Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oroville Hospital Post-acute Center during CMS and state inspections, most recent first.
Inadequate Training and Competency for CNAs Assigned to Dietary Tasks: CNAs were pulled from nursing units to help in the kitchen when dietary staffing was short, and they performed food prep tasks such as making pudding, cottage cheese, fruit cups, sandwiches, tuna salad, and tray line service. One CNA also blended cottage cheese with milk for a pureed diet. The RD stated CNAs should only do simple tasks with a DA present and confirmed there were no formal training records or competency documents showing CNAs were trained or competent for dietary duties.
A gallon of milk and a jar of dill pickle relish were found in the kitchen refrigerator without open dates after being opened and used. The DSM confirmed the items were not labeled as required by the facility's food labeling and dating policy.
The facility failed to submit required PBJ staffing data to CMS. During record review with the DON, the CASPER report showed that staffing data for the quarter had not been submitted, and the DON stated the facility tried to submit the PBJ but the password did not work and CMS was not contacted in a timely manner. By the end of the survey, the facility could not provide evidence of compliance with the PBJ reporting requirement.
Essential equipment was not kept operable in the kitchen and a resident bathroom. Staff observed the oven with broken doors and stated it had been unusable for cooking for months, with the DSM, RD, and Maintenance staff confirming the unit could not function as intended and that no facility-wide maintenance policy existed. The wall by the dishwasher was left with open drywall exposed to moisture, and in room [ROOM NUMBER], the sink and toilet were out of order with staff confirming the pipe had disintegrated and the bathroom fixtures were not working.
A facility failed to maintain residents’ personal clothing and belongings when multiple items were lost or not returned from laundry, including socks, dresses, pajama tops, a blanket, a phone, pants, charging cords, and a necklace. Residents and family reported missing items, grievance forms documented clothing removal and delayed return, and staff confirmed unlabeled clothing was found in another resident’s closet and that the facility had a large amount of lost and found clothing. Residents involved had significant medical conditions including COPD, ESRD on dialysis, lung cancer, DM, HF, and CVA.
Delayed MDS Assessments: The facility failed to complete one admission MDS and two Annual MDS assessments within required timeframes. One resident’s admission MDS remained in progress with no care areas documented, and two residents with diagnoses including dementia, seizures, irregular heart rate, falls, diabetes, and chronic pain had overdue Annual MDSs. The MDS nurse stated assessments are supposed to be completed sooner, but they were not finished and were overdue.
Late Quarterly MDS Assessments for Two Residents: The facility failed to complete Quarterly MDS assessments within the required 92-day timeframe for two residents. One resident had DM2, restless legs, and HTN, and another had a stroke, restless leg, and anxiety. MDS staff acknowledged the quarterly assessments were overdue and stated the facility does not always complete them within the required time frame.
A facility failed to provide enough nursing staff to meet resident needs, with repeated complaints of delayed call light response and delayed help with toileting, oral care, brief changes, showers, and pain medication. Residents reported waits ranging from 30 minutes to several hours, feeling neglected, and having care preferences ignored. The Scheduler stated CNA assignments were based mainly on census rather than resident acuity, and staffing varied by nursing station.
A resident with anxiety and a history of TBI was punched in the face by another resident with a mental health condition while exiting the dining room. The assault caused a 3-cm upper lip laceration requiring sutures and an ER visit, and the resident reported being very scared. The ADON confirmed the incident on video, and another resident later reported fear after the altercation and said staff provided extra monitoring.
Dialysis care and services were not adequately documented for a resident with ESRD who received dialysis three times weekly. Dialysis transfer forms were missing or incomplete, LNs did not document daily fistula assessments in the MAR after the fistula was placed, and the resident’s care plan was not updated to include daily fistula monitoring instructions.
Outdated Psychotropic Consent Form: A resident with chronic pain and major depressive disorder was prescribed Cymbalta 60 mg daily, but the psychotropic drug disclosure and consent form was not renewed every 6 months as required. During record review, the ADON confirmed the consent form was outdated.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with dementia, agitation, and a history of elopement was left unsupervised when a hospitality aide took a break without arranging coverage, resulting in the resident wandering into another room. The care plan required 1:1 supervision at all times, but staff did not follow this directive, and the facility lacked an appropriate care plan policy.
The facility failed to provide written bed hold notifications to residents or their representatives upon transfer to a hospital, affecting several residents with various medical conditions. Despite notifying the Long-Term Care Ombudsman, the facility did not comply with its policy to inform residents or their responsible parties about the bed hold policy, leading to a deficiency.
A long-term care facility failed to complete MDS assessments for several residents within the required timeframe, leading to potential delays in developing comprehensive care plans. The backlog was attributed to the facility being busy and understaffed, with the MDS RN expressing concern about care plans not reflecting current interventions. The Administrator was aware of the issue but not fully informed of its extent.
Several residents in an LTC facility did not receive necessary assistance with ADLs, including eating and personal hygiene. A resident with severe cognitive impairment was unable to eat due to an unreachable lunch tray, while others reported inconsistent oral care and hair brushing. Staff acknowledged oversights, and documentation showed gaps in care provision.
Two residents experienced deficiencies in care at the facility. A resident with multiple diagnoses, including Parkinson's and chronic kidney disease, did not receive documented coccyx treatments for her Moisture Associated Skin Damage as ordered. Another resident with anoxic brain damage and dementia had inconsistent monitoring of her venous ulcers, with several shifts lacking documentation of assessments. The facility's policies on skin integrity and medication administration were not followed, leading to these deficiencies.
The facility failed to implement downtime procedures during an internet outage, preventing staff from accessing residents' EMR and delaying care. Despite having a policy for such situations, staff were unable to use provided cell phones or jetpack devices to access records. Paper MARs were printed as a temporary solution until the internet was restored.
A survey found a 27.59% medication error rate in an LTC facility, involving two residents. Errors included improper medication administration via g-tube for a resident with dysphagia and dementia, and failure to provide vitamin D3 for another resident due to inventory issues. The DON confirmed protocol lapses and medication unavailability.
The facility failed to properly store and label medications, leading to several deficiencies. A medication label did not match the physician's order, and storage conditions were inadequate, with ice buildup in a medication refrigerator posing contamination risks. Unlabeled medication cups, expired Ativan, and improper storage of cleaning supplies with medications were also observed. Additionally, an unlabeled Kangaroo bag was found in a resident's room.
The facility failed to maintain a sanitary kitchen environment, with grime and dust observed on equipment and improper cleaning schedules. Staff did not consistently prevent cross-contamination, with improper use of hair restraints, gloves, and apron storage. Food cooling processes were inadequately documented, and pureed fish did not meet consistency standards. Despite ongoing training, these issues persisted, raising concerns about the effectiveness of the facility's oversight.
The facility did not follow a preplanned vegetarian menu cycle, potentially compromising the nutritional needs of vegetarian residents. Despite having a diet manual approved by the RD and Medical Director, there was no evidence of a comprehensive vegetarian menu cycle or nutrient analysis specific to vegetarian meals. Kitchen staff prepared meals based on available ingredients and personal judgment, and the RD was unaware if the nutrient analysis provided was for vegetarian alternatives or standard meals.
The facility failed to serve food at an appetizing temperature, as reported by several residents who consistently received cold meals. Observations showed delays in meal tray delivery and inadequate food temperatures, confirming the residents' complaints.
