stated that routine pest control services were provided every 2 weeks and that the scheduled service date was a routine visit. The Infection Preventionist was not aware of the flies in the kitchen and stated that staff should notify pest control immediately if a fly issue arises. The facility's pest control policy stated that staff should report pest sightings immediately and that the facility had a licensed pest management professional under contract for routine inspections, treatments, and emergency response. Review of pest control invoices showed routine service on one date with no specific fly treatment, followed by later invoices documenting drain treatment for flies and fruit flies and a technician suggestion to install fly lights.
Failure to Sanitize Food Thermometer Between Uses
Penalty
Summary
The facility failed to adhere to its policy on sanitizing food thermometers between measuring the temperatures of different food items, which could potentially affect all 138 residents receiving food from the dietary department. The policy, revised in March 2023, emphasized the importance of preventing cross-contamination by cleaning and sanitizing food contact surfaces and equipment. Additionally, the facility's policy on food temperatures, revised in March 2020, required the thermometer to be washed, rinsed, and sanitized with an alcohol wipe after each use. However, during an observation, it was noted that a staff member did not sanitize the thermometer between measuring the temperatures of various food items, including pureed meat, pureed egg roll, pho broth, vegetables, salmon, rice, mashed potatoes, beef, and vegetable broth. Interviews conducted with the staff member involved, the Dietary Supervisor, the Director of Nursing (DON), and the Administrator confirmed the expectation that thermometers should be sanitized between uses to prevent cross-contamination. The staff member acknowledged being trained to sanitize the thermometer between food items, while the Dietary Supervisor and DON reiterated the importance of this practice. The Administrator also confirmed that staff were expected to follow the facility's policy regarding thermometer sanitation. Despite these expectations, the failure to sanitize the thermometer as required was observed, indicating a lapse in following established procedures.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) for two residents, leading to deficiencies in reflecting their mental health diagnoses. Resident #138 was admitted with a history of adjustment disorder with depressed mood and brief psychotic disorder, yet their Level I PASARR inaccurately indicated no serious mental disorder. Interviews with facility staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Quality Assurance (QA) Nurse, confirmed the inaccuracies in the PASARR, which should have included the resident's diagnoses of depression and psychotic disorder. Similarly, Resident #67 was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). However, their Level I PASARR only reflected the major depressive disorder and omitted the PTSD diagnosis. The RN, DON, and QA Nurse acknowledged the inaccuracy, emphasizing the importance of accurate PASARRs for proper resident placement and care. The Administrator also expected PASARRs to accurately reflect residents' diagnoses, highlighting the facility's failure to ensure accurate documentation of mental health conditions.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by an 8% error rate during medication administration observations. Two medication errors were identified out of 25 opportunities, affecting two residents. The errors involved the underdosing of medications for residents with specific medical conditions. Resident #137, who was admitted with a diagnosis of depression, was prescribed sertraline 100 mg daily but received only 50 mg. Similarly, Resident #105, diagnosed with unspecified dementia, was prescribed memantine 10 mg daily but received only 5 mg. The errors were attributed to the actions of LVN #1, who failed to administer the correct dosage as per the physician's orders. During interviews, LVN #1 acknowledged the oversight, admitting to not reading the entire order before administering the medications. Both RN #2 and the Director of Nursing confirmed the underdosing and emphasized the importance of matching the medication card to the order screen and reading the entire order. The facility's policy on administering medications, which requires checking the label three times to ensure the correct resident, medication, dosage, time, and route, was not adhered to in these instances.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was assessed to be at high risk for falls and totally dependent on staff for transferring. On the morning of the incident, the resident was left sitting in her wheelchair in the hallway without staff supervision while a CNA went inside another resident's room. This lapse in supervision resulted in the resident falling and sustaining a subdural hematoma on the right temporal region, which ultimately led to her death after 15 days in a general acute care hospital. The resident had a history of dementia, epilepsy, muscle weakness, abnormality of gait and mobility, and a history of falling. Her care plan indicated that she required extensive assistance with one-person physical assist in transferring and needed to be closely monitored by staff. Despite these documented needs, the resident was left unsupervised in the hallway, leading to her fall and subsequent injury. Interviews with facility staff, including the CNA, LVN, and DON, confirmed that the resident was left unmonitored at the time of the fall. The facility's policy on fall management emphasized the need for adequate supervision to minimize fall risks, but this policy was not adhered to, resulting in the resident's fatal injury.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 305 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 San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Ridge Post Acute | 2.8 mi | ★★★★★ | 26 | 0 |
| Vista Manor Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| Canyon Springs Post-acute | 3.2 mi | ★★★★★ | 1 | 0 |
| San Jose Healthcare & Wellness Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Inspire Behavioral Health | 4 mi | ★★★★★ | 16 | 1 |
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 October 2026) and official state health department websites.