Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Ridge Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease, dementia, and generalized anxiety was paired as a roommate with another severely cognitively impaired resident who had anxiety disorder and depression. After the room change, staff documented that the second resident did not adjust well, repeatedly yelled at staff and the roommate, and shouted statements such as “Who let this woman in my house,” with ongoing notes of agitation and verbal aggression. Staff and family reported that the aggressive resident frequently cursed, used hateful and derogatory language in Spanish, and called the roommate offensive names such as “son of a b---” and “Get this b--- out of my house,” leading staff to move the affected resident out of the room during the day because the two residents fought and disturbed others. Nursing staff, the DON, and the Administrator acknowledged that such name‑calling and cursing directed at another resident could be verbal abuse if it caused emotional distress, and family reported the affected resident became angry and upset when sworn at, consistent with the facility’s abuse policy definition of verbal abuse.
The facility failed to accurately code a resident’s MDS for verbal behavior symptoms when documentation and staff interviews showed ongoing yelling and verbal aggression toward staff and a roommate. The resident, with anxiety, depression, and severe cognitive impairment, had a change-of-condition note describing increased yelling and verbal aggression, and the MAR documented Lorazepam use for constant yelling causing exhaustion, with behavior monitoring every shift. A nurse who spoke Spanish reported the resident cursed at her roommate using very hateful language, yet the MDS nurse coded Section E as having no verbal behaviors directed toward others, later acknowledging that the documented yelling episodes could meet criteria for behaviors affecting others and that he likely missed this information despite reviewing MARs and progress notes.
A resident with MS, bilateral knee contractures, kyphosis, scoliosis, and edema, and with no cognitive impairment per BIMS, had her personal motorized wheelchair withheld by facility administration after two occasions when she left the facility using specialized public transportation and was unable to return, leading to 911 calls and hospital transports. The Administrator acknowledged that the resident’s motorized wheelchair was kept in the facility but that she was not allowed to use it, and she was instead provided a manual wheelchair that she reported was very uncomfortable, caused her arm to become stuck, and did not allow leg elevation for edema. The resident stated she did not know where her wheelchair was and that staff would not tell her, while facility documents stated residents have the right to retain and use personal possessions unless they affect the rights or health and safety of other residents.
Missing Monthly Medication Regimen Review: The facility failed to ensure the Consulting Pharmacist completed and maintained a monthly MRR for all residents. The MRR binder did not contain the pharmacist's October report, and the DON stated the report was unavailable because the pharmacist was out on paternity leave. The report was later emailed to surveyors and showed review of 67 medication lists with zero recommendations, despite the facility policy requiring monthly review of each resident's medication regimen and medical chart and timely availability of the findings.
Unsafe Food Storage and Kitchen Sanitation Practices: A cook was observed in the prep area without a beard restraint or face mask, and the facility did not have beard restraints available. Prepared cheese sandwiches and an open bag of chicken breasts were found unlabeled and undated, two seasoning containers were past their use-by dates, boxes of mashed potatoes were stored directly on the floor, and a manual can opener had worn metal on the blade with food build-up.
Failure to Inform Residents About Advance Directives: The facility did not provide or document written or verbal information about Advance Directives for multiple residents, including residents with no AD on file and others whose POLST forms had blank AD sections. The DON stated POLST is not the same as an AD and that SSD should discuss ADs on admission and document the conversation, while the SSD said she offered AD forms but did not document the discussions.
Failure to Hold Quarterly IDT Care Conferences: The IDT did not consistently meet to review and revise care plans for several residents. A resident with stroke-related deficits, dementia, aphasia, and severe cognitive impairment had no documented care conferences or revised care plans, while other residents with failure to thrive, malnutrition, stroke-related weakness, repeated falls, PTSD, and vascular dementia also lacked documented quarterly care conferences. The SSD stated care conferences were behind across the board, and the MDS Coordinator said the quarterly meetings usually included the SW, MDS Coordinator, and other team members when available.