The facility failed to meet the dietary texture needs of several residents, as observed when whole parsley sprigs were placed on trays for residents on pureed and mechanical soft diets, contrary to the diet manual's instructions. Additionally, pureed fish was found to have a gummy texture, not meeting the required smooth consistency. A resident expressed dissatisfaction with the dryness of the food, and her preferences were not documented. The dietary services manager and RD acknowledged the texture issue, indicating a failure to adhere to dietary modifications and resident preferences.
The facility failed to maintain food safety and sanitation standards, with unsanitary kitchen conditions, improper storage and handling practices, and inadequate management of dented cans. Kitchen staff did not follow cross-contamination prevention protocols, and non-food-safe chemicals were used in nourishment rooms.
The facility failed to ensure sanitary food storage for residents' personal food in three nourishment rooms, where food was not labeled with patient identifiers. Observations revealed employee personal belongings and opened beverages in the rooms, along with soiled floors and counters. Interviews confirmed that staff personal items and food were a consistent problem, and the facility lacked a policy on employee property storage.
The facility failed to effectively use its QAPI program to address deficiencies in timely completion of resident assessments, affecting 13 residents. The MDS RN reported being behind due to insufficient nursing hours, leading to incomplete MDS assessments and potentially outdated care plans. The Administrator was aware of the backlog but not its full extent, and expected reporting for root cause analysis, which did not happen.
The facility's QAA committee failed to implement effective plans for infection control, as revealed by a lack of documentation and incomplete hand hygiene audits. The ongoing Infection Control PIP lacked essential elements like root cause analysis and action plans, as admitted by the ADON.
The facility exhibited multiple infection control deficiencies, including staff failing to perform hand hygiene during meal service, unsanitary nourishment rooms, and improper cleaning practices. Additionally, resident care equipment was found dirty, and staff did not follow proper procedures during resident care activities, posing infection control concerns.
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as cockroaches and unidentified bugs in resident areas and dining rooms. The Maintenance Supervisor acknowledged ongoing pest issues, but the pest control service primarily focused on exterior spraying, and deep cleaning was not routinely performed. The facility's nourishment rooms were unsanitary and cluttered, contributing to the infestation. Despite the known issue, there were no Quality Assurance/Performance Improvement processes in place to address the problem.
A resident expressed distress over staff going through her personal belongings without permission, but the facility failed to address her grievance. Despite the resident's clear complaint, the Social Service Director did not offer to file a grievance report, and the grievance binder showed no report for the incident. Interviews confirmed that staff were expected to file grievances, but the complaint went unaddressed, indicating a lapse in the facility's grievance handling process.
A facility failed to provide a written notice of transfer or discharge to a resident and the State LTC Ombudsman when the resident was sent to the hospital for emergency care. The resident, who was admitted with multiple diagnoses and was her own representative, was transferred to an acute hospital within 24 hours due to severe chest pain. The ADON confirmed that no written notice was provided, as required by the facility's policy.
The facility failed to complete Quarterly MDS assessments within the required timeframe for two residents, leading to overdue assessments. One resident's assessment was 35 days overdue, while another's was 18 days overdue. Staff cited a busy environment and insufficient nursing hours as reasons for the delays, raising concerns about the impact on residents' care plans.
A facility failed to ensure the accuracy of a Level 1 PASARR for a resident, missing a bipolar disorder diagnosis and incorrectly including dementia. The hospital conducted the initial PASARR, but the facility's medical records department was responsible for verifying its accuracy. Discrepancies were confirmed during interviews and record reviews, with the ADON acknowledging the issues.
A resident experienced significant weight loss due to the facility's failure to implement an individualized care plan. Despite being at risk for weight loss, no care plan was created, and the resident was not informed of any plan to address her condition. The facility's processes failed to manage the resident's nutritional needs effectively, as confirmed by the ADON and RD.
A resident with a peg-tube was subjected to improper care when LNs used a DeClogger without a physician's order, care plan, or monitoring system. The DeClogger, meant for use with a prescription, was used multiple times without proper water flushing, and the facility's DON confirmed the absence of necessary documentation and monitoring.
A resident with a history of UTIs and other medical conditions experienced repeated infections due to inadequate peri-care by CNAs. Despite being fully dependent on staff for hygiene, the resident reported insufficient cleaning after incontinent episodes, confirmed by staff observations. The Infection Preventionist had not provided necessary training, contributing to the issue.
A resident experienced significant weight loss over two weeks, which was not identified or addressed by the facility. Despite policies for monitoring and re-weighing, the RD failed to document the weight loss or initiate a care plan. The ADON confirmed no meetings were held to discuss the resident's weight loss, resulting in a failure to maintain the resident's nutritional status.
A resident with dementia and bipolar disorder was prescribed Asenapine and Haloperidol, but the facility failed to monitor specific behaviors and adverse reactions as required by their policies. This lack of monitoring was confirmed during an interview and record review with a Registered Nurse/Neuropsychiatric Assistant.
The facility failed to ensure adequate oversight of Food and Nutrition Services, as the RD did not provide evidence of regular consultations and audits. Sanitation and food safety concerns were observed, including soiled equipment and improper food handling. The facility also did not follow a pre-planned vegetarian menu cycle, with kitchen staff unaware of its existence, leading to concerns about meeting residents' dietary needs.
A resident, who primarily speaks Spanish, signed an arbitration agreement in English without understanding it, as the facility failed to provide the document in her language. The Admissions Transition Coordinator relied on the resident's English-speaking son for agreement, leading to the resident signing a document she did not comprehend.
A resident with a history of chronic pain and a broken leg experienced increased pain due to the facility's failure to administer Norco on time, as per the care plan and physician's orders. The medication was frequently given late, with staff citing busy shifts and shared medication carts as reasons. The Executive Nurse Director confirmed the late administration, which was not in line with the facility's policy.
A resident with severe cognitive impairment was abducted from a facility by a restricted visitor due to inadequate visitor screening and staff training. The visitor used a false name to enter the facility, and staff failed to verify the visitor's identity or check the restricted visitor list. The facility's lack of a comprehensive visitor management policy and insufficient staff training contributed to the incident.
Inadequate Training and Competency for CNAs Assigned to Dietary Tasks
Penalty
Summary
The facility failed to ensure staff assigned to perform food and nutrition services possessed the competencies and skill sets necessary to carry out those functions. Certified Nursing Assistants (CNAs) were reassigned from the nursing units to assist in the kitchen with food preparation tasks when the dietary department was short staffed, including during periods when a dietary employee was absent and when the department had been short staffed for several weeks. The CNA job description identified direct resident care duties, while the Dietary Aide job description included preparing food, assembling trays, checking tray accuracy, preparing snacks, maintaining safe food temperatures, and kitchen cleaning tasks. During interviews, dietary staff stated CNAs were pulled into the kitchen to help with tasks such as preparing pudding, cottage cheese, fruit cups, sandwiches, tuna salad, and tray line service, and one CNA reported blending cottage cheese with milk to make the correct consistency for a pureed diet. The Registered Dietician stated CNAs could complete simple tasks if a Dietary Aide was present, but also stated CNAs should not be blending cottage cheese or modifying food textures. The RD further acknowledged the facility did not have formal written training records or competency documentation for CNAs assigned to dietary tasks, and that no supporting documentation was present in CNA personnel files to show they had been trained or deemed competent for those duties.
Unlabeled Open Food Items in Kitchen Refrigerator
Penalty
Summary
Food safety requirements were not maintained in the kitchen for all residents receiving nutritional intake from the facility kitchen when a gallon of milk and a jar of dill pickle relish were found without open dates after being opened and used. During review of the facility policy and procedure titled, "Labeling and Dating of Foods," dated 2023, the policy stated that newly opened food items must be closed and labeled with an open date and use-by date according to storage guidelines. During an observation and interview with the Dietary Service Manager in the kitchen on 5/5/26 at 11:00 AM, the three-door refrigerator was checked for adequate food storage, and the Dietary Service Manager confirmed that the gallon of milk and jar of pickle relish were not labeled with opening dates as required.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data. During a concurrent interview and record review with the DON, the PBJ reporting data and CASPER report 1705D for fiscal year quarter 1 2026 were reviewed, and the facility had not submitted staffing data for that quarter. The DON stated the facility tried to submit the PBJ, but the password did not work and CMS was not contacted in a timely manner. By the conclusion of the survey, the facility was unable to provide evidence that it had complied with the requirement to submit PBJ data and reports to CMS.
Kitchen Oven, Dishwasher Wall, and Resident Bathroom Equipment Not Maintained
Penalty
Summary
Essential equipment was not maintained in operable condition in the kitchen and in a resident bathroom. The facility’s Maintenance Director and Maintenance Technician job descriptions stated they were responsible for repairs, preventative maintenance, carpentry work, drywall repair, plumbing systems and fixtures, and maintenance and repair of kitchen equipment including ovens. However, during observation and interview, the kitchen oven was found with broken doors and staff stated it had been broken for a long time and could not be used to cook food, only to warm plates. The Dietary Service Manager stated the oven doors had been broken for greater than seven months and that the unit did not appear fixable because of its age. The manager also stated maintenance had tried to fix it, but it kept breaking, and that roasts had to be purchased precooked and warmed in smaller equipment. The Registered Dietician stated the oven was necessary to make the best food for residents and to do an efficient and effective job in the kitchen. Five of five residents interviewed stated food quality could be improved and food service often seemed late. The facility also had no policy on maintenance of equipment for the entirety of the facility, as confirmed by Maintenance staff and the DON. In the kitchen, the wall by the dishwasher was observed under construction with open areas revealing unfinished drywall. The Dietary Service Manager stated the wall renovation had never been completed and that the dishwashing area was very wet and damaging the open drywall. In room [ROOM NUMBER], the bathroom was observed with an out-of-order sign, and staff reported the sink and toilet were not working. A caregiver stated he had been told there was a root growing out of the toilet. A plumbing invoice noted a cable was run into the toilet and mud was found on the end of the cable, and the repair log showed the problem had been reported earlier. Maintenance staff confirmed the pipe had disintegrated and could no longer be used, and the Maintenance Service Director stated there was no capital expense plan to repair the bathroom water pipe.
Lost Resident Clothing and Belongings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four sampled residents when personal clothing and belongings were not maintained and were lost. The deficiency was identified through observation, interview, and record review, and involved Residents 34, 42, 45, and 59. Facility policies reviewed indicated that resident property was to be safeguarded, suspected loss or theft was to be investigated, and resident clothing was to be permanently labeled. Resident 34, who had diagnoses including COPD, seizures, CVA, and high blood pressure, stated that 20 labeled pairs of socks sent to laundry were never returned and that a pink dress placed in a labeled bag was also not returned. Resident 34 said no one had followed up about the missing items, and observation of the closet showed no socks or pink dress present. Resident 42, who had end stage renal disease and dependence on renal dialysis, had a grievance form documenting clothing removed from a clothing hamper by an unknown individual, and a social services note later documented continued missing personal items including charging cords and a necklace. Another grievance form indicated clothing was not consistently returned from laundry and was not returned until 11 days after the grievance was initiated. Resident 45, who had lung cancer, COPD, DM, and high blood pressure, was reported by a family member to have multiple pajama tops missing after items were purchased for the resident, along with a missing blanket and a phone lost during a fire evacuation standby that was never replaced. Resident 59, who had kidney disease, COPD, DM, heart failure, and high blood pressure, stated that a dark navy pair of pants sent to laundry had not been returned and that clothing had been found in the roommate’s closet and the roommate’s clothing had been found in the resident’s closet. Staff interviews confirmed that unlabeled clothing had been found in another resident’s closet and sent to laundry to be labeled, and facility staff acknowledged a large amount of lost and found clothing and problems returning items to residents.
Delayed MDS Assessments
Penalty
Summary
The facility failed to complete the admission MDS assessment in a timely manner for one resident and failed to complete the Annual MDS assessments for two residents. The CMS RAI Manual dated 10/1/25 requires admission MDS assessments to be completed within 14 calendar days of admission and Annual MDS assessments within 14 days of the ARD. Resident 123 was admitted on [DATE], and the admission MDS was due by 5/1/26, but on 5/2/26 it remained in progress with no care areas documented and had not been completed. Resident 126 was admitted with diagnoses including dementia, seizures, and irregular heart rate, and the most recent MDS assessment had an ARD of 4/21/26 and was due by 5/5/26, but it was three days overdue. Resident 14 was admitted with diagnoses including history of falling, diabetes, and chronic pain, and the most recent MDS assessment had an ARD of 4/17/26 and was due by 5/1/26, but it was seven days overdue. During interview and record review, the MDS Nurse stated admission MDS assessments are supposed to be done in seven days, but that it is not always done in that time frame. The MDS Nurse also stated the facility uses the CMS-approved RAI Manual regulations to determine the type and timing of MDS assessments, but could not produce a hard copy of the admission MDS for Resident 123 or the Annual MDS assessments for Residents 14 and 126. The MDS Nurse stated the MDS assessments for Residents 14, 123, and 126 were not completed and were overdue.
Late Quarterly MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete Quarterly MDS assessments within 92 calendar days of the previous assessment for two sampled residents. Resident 11 had diagnoses including type 2 diabetes, restless legs, and hypertension, and the most recent MDS assessment in the record showed the quarterly assessment was due by 5/3/26 and was five days overdue. Resident 12 had diagnoses including stroke, restless leg, and anxiety, and the most recent MDS assessment also showed the quarterly assessment was due by 5/3/26 and was five days overdue. During a concurrent interview and record review on 5/7/26, MDS Nurse B stated that Quarterly MDS assessments are required every three months or every 92 days. MDS Nurse A stated that MDS assessments are not always done within this time frame due to the facility's resident population, acuity, and frequent turnover. During a later interview and record review the same day, MDS Nurse A stated the facility uses the RAI manual to determine the type and timing of MDS assessments and could not produce a hard copy of the Quarterly Comprehensive MDS assessments for Residents 11 and 12, confirming that the assessments were not completed and were overdue.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident care needs and did not maintain a licensed nurse in charge on each shift as required by the cited deficiency. Resident council minutes and grievance forms from January through May 2026 documented repeated complaints about delayed call light response times and delayed assistance with care needs. Residents reported waiting long periods to be changed, including waits of two hours and twenty-five minutes, six hours, seven hours, and overnight periods without being changed. Residents also reported not receiving timely help with toothbrush preparation, toileting, oral care, and other activities of daily living, and several stated that the staffing shortage made them feel neglected and frustrated. Interviews with seven of twenty-four residents confirmed ongoing concerns about insufficient direct care staff and delayed responses to call lights. One resident reported frequent delays of 30 minutes to two hours for pain medication related to wounds causing constant pain, while another described being rushed during showers and not having care preferences honored. Other residents reported waits of up to two hours for brief changes and personal care, up to thirty minutes for call light response, and up to ninety minutes for assistance, with one resident stating that delays led to accidents after bladder surgery. During a concurrent interview, the facility Scheduler stated that CNA staffing for the West, East, and North Nursing Stations was based mostly on census rather than resident acuity, and that the long-term care side received more staff than the short-term side. The Scheduler also stated that the facility relied on CNAs to report when residents became more dependent and needed additional help.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that one sampled resident was free from abuse when another resident punched that resident in the face. Resident 46 had diagnoses of anxiety and a personal history of traumatic brain injury and was not their own responsible party. Resident 128 had an unspecified mental disorder and was their own responsible party. The facility’s abuse policy stated residents had the right to be free from physical abuse. According to the report, Resident 46 stated that Resident 128 punched them in the face while exiting the dining room, and said, “I was scared half to death.” The altercation resulted in a 3-centimeter laceration to the left upper lip that required sutures and an emergency room visit. The interdisciplinary note documented that Resident 46 was placed with a one-on-one sitter for safety concerns. The ADON confirmed after reviewing video surveillance that Resident 128 punched Resident 46 in the face. Another resident also reported fear after the incident and said staff provided extra monitoring.