Food Not Served in a Palatable or Appetizing Manner: Several residents complained that meals were horrible, awful, bland, or otherwise unappetizing, including a resident on a pureed diet who reported lumps, poor taste, and unclear meal identification. During tray observation, the regular meal was bland and the pureed meal was unappetizing, lacked taste, and had a gummy texture. Residents also reported overcooked meat, dry chicken, and pizza like cardboard, and the RD noted palatability concerns could reduce intake and contribute to unplanned weight loss.
Failure to Provide Hot Beverages Consistent With Preferences: A facility did not provide coffee or tea to several residents for more than two weeks after the coffee maker broke and a temporary machine was deemed too hot to use. Multiple residents stated they had not received coffee or hot tea, that it was a problem, and that they were unhappy because these preferred beverages were not available during meals or the coffee social.
Failure to care plan oxygen therapy for a resident with COPD, pleural effusion, and atelectasis. The resident had an order for supplemental O2 at 2-3 LPM and pulse checks each shift, but the care plan did not include oxygen therapy. During observation, the resident was awake and alert, wearing a nasal cannula with the concentrator set at 2 L of humidified O2, and an LN confirmed there was no oxygen care plan.
Failure to Provide Translation Services for a Mandarin-Speaking Resident: Staff did not consistently use translation services for a resident whose preferred language was Mandarin Chinese. The resident had difficulty communicating needs such as pain and sleep concerns, while nurses relied on nonverbal communication or personal phone translation apps and were unsure of the resident’s dialect or whether facility translation services were available. Invoice review showed Mandarin translation services were used only twice during the review period.
Failure to Complete Trauma-Informed Care Screening: A resident admitted with hemiplegia, hemiparesis after CVA, and PTSD was not screened for trauma-informed care on admission. Staff documented verbal outbursts, agitation, and anxiety, and the resident stated he did not feel safe and felt threatened by another resident. An LPN described episodes triggered by loud singing and the resident believing he was being followed, while the SSD confirmed the TIC screening form was not completed even though it was used to identify trauma history and triggers.
A resident with pneumonia and an oxygen order had a rented oxygen concentrator in the room that was visibly dirty, with debris on the machine, a black filter needing replacement, and dust buildup in the vents. The DON, MNT, IP, and ADM each acknowledged the equipment was not being kept clean and usable as required by the facility's respiratory equipment cleaning policy.
A resident with sepsis and a left hip prosthesis infection was discharged from LTC to an ILF despite needing help with ADLs, including bathing, meal setup, and mobility with a wheelchair and FWW. Records and interviews showed the resident was told the ILF would help him, but the ILF was not wheelchair accessible and did not provide the needed assistance; the resident said he trusted the SSD and did not eat after discharge because he could not cook or set up his food.
A resident with severe cognitive impairment was struck on the cheek by another resident with dementia while in the dining room. The incident was witnessed by a staff member, and the affected resident was assessed by an LPN, who noted slight redness but no pain. The Social Services Director confirmed the event as abuse and acknowledged the facility's responsibility to keep residents safe, as outlined in the facility's abuse prevention policy.
A resident experienced two falls, and the facility failed to immediately notify the responsible party because the contact number on file was incorrect. Nursing staff attempted to call and left voicemails, but the responsible party did not receive them. The error was only discovered and corrected at the time of the resident's discharge, resulting in delayed notification of the falls.
A resident's responsible party was not provided with a summary of the baseline care plan within 48 hours of admission, as required by facility policy. Review of records and staff interviews confirmed that there was no documentation showing the BCP summary was given to the responsible party, despite the policy mandating this communication.
A resident with Alzheimer's Disease and a history of falls was placed in a wheelchair without an assessment or care plan supporting its use. The resident, previously ambulatory with a cane, slid from the wheelchair and fell. Staff and DON confirmed there was no documentation or evaluation for wheelchair use, and the facility's fall management policy was not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nursing staff failed to promptly initiate CPR and follow emergency response protocols for a resident with a full code status who was found unresponsive and pulseless. Staff were unclear on facility policy, delayed CPR while verifying code status, did not immediately call 911, and lacked access to an AED. Not all licensed nurses were current in CPR/BLS certification at the time of the event.