Dialysis Care Documentation and Fistula Monitoring Were Incomplete
Penalty
Summary
Adequate dialysis care and services were not provided for Resident 42, who was admitted with end stage renal disease and dependence on renal dialysis and received dialysis three times a week. The facility’s dialysis communication forms were incomplete and missing: the Dialysis Transfer Forms for 2/1/26 through 2/28/26 and 5/1/26 through 5/7/26 were not provided, and additional review showed that forms dated 3/14/26, 4/11/26, and 4/19/26 were also missing. The ADON confirmed that the forms dated 4/7/26 and 4/23/26 lacked a complete LN assessment of the resident’s dialysis fistula. The facility also did not document daily assessments of the resident’s dialysis fistula in the MAR. Resident 42 stated that staff did not listen to the fistula and that only student nurses did so. Review of the MAR from 4/1/26 through 5/7/26 showed no documented fistula assessments, and the ADON confirmed there were no LN assessments after the fistula was placed in the right upper arm on 3/31/26. In addition, Resident 42’s dialysis care plan dated 10/27/25 was not updated to include daily assessment of the fistula site, and the ADON confirmed that the care plan did not include those instructions.
Outdated Psychotropic Consent Form
Penalty
Summary
The facility failed to ensure one sampled resident, Resident 12, was free from unnecessary drugs when the required psychotropic medication informed consent form was not renewed every six months. Resident 12 was admitted to the facility on 11/3/20 with diagnoses of chronic pain and major depressive disorder recurrent. The resident’s order listing showed that on 11/20/22 the physician prescribed Cymbalta 60 mg by mouth daily for chronic pain, and the resident’s Psychotropic Drugs Disclosure and Consent form was dated 11/27/22. During a concurrent interview and record review on 5/7/26 at 9:31 am, the ADON reviewed the consent form and confirmed that it was outdated and had not been renewed every six months as required.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required 1:1 Supervision for Resident with Elopement Risk
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of elopement, impaired safety awareness, and multiple behavioral issues related to dementia and neurological conditions. The resident's care plan required 1:1 supervision at all times due to risks of wandering, elopement, and communication difficulties. Despite this, a hospitality aide assigned to the resident left the room for a break without ensuring another staff member was present to maintain supervision. As a result, the resident was left unattended and subsequently wandered from his room into another resident's room. Record reviews confirmed that the hospitality aide's job description required understanding and carrying out resident care plans, and the resident's care plan specifically mandated continuous 1:1 supervision. Interviews with the Director of Nursing confirmed that the facility did not have an appropriate care plan policy and that staff did not follow the established care plan or job expectations. The incident occurred when the hospitality aide failed to arrange for coverage during their absence, and the registered nurse did not provide the required supervision, leading to the resident's unsupervised wandering.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to five residents or their representatives when they were transferred to a hospital or for therapeutic leave. This deficiency was identified during a review of the facility's practices and documentation. The facility's policy requires that at the time of transfer, the resident or their responsible party should receive a copy of the bed hold policy, which specifies the duration for which the bed will be held and the conditions under which the resident must notify the facility of their intention to return. Resident 2, who has multiple diagnoses including dementia, Parkinson's disease, severe intellectual disability, and schizophrenia, was transferred to an acute care emergency department after becoming unconscious. The review of Resident 2's medical record showed no evidence that the resident or his representative was given notification of the bed hold requirement. Similarly, Resident 292, who was admitted with conditions such as anemia, depression, and chronic pain, was transferred to a hospital after reporting severe chest pain, but there was no documentation of a bed hold policy being provided. Additional residents, including Resident 14 with chronic kidney disease, Resident 73 with a cerebral infarction, and Resident 130 with a knee replacement, were also transferred to hospitals without receiving the required bed hold notification. Interviews with the Assistant Director of Nursing confirmed that the facility did not provide the necessary written notice to residents or their representatives, although the Long-Term Care Ombudsman was notified of the transfers.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments for 12 out of 29 sampled residents within the required timeframe. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments were not completed within 14 days, as required by the Resident Assessment Instrument (RAI) Manual. The delay in completing these assessments had the potential to delay the development of comprehensive care plans necessary for providing appropriate individualized care and services for the residents. Resident 44's case highlighted the issue, as their annual MDS assessment, which was due on 11/24/24, was found to be 8 days overdue. Similarly, Resident 41's annual MDS assessment was 24 days overdue. The MDS Licensed Nurse (MDS LN) acknowledged the delay, attributing it to the facility being very busy and behind on completing residents' MDS assessments. This backlog was further confirmed by the MDS Registered Nurse (MDS RN), who stated that the facility was significantly behind on completing discharge assessments, going back to the end of August 2024. The report also detailed several other residents with overdue MDS assessments, including Residents 7, 14, 73, 87, 27, 55, 96, 100, 291, 293, and 294. These residents had various medical conditions, such as sepsis, diabetes, heart failure, and infections, which required timely and accurate assessments to ensure their care plans were up-to-date. The MDS RN expressed concern that the incomplete MDS assessments could result in care plans not reflecting the current interventions needed for the residents' care. The facility's Administrator was aware of the backlog but was not fully informed of the extent of the issue, indicating a lack of communication and oversight in addressing the deficiency.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in their care. Resident 5, who had severe cognitive impairment and required assistance with eating, was left with an untouched lunch tray out of reach, resulting in her being unable to eat. Staff acknowledged the oversight, indicating a lack of awareness of her needs. Similarly, Resident 334, who was dependent on staff for personal hygiene, was observed with long, dirty fingernails, and there was no documentation process in place to ensure nail care was addressed during showers. Residents 23 and 29, both with good cognition but requiring substantial assistance for personal hygiene, reported not receiving regular help with oral care and hair brushing. Resident 23 expressed discomfort in asking for help, while Resident 29's hair was tangled, and oral hygiene was neglected, despite her care plan indicating the need for assistance. Staff confirmed the lack of assistance, and there was a discrepancy between the resident's account and staff's claims of refusal. Residents 73, 291, and 46 also experienced inconsistent oral care. Resident 73, with severely impaired cognition, was found with dry mucus membranes and debris in the mouth, contradicting staff claims of regular oral care. Resident 291, mildly cognitively impaired, lacked access to oral hygiene items, and records showed infrequent care. Resident 46, with intact cognition, reported never being offered oral care, and staff could not locate his oral hygiene items. The facility's documentation indicated inconsistent care, and staff interviews revealed a lack of adherence to care plans and personal preferences for oral hygiene.
Deficiencies in Skin Care and Monitoring for Two Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents. Resident 44, who was admitted with multiple diagnoses including sepsis, Parkinson's, and chronic kidney disease, experienced a deficiency in care related to her Moisture Associated Skin Damage (MASD). Despite having an order for coccyx treatments to be administered daily, there were 13 instances where the treatments were not documented as completed. Interviews with the Treatment Nurse and Assistant Director of Nursing confirmed the lack of documentation, indicating that the treatments may not have been administered as required. Resident 5, who was admitted with anoxic brain damage, dementia, and lymphedema, also experienced a deficiency in care. An order was in place to monitor her left lower extremity venous ulcers for signs of worsening or infection every shift. However, there were seven shifts where the monitoring was not documented, and the Assistant Director of Nursing confirmed that assessments were not performed on three specific shifts. This lack of consistent monitoring could have led to a change in condition going unnoticed. The facility's policies on skin integrity and medication administration were not adhered to, as evidenced by the missing documentation and unperformed treatments. The Assistant Director of Nursing acknowledged the deficiencies in both cases, highlighting a failure to ensure that residents received the necessary care and treatment as per their medical orders.
Failure to Implement Downtime Procedures During Internet Outage
Penalty
Summary
The facility failed to implement its downtime policies and procedures during an internet outage, which occurred on 12/13/24. This outage resulted in the staff's inability to access the residents' electronic medical records (EMR), potentially delaying resident care. The facility's policy, titled 'Downtime Access to Patient Records,' outlined that a 24-hour summary should be saved daily and accessible to staff during network outages. Additionally, the policy stated that a jetpack device should be used to connect to a wireless network to access the EMR remotely. However, during the outage, staff members, including Licensed Nurses (LNs) A and B, were unable to access the EMR using the provided cell phones or the jetpack devices, as these devices were not functioning as intended. Throughout the morning, staff members were observed struggling to access the EMR and were unable to document medication administration. The Assistant Director of Nursing (ADON) informed the LNs that paper Medication Administration Records (MARs) were being printed as a temporary solution. Despite efforts to resolve the issue, including contacting the facility's IT department, the internet remained down, and the jetpack devices were ineffective. The situation persisted until the internet was restored later in the morning, allowing staff to resume normal operations. The deficiency was confirmed by the ADON, who acknowledged the internet outage and the non-functional jetpack devices.
High Medication Error Rate and Inventory Issues
Penalty
Summary
The facility was found to have a medication error rate of 27.59% during a survey, which is significantly higher than the acceptable threshold of 5%. This was observed during medication passes for two residents. For Resident 73, who has a history of dysphagia, dementia, and gastrostomy status, several errors were noted. The Licensed Nurse (LN) A was observed preparing medications without measuring the water used for flushing the g-tube or mixing the Juven packet, contrary to the facility's policy and the manufacturer's instructions. Additionally, LN A attempted to administer Lansoprazole multiple times without success, as the medication beads did not dissolve properly due to the use of cold water instead of warm water as required. Furthermore, the Biotene Spray was not spread around the mouth as recommended. For Resident 184, the survey revealed that the facility failed to provide vitamin D3 as ordered. LN T was unable to locate the medication in the medication cart or storage rooms and subsequently planned to notify the physician and contact the pharmacy. This indicates a lack of proper medication inventory management, which led to the resident not receiving the prescribed medication. The Director of Nursing (DON) confirmed the absence of specific orders for water flushes between medications for Resident 73 and acknowledged the discrepancies in the water measurements used for the Juven packet. The DON also confirmed that the facility should not have run out of vitamin D3 for Resident 184. These findings highlight the facility's failure to adhere to medication administration protocols and ensure the availability of prescribed medications, which could potentially compromise resident health.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs in accordance with professional standards, leading to several deficiencies. One incident involved a medication label that did not match the physician's order for a resident. The label indicated that modafinil was to be taken as needed, while the order specified it should be taken once daily. This discrepancy was confirmed by both the Licensed Nurse (LN) and the Director of Nursing (DON), who acknowledged that the label and order should have matched. In another instance, the medication storage conditions were found to be inadequate. The freezer section of the medication refrigerator in the [NAME] Wing had ice buildup and icicles, which posed a risk of contamination to medications stored nearby. An emergency medication kit was found in a tray with ice and clear liquid, further indicating potential contamination. The DON confirmed these observations and acknowledged the risk of medication contamination due to the storage conditions. Additional issues included unlabeled medication cups and a pill cutter covered in residual pill powder found in a medication cart, expired Ativan in an emergency kit, and a loose pill in another medication cart. Furthermore, a medication cart was found to have cleaning supplies stored alongside medications, which is against the facility's policy. An unlabeled Kangaroo bag used for administering water through a peg-tube was also found in a resident's room, lacking proper identification of its contents. These findings highlight the facility's failure to maintain safe and compliant medication storage and labeling practices.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during a survey conducted over several days. The kitchen had accumulated grime and dust, particularly in the walk-in refrigerator and on various kitchen equipment, such as food processors and storage containers. The Dietary Services Manager acknowledged that deep cleaning of pots and pans occurred weekly, but there was no evidence of a comprehensive cleaning schedule for other areas, such as the walk-in refrigerator. Staff did not consistently adhere to professional standards to prevent cross-contamination. Observations revealed that kitchen staff did not properly use hair restraints, with facial hair left uncovered, and gloves were not changed between tasks, leading to potential contamination. Aprons were improperly stored, increasing the risk of cross-contamination. Despite training on these topics, staff did not consistently follow the guidelines, as evidenced by multiple observations during the survey. The facility also failed to consistently document food cooling processes, which are critical for food safety. The cooling log for certain food items, such as flan, lacked start times, making it impossible to determine if cooling met safety requirements. Additionally, pureed fish prepared by staff did not match the consistency required by the facility's diet manual, resulting in a thick, gummy texture. Despite ongoing training and education, these issues persisted, raising concerns about the effectiveness of the facility's training and oversight processes.
Failure to Follow Preplanned Vegetarian Menu Cycle
Penalty
Summary
The facility failed to adhere to a preplanned standardized menu cycle or provide cooks with spreadsheets for vegetarian meals, potentially compromising the nutritional needs of vegetarian residents. The facility's assessment indicated a commitment to meeting individualized dietary requirements, including specialized diets and cultural or ethnic dietary needs. However, the facility did not have a vegetarian menu cycle or cook's spreadsheets, unlike other diets that had a four-week menu cycle. The Registered Dietitian (RD) and the Medical Director had approved a diet manual that included guidelines and a sample menu for a vegetarian diet, but there was no evidence of a comprehensive vegetarian menu cycle or nutrient analysis specific to vegetarian meals. Interviews with kitchen staff revealed that vegetarian meals were prepared based on available ingredients and personal judgment rather than a structured menu. The staff mentioned a vegetarian recipe binder, but it was not present in the kitchen as the RD had it. The facility provided a four-week vegetarian menu to surveyors, but it did not align with the meals reportedly prepared for a vegetarian resident, such as cheesy potatoes and tacos. The RD was unaware if the nutrient analysis provided was for vegetarian alternatives or standard meals, indicating a lack of clarity and organization in meeting the dietary needs of vegetarian residents.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature, as observed during a survey. Four out of twenty-nine residents interviewed reported that their meals were consistently cold. Resident 29, who was on a fortified mechanical soft texture diet, expressed dissatisfaction with the taste and temperature of the meals, which were barely warm. Resident 284 and Resident 54 also reported that their food was cold, with Resident 54 noting that being in the last hall contributed to this issue. Resident 44 mentioned that the food was cold upon arrival and that staff were not allowed to reheat it. Observations during the survey revealed that the meal tray line was frequently stopped due to missing items, causing delays. The meal cart schedule indicated staggered delivery times, with the last trays being delivered significantly later. Temperature checks of test trays showed that food temperatures were below the recommended levels, with pureed and regular diet trays showing temperatures as low as 95 F to 116 F. Despite the flavor being deemed pleasant, the food was not warm enough, confirming the residents' complaints.