A resident with multiple medical conditions did not receive all physician-ordered laboratory tests, including a norovirus test and timely repeat labs for magnesium and CMP, despite documentation indicating the orders were noted and supposed to be carried out. Staff confirmed the tests were not completed as ordered, in violation of facility policy requiring adherence to physician orders.
The facility failed to complete quarterly MDS assessments for two residents and did not complete them timely for two others. A resident readmitted in August did not have a subsequent MDS completed, and another admitted in August also lacked a follow-up MDS. The MDS Coordinator was unaware of these needs and acknowledged delays. Additionally, two residents had their MDS assessments completed late, with the MDS Coordinator admitting to struggling with timely completion. The DON and Administrator were unaware of these issues and expected timely completion.
A resident with a history of cerebral infarction and inability to speak was not provided with necessary communication aids, such as a communication board and pointer, as outlined in their care plan. Observations and interviews revealed that the communication board was out of reach and the pointer was missing, which staff were unaware of until informed by a surveyor.
A resident with severe cognitive impairment and a history of chronic pain, acute systolic heart failure, and epilepsy eloped from the facility twice due to inadequate supervision and environmental hazards. The resident's room had a sliding door that allowed them to exit without staff knowledge. Despite initial exit-seeking behavior, the facility did not move the resident to a safer room until after the second elopement.
The facility did not comply with regulatory guidelines for resident room sizes, with seven rooms providing less than the required 80 square feet per resident. Measurements confirmed the deficiency, and while the Administrator was aware of the issue, the DON was not informed about the square footage requirements.
A resident, legally blind and using a walker, was allowed to leave a facility without a physician's order, accompanied by staff to purchase alcohol. The resident consumed the alcohol, became intoxicated, and attempted to leave against medical advice. The facility failed to document the outing or follow its policy requiring a physician's order for such passes, and the incident was not investigated or recorded in the resident's care plan.
The facility failed to report an allegation of abuse within the required two-hour timeframe. A resident reported that a CNA put his hand on her face and around her mouth area. The incident was reported to law enforcement and CDPH the following day, which delayed the timely investigation by authorities.
Failure to Protect Resident From Ongoing Verbal Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a roommate. One resident (Resident 7) had Alzheimer’s disease, unspecified dementia, generalized anxiety, and severe cognitive impairment per a recent MDS. Another resident (Resident 6) had anxiety disorder, depression, and severe cognitive impairment. On 12/10/25, social services moved Resident 6 into a new room to have a Spanish‑speaking roommate, pairing her with Resident 7. Nursing notes beginning 12/11/25 documented that Resident 6 was not adjusting well to the room change, was yelling at staff and her roommate, and was shouting statements such as “WHO LET THIS WOMAN IN MY HOUSE,” with repeated documentation that she was not adjusting to the roommate. Subsequent nursing documentation on 12/12/25 and a change of condition note on 1/9/26 showed ongoing monitoring for emotional distress and continued yelling and verbal aggression by Resident 6 toward staff and her roommate. Staff notes indicated Resident 6 continuously shouted at her roommate and staff and remained agitated. During surveyor observations on 2/10/26, Resident 6 was heard yelling loudly from her bed, saying “This is my house” and “Call the police.” Staff interviews revealed that Resident 6 did not want a roommate, believed the room was her house, and that the two residents “fought all the time,” leading staff to close the room door and to move Resident 7 out of the room during the day because the interactions upset and disturbed others. Family members of Resident 7 reported that Resident 6 did not want anyone in the room and directed offensive words at Resident 7, causing Resident 7 to be angry and upset when sworn at. Nursing staff described Resident 6 as angry, confused, and agitated, and stated that when Resident 7 returned to the room, Resident 6 became agitated and used very ugly and hateful curse words in Spanish, including calling Resident 7 a “son of a b---” and saying “Get this b--- out of my house.” Staff, including an LN and the DON, acknowledged that such name‑calling, cursing, and use of terms like “b---” and “stupid” directed toward another resident could constitute verbal abuse if it upset the recipient. The Administrator stated he would have investigated if he had known residents were using such terms toward each other, recognizing it as potential verbal abuse. The facility’s abuse policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, and required supervisors to immediately correct and intervene in situations in which abuse is at risk for occurring.