Failure to Meet Dietary Texture Needs
Penalty
Summary
The facility failed to meet the individual dietary texture needs of six residents, as observed during a survey. The deficiency was identified when the food consistencies provided did not align with the facility's diet manual standards or the residents' preferences. Specifically, during a lunch tray line observation, kitchen staff placed whole parsley sprigs on trays for residents on pureed and mechanical soft diets, contrary to the diet manual's instructions to use parsley flakes to reduce choking risks. Additionally, the pureed fish prepared by kitchen staff was found to have a gummy texture, which did not meet the required smooth consistency as per the facility's diet manual and recipe guidelines. The report also highlighted that a resident expressed dissatisfaction with the dryness of the food, stating that no one had inquired about her food preferences or need for moist foods. The resident's lunch tray ticket did not indicate any alerts regarding moist food preferences, although it did list specific food dislikes. The dietary services manager and registered dietitian acknowledged the gummy texture of the pureed fish during an evaluation, although they did not consider it a choking hazard. These observations and interviews indicate a failure in the facility's dietary services to adhere to prescribed dietary modifications and resident preferences, potentially impacting residents' ability to consume their meals safely and comfortably.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of practice in food service safety, leading to several deficiencies. The kitchen was found to be unsanitary, with dust and grime accumulated in the walk-in refrigerator and freezer, and soiled equipment such as pots, pans, and storage bins. The cook's food preparation sink was used improperly for multiple tasks without proper cleaning, increasing the risk of cross-contamination. Additionally, a box fan in the kitchen was covered in thick dust, posing a contamination risk. Kitchen staff did not adhere to professional standards to prevent cross-contamination. Aprons were improperly stored with personal belongings, and gloves were not changed between tasks, leading to potential contamination. Hair restraints were not effectively used, as observed with a staff member's facial hair exposed during food preparation. The ambient food cool down process was inconsistently performed, with missing or incomplete temperature logs, raising concerns about food safety. The facility also lacked an effective process for managing dented cans, with dented cans found in the dry storage room without a designated area for separation. Three nursing unit nourishment rooms were unsanitary, with soiled condiment drawers, refrigerators, and counters, and personal items stored inappropriately. Non-food-safe chemicals were used to clean food contact surfaces in these rooms, contrary to manufacturer recommendations and facility policy.
Sanitary Food Storage Deficiency in Nourishment Rooms
Penalty
Summary
The facility failed to ensure sanitary food storage for residents' personal food in three nursing unit nourishment rooms. Observations revealed that resident food stored in the freezer was not labeled with patient identifiers such as name, room number, and date, which is necessary to ensure the correct patient receives their personal food items. This lack of labeling had the potential to cause foodborne illness and a decline in residents' quality of life if personal foods were discarded or given to someone else. During observations, the nourishment rooms were found to be commingled with large plastic closets full of employee personal belongings, including coats and opened beverages stored on counters. The rooms were also noted to have soiled and sticky floors, uncovered trash, and soiled condiment drawers. The refrigerators and freezers contained various unlabeled and undated food items, including ice cream, protein shakes, and fruit cocktail, which were not properly stored according to the facility's policy. Interviews with staff, including a housekeeper, the Dietary Services Manager, a Registered Dietician, and the Director of Nursing, confirmed that staff personal belongings and food were a consistent problem in the nourishment rooms. The Director of Nursing acknowledged that the rooms were not intended for staff use and that the facility had not removed the plastic closets used during COVID. The facility lacked a policy on the storage of employee personal property, food, or beverages, contributing to the ongoing issues in the nourishment rooms.
Deficiency in Timely Completion of Resident Assessments
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to identify and resolve deficiencies related to the timely completion of residents' assessments. This deficiency affected 13 out of 29 sampled residents, potentially leading to inaccurate data regarding their health status and delaying the development of comprehensive, individualized care plans. The facility's QAPI policy outlines goals and objectives aimed at identifying and resolving negative outcomes, supporting root cause analysis, and coordinating performance improvement projects. However, the facility did not adhere to these guidelines, resulting in incomplete Minimum Data Set (MDS) assessments. During interviews, the Minimum Data Set Registered Nurse (MDS RN) acknowledged being significantly behind in completing MDS assessments, citing insufficient nursing hours as a contributing factor. The MDS RN expressed concern that incomplete assessments could lead to outdated care plans, impacting resident care. The Administrator admitted awareness of the backlog but was not fully informed of its extent. The Administrator expected the MDS RN to report such issues to facilitate a root cause analysis and corrective action, which had not occurred, contributing to the ongoing deficiency.
Inadequate Infection Control PIP Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to develop and implement appropriate plans of action to correct an identified deficiency related to infection control. This deficiency was noted during a review of the facility's Quality Assessment and Performance Improvement (QAPI) policy, which lacked a revised date. The policy outlined the design and scope of the QAPI program, governance and leadership, systems to monitor care and services, performance improvement projects, and systematic analysis and action. However, the facility did not adhere to these guidelines, particularly in the area of infection control. During interviews and record reviews, it was revealed that the facility had an ongoing Infection Control Performance Improvement Project (PIP) initiated by a previous Infection Control Preventionist (IP) in May 2023. The current IP had been conducting hand hygiene audits since July 2024, but only two audit reports were available, dated July 9 and July 16, 2024. The Administrator could not provide documentation of the resources, plan, action, and goals for the ongoing Infection Control PIP. Additionally, the Assistant Director of Nursing (ADON) admitted that the facility's document titled 'Hand Hygiene and Personal Protective Equipment QAPI Statement and Charter' did not contain essential elements of PIPs, such as root cause analysis, feedback systems, plans of action, implementation timelines, and benchmarks.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to ensure effective infection control practices in several areas, as observed during a survey. Staff members did not consistently perform hand hygiene during meal service, which is a critical procedure for preventing the spread of healthcare-associated infections. Multiple instances were noted where CNAs and other staff members handled food and interacted with residents without sanitizing their hands before and after these activities. This lack of adherence to hand hygiene protocols was confirmed through interviews with the staff, who either admitted to not following the procedures or were unsure of the requirements. The nourishment rooms in the nursing units were found to be unsanitary, with food debris, grime, and personal staff items stored inappropriately. The use of non-food-safe chemicals to clean food contact surfaces further compounded the issue, as the facility's disinfectant was not verified as safe for use in food service areas. Additionally, the RNA room was observed to be unsanitary, with live cockroaches present, and the room's condition was not conducive to maintaining a hygienic environment for resident care. Specific resident care practices also failed to meet infection control standards. For instance, a resident's CPAP and nebulizer equipment were found to be dirty, and oxygen tubing was observed on the floor where insects were present. In another case, a bedpan was improperly stored under a resident's bed without a barrier, and a CNA was observed handling personal care items with soiled gloves during peri care. Furthermore, a licensed nurse did not follow proper procedures when checking a resident's blood sugar, failing to use barriers and appropriate disinfectant wipes, which posed an infection control concern.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of pests in various areas. An unidentified bug resembling an earwig was observed in a resident's room, which was cluttered with cardboard boxes and had a buildup of grime. The Maintenance Supervisor acknowledged ongoing pest issues, including cockroaches, and noted that the facility had a monthly pest control service. However, the service primarily focused on spraying outside the facility, and there was a lack of deep cleaning in affected areas due to staffing shortages. In the Restorative Nursing Assistant (RNA) dining room, cockroaches were observed on multiple occasions, including during meal times when residents were present. The room was noted to be dirty, with grime on the floors and baseboards. Interviews with staff revealed that the pest control company did not regularly spray inside the facility, and deep cleaning was not routinely performed. The presence of cockroaches was a known issue, yet there were no additional actions taken to address the infestation effectively. The facility's nourishment rooms, where resident food is stored, were also found to be unsanitary and cluttered with employee personal belongings. Open beverages and uncovered trash were present, creating conditions conducive to pest infestations. Despite the ongoing presence of cockroaches, there were no Quality Assurance/Performance Improvement (QAPI) processes in place to address the issue. The facility's failure to implement an effective pest control program compromised the health and safety of residents, staff, and visitors.
Failure to Address Resident Grievance Regarding Privacy Violation
Penalty
Summary
The facility failed to address a grievance raised by a resident, identified as Resident 183, regarding staff going through her personal belongings without permission. Resident 183, who was admitted with severe sepsis, a urinary tract infection, and metabolic encephalopathy, expressed her concerns during an observation and interview. Despite the resident's clear expression of distress and her statement that the night staff had invaded her privacy, the Social Service Director (SSD) did not offer the resident the opportunity to file a grievance report. This oversight was noted during a review of the facility's grievance procedure, which mandates that grievances be taken seriously and reported appropriately. Further investigation revealed that the facility's grievance binder, managed by the Activities Director (AD), contained no grievance report for the month in question. Interviews with the SSD and the Assistant Director of Nursing (ADON) confirmed that staff were expected to file grievance reports on behalf of residents. However, the SSD acknowledged hearing the resident's complaint but did not take immediate action to file a report or initiate an investigation. This inaction led to the resident's grievance going unaddressed, highlighting a failure in the facility's grievance handling process.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and the State Long-Term Care Ombudsman when the resident was sent to the hospital for emergency care. The facility's policy requires that before a transfer or discharge, the resident and, if applicable, a family member or legal representative must be notified in writing, including the reasons for the move, the effective date, the location to which the resident is transferred, the right to appeal, and the contact information for the State LTC Ombudsman. However, this procedure was not followed for a resident who was admitted with multiple diagnoses, including anemia, depression, anxiety, chronic pain, heart disease, and lung disease, and who was her own representative. The resident was admitted to the facility and within less than 24 hours, she became agitated and reported severe chest pain, leading to her transfer to an acute hospital for further evaluation. During interviews, the Assistant Director of Nursing (ADON) confirmed that there was no written notice of discharge provided to the resident or the Ombudsman, as required by the facility's policy. This oversight had the potential to disrupt the coordination of support for the resident during discharge planning.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the required 92 days for two residents, Resident 57 and Resident 8. Resident 57, who was readmitted with multiple diagnoses including stroke, dementia, and chronic pain, had a quarterly MDS assessment dated 10/28/24 that was not completed by the due date of 11/12/24, making it 35 days overdue. During a review, the Minimum Data Set Licensed Nurse (MDS LN) acknowledged the delay and attributed it to the facility being very busy and behind on completing residents' MDS assessments. Similarly, Resident 8, admitted with conditions such as sepsis, heart failure, and bipolar disorder, had a quarterly MDS assessment dated 11/16/24 that was due by 11/30/24 but was 18 days overdue. The Minimum Data Set Registered Nurse (MDS RN) expressed concerns about the backlog of MDS assessments and the potential impact on residents' care plans, noting that the issue had been discussed with the facility's Administrator. The MDS RN highlighted the shortage of nursing hours as a contributing factor to the delay in completing the assessments.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Level 1 Preadmission Screening and Resident Review (PASARR) for a resident, which is crucial for determining the appropriateness of admission for individuals with mental disorders or intellectual disabilities. Specifically, the Level 1 PASARR for a resident was missing a diagnosis of bipolar disorder, which was present in the resident's admission records. Additionally, the PASARR incorrectly included a diagnosis of dementia, which was not documented in the resident's discharge summary or any records until a later date. This discrepancy was confirmed during interviews and record reviews with the Health Information Assistant (HIA) and the Minimum Data Set (MDS) nurse. The Assistant Director of Nursing (ADON) and HIA confirmed that the hospital was responsible for performing the initial PASARR, while the facility's medical records department was tasked with ensuring its accuracy. However, the facility did not provide a policy and procedure outlining the PASARR process when requested. The ADON acknowledged the discrepancies in the PASARR, which could potentially lead to residents being admitted without a proper understanding of their mental health needs or the facility's ability to meet those needs.
Failure to Implement Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident identified as malnourished at admission, resulting in significant weight loss. The resident, who was capable of making her own healthcare decisions, experienced an 11-pound weight loss, equating to 6.24% of her body weight, over a two-week period. Despite being at risk for weight loss due to inadequate intake and other factors, no care plan was created to address this issue. Observations and interviews revealed that the resident was aware of her weight loss but was not informed of any plan to address it. The Restorative Nursing Aid (RNA) confirmed that the resident's weight was monitored weekly and reported to the Registered Dietitian (RD) when significant weight loss was detected. However, the RD could not find documentation of any follow-up actions or discussions with the resident regarding her weight loss. Further review with the Assistant Director of Nursing (ADON) confirmed that the facility had regular meetings to discuss nutrition and weight loss issues, but no such meeting was held for this resident. The ADON acknowledged the absence of a weight loss care plan and the lack of an Interdisciplinary Team (IDT) meeting to address the resident's significant weight loss, indicating a failure in the facility's processes to manage the resident's nutritional needs effectively.
Improper Use of DeClogger on Resident's Peg-Tube Without Physician's Order
Penalty
Summary
The facility failed to provide professional standards of care for one resident when Licensed Nurses (LNs) used a DeClogger on the resident's peg-tube without a physician's order, a care plan, or a monitoring system in place. The DeClogger, a device used to de-clog peg-tubes, was used on a resident who was not their own responsible party and had been admitted with diagnoses including dysphagia, dementia, and gastrostomy status. The DeClogger package instructions indicated it was for use with a physician's prescription, yet no such order was present. During an observation, LN A was seen using the DeClogger multiple times on the resident's peg-tube without measuring the water mixed with medication and without flushing the tube after use. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed there was no physician's order for the DeClogger, and the resident's care plan did not include its use. Additionally, there was no treatment monitor to track the frequency of DeClogger use, which could lead to unnoticed peg-tube malfunctions and potential health declines.
Inadequate Peri-Care Leads to Repeated UTIs
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections (UTIs) for one resident, identified as Resident 44, due to improper peri-care by Certified Nursing Assistants (CNAs). Resident 44, who was fully dependent on staff for toileting and perineal hygiene, reported that CNAs did not clean her adequately after incontinent episodes, leading to discomfort and repeated hospitalizations for UTIs. The resident's medical history included conditions such as sepsis due to E. coli, urinary tract infection, Parkinson's disease, diabetes, and chronic kidney disease. Lab results confirmed the presence of E. coli in her urine, and she was treated with antibiotics. Interviews with staff revealed that the Infection Preventionist had not conducted peri-care training for CNAs, despite being aware of Resident 44's complaints about inadequate cleaning. A CNA reported finding dried bowel inside the resident's vagina, indicating incomplete cleaning after an incontinent episode. The Infection Preventionist acknowledged that improper peri-care could lead to UTIs and emphasized the importance of thorough cleaning from front to back. The Assistant Director of Nursing also stated that residents should be cleaned completely, aligning with the expectations for proper hygiene to prevent infections.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain the nutritional status of Resident 288, who experienced significant weight loss over a two-week period. Resident 288, identified as malnourished upon admission, lost 11 pounds, equating to a 6.24% decrease in body weight, from November 19, 2024, to December 3, 2024. This weight loss was not identified in a timely manner, and no interventions were implemented to address the issue, despite the facility's policy requiring weekly weight monitoring and re-weighing in cases of significant weight changes. The Registered Dietitian (RD) and Restorative Nursing Aid (RNA) were involved in the weight monitoring process. The RNA reported Resident 288's weight loss to the RD on December 3, 2024, but the RD did not document this in the resident's clinical record. Additionally, the RD failed to initiate a weight loss care plan or bring the issue to the Interdisciplinary Team (IDT) for discussion, as required by the facility's procedures. The RD acknowledged the oversight but could not find any notes or documentation regarding the weight loss or any discussions with the resident about a plan to address it. The Assistant Director of Nursing (ADON) confirmed that the facility held regular meetings to discuss nutrition, hydration, and skin issues, where weight loss cases should be addressed. However, no such meeting was held for Resident 288, and no care plan was initiated to manage the resident's weight loss. The ADON expected the RD to identify and address the weight loss issues, but this did not occur, leading to a failure in maintaining the resident's nutritional status.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide necessary monitoring for a resident who was prescribed antipsychotic medications, specifically Asenapine and Haloperidol. The resident, who was not their own responsible party, had diagnoses including dementia, bipolar disorder, and unspecified psychosis. Despite the physician's orders for Asenapine Transdermal Patch to be applied daily for mood swings and outbursts, there was no monitoring in place to track specific behaviors related to the use of this medication. This lack of monitoring was confirmed during an interview and record review with a Registered Nurse/Neuropsychiatric Assistant (RN/NA). Additionally, the facility did not have monitoring in place to assess for adverse reactions to Haloperidol, which was prescribed to the resident for mood swings evidenced by emotional outbursts and aggression. The facility's policy required staff to monitor residents on antipsychotics for complications or side effects, but this was not done for the resident. The absence of monitoring for both medications was confirmed during the same interview and record review with the RN/NA, indicating a failure to adhere to the facility's policies and procedures.
Deficiencies in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure adequate oversight of the Food and Nutrition Services (FNS) by the Registered Dietitian (RD) and Dietary Services Manager (DSM). The RD did not provide evidence of regularly scheduled consultations and audits of the kitchen, and the documentation provided did not offer detailed insights into the issues identified. The RD's oversight was questioned as sanitation and food safety concerns were observed, including soiled equipment, potential cross-contamination, and improper food handling practices. The RD's audits showed declining scores in various areas, but there was no detailed information to understand the reasons behind these declines or if corrective actions were being taken. Effective systems and monitoring were not in place to ensure the sanitation of the kitchen, proper food cooling, consistency of pureed foods, and management of dented cans. The kitchen was found to be unsanitary, with dust and grime accumulation, improper use of the cook's prep sink, and inadequate cleaning practices. Food cooling logs were incomplete, and there was a lack of documentation to verify that food temperatures were being properly monitored. The preparation of pureed diets did not follow the prescribed recipes, resulting in improper food consistency. Additionally, dented cans were found in the kitchen's dry storage room, and there was no clear process for handling them. The facility also failed to follow a pre-planned vegetarian menu cycle for residents requiring vegetarian diets. Although a four-week vegetarian menu cycle was reportedly in place, kitchen staff were unaware of it and did not follow it. Instead, they prepared meals based on their discretion, which did not align with the documented menu. This lack of adherence to the planned menu cycle raised concerns about the facility's ability to meet the dietary needs of residents with specific dietary requirements.
Failure to Provide Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to explain the terms of the arbitration agreement to a resident in a language that she understood. Resident 283, who was admitted with diagnoses including left knee osteoarthritis and an artificial left knee joint, primarily speaks Spanish and is capable of making her own healthcare decisions. However, the arbitration agreement was provided to her only in English, despite the Admissions Transition Coordinator (ATC) being aware that Resident 283 only spoke and understood Spanish. The ATC relied on the resident's son, who spoke English, to agree to the terms, leading to Resident 283 signing a document she did not comprehend. During an interview with the assistance of an interpreter, Resident 283 confirmed that she signed the agreement because her son instructed her to do so, without understanding its contents. The ATC admitted to providing the arbitration agreement in English and acknowledged that no effort was made to communicate the terms in Spanish or ensure that Resident 283 understood what she was signing. This oversight resulted in the resident being unable to make an informed decision regarding the arbitration agreement, potentially denying her rights.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain medication to a resident in accordance with the resident's comprehensive care plan and physician's orders, leading to increased pain and discomfort. The resident, who had a history of a broken leg, muscle weakness, lung disease, and chronic pain, was supposed to receive Norco every four hours. However, the medication was frequently administered late, beyond the 60-minute window allowed by the facility's policy. The resident reported that the delay in receiving pain medication caused her pain to increase, making it difficult to manage. The Medical Administration Record (MAR) showed that from June 11 to June 26, the resident received 12 doses of Norco more than 60 minutes late. Interviews with the nursing staff revealed various reasons for the delays, including busy shifts and shared medication carts, which contributed to the late administration of medication. The Executive Nurse Director confirmed that the Norco tablets were given late on 12 occasions, contrary to the facility's policy. Despite one nurse's claim that the medication was administered on time but recorded late, the narcotic count book did not support this assertion. The facility's failure to adhere to the scheduled times for administering pain medication resulted in the resident experiencing increased pain and discomfort.
Resident Abducted by Restricted Visitor Due to Inadequate Visitor Screening
Penalty
Summary
The facility failed to protect a resident from mistreatment and mental abuse when a restricted visitor abducted him from the facility. The resident, who had severe cognitive impairment and was unable to make his own healthcare decisions, was taken by a restricted visitor to a local check cashing business with the intent of financial exploitation. The facility's visitation policy lacked procedures to address visitor precautions or restrictions, allowing the restricted visitor to enter the facility using a fictitious name without being identified or questioned. The receptionist on duty at the time of the incident was not fully trained on handling visitors and did not check the Visitor and Phone Call Precautions list, which included the names of restricted visitors. The receptionist allowed the visitor to sign in with a false name and did not verify the visitor's identity or reason for the visit. Additionally, the facility staff, including nurses and certified nursing assistants, were not adequately informed or trained on the procedures for handling restricted visitors, leading to a lack of communication and awareness about the resident's vulnerability and the presence of restricted visitors. The facility's failure to implement a comprehensive visitor screening system and adequately train staff on visitor management contributed to the resident's abduction. The staff did not consistently check the restricted visitor list or the resident's care plan for special instructions regarding visitors. The lack of a coordinated approach to visitor management and the absence of a clear policy for handling restricted visitors resulted in the resident being taken from the facility without proper authorization or supervision.
Removal Plan
- All facility staff training on the new policy titled Visitation which included checking identification for all visitors coming to visit a resident on the Visitor and Phone Call Precaution list.
- The Visitor's log will now include reason for visit and pictures of restricted visitors.
- Nursing staff should be aware of all visitors and any concerns regarding visitors should be reported to immediate supervisor or security/maintenance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oroville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Feather River Care Center | 0 mi | ★★★★★ | 7 | 0 |
| Country Crest Post-acute | 1.3 mi | ★★★★★ | 17 | 0 |
| Gridley Post Acute | 12.6 mi | ★★★★★ | 2 | 0 |
| River Valley Care Center | 18.2 mi | ★★★★★ | 1 | 0 |
| California Park Post Acute | 20.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.