Inaccurate MDS Behavior Assessment for Resident With Verbal Aggression
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident when Section E of the MDS indicated the resident had no verbal behavior symptoms directed toward others, despite documentation and staff reports to the contrary. The resident had diagnoses of anxiety disorder and depression and was documented as having severe cognitive impairment on the MDS. A change of condition narrative note dated 1/9/26 described monitoring for increased yelling and verbal aggression toward staff, stating the resident continued to yell toward staff and her roommate. The resident’s MAR for January 2026 documented administration of antianxiety medication (Lorazepam) for behavior manifested by constant yelling causing exhaustion to self, with instructions to monitor behavior every shift. During interviews, a licensed nurse who spoke Spanish reported that the resident cursed at her roommate in Spanish using very ugly, hateful words directed at the roommate. The MDS nurse stated he used various data sources for assessments, including observations, the electronic MAR, and nursing progress notes. Upon reviewing Section E of the resident’s MDS, he confirmed it showed no verbal behavior symptoms directed toward others, and upon reviewing the January MAR, he confirmed the resident was being monitored for yelling that caused exhaustion and had multiple episodes of yelling incidents. He acknowledged that yelling to exhaustion could meet the criteria of behaviors affecting others and stated he did not know why he did not identify this when completing the MDS, indicating he probably just missed it. Facility policy required that the RAI/MDS be completed accurately and used to guide individualized, resident-centered care planning and quality outcomes.
Resident’s Personal Motorized Wheelchair Withheld, Forcing Use of Inappropriate Manual Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions, specifically her personal motorized wheelchair. The resident was admitted with MS, bilateral knee contractures, kyphosis, and scoliosis, and had a BIMS score of 15 indicating no cognitive impairment. She reported that she had been very mobile until about two weeks prior, when she went to a movie using her motorized wheelchair and a specialized public transportation service. When the transportation company did not return to take her back, she called the facility and was instructed to call 911, resulting in transport to a hospital and return to the facility the next morning. Upon her return, the Administrator told her she was “grounded,” and later acknowledged that her personal motorized wheelchair, which had come with her to the facility, was being kept in the facility but that she was not allowed to use it. The Administrator stated that after the first incident, the IDT met and the MD agreed to revoke the resident’s ability to leave on pass, and that after a second similar incident where the resident again left using her motorized wheelchair and specialized transportation and could not get back, he decided the only option to keep her safe was to deny her access to her motorized wheelchair. The resident reported that she did not know where her wheelchair was and that staff would not tell her, and she expressed that she wanted her personal wheelchair because the facility’s manual wheelchair was very uncomfortable. She described her arm getting stuck behind the manual wheelchair and difficulty elevating her legs to address edema. Observations showed her in bed tilted to the side with cushions for positioning. Facility policy and the admission packet stated that residents have the right to use and retain personal possessions unless doing so would infringe upon the rights or health and safety of other residents, but the facility nonetheless withheld her personal wheelchair and substituted an uncomfortable manual wheelchair.
Missing Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure the Consulting Pharmacist completed a monthly Medication Regimen Review (MRR) for a census of 81 residents. During review of the MRR facility binder, the Consulting Pharmacist's October 2025 MRR report was not present. When the DON was interviewed, she stated she did not have a copy of the October 2025 MRR because the Consultant Pharmacist was out on paternity leave during that month, and the report was not provided to the survey team before they exited the facility. After the survey, the DON emailed a copy of the October 2025 MRR report. The report showed the Consultant Pharmacist reviewed 67 resident medication lists and made zero recommendations. The facility policy titled, Medication Monitoring Medication Regimen Review and Reporting, stated the consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly and that a record of observations and recommendations is made available in an easily retrievable format to nurses, physicians, and the care planning team within 48 hours of MRR completion.
Unsafe Food Storage and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 83. During the kitchen tour, a cook was observed in the prep area with a full-face beard and no beard restraint or face mask, and the Dietary Manager stated the facility did not have beard restraints available for staff use. The facility’s Food Handling Practices policy required proper food handling techniques and personal hygiene, including restraining hair, and the FDA Food Code section 2-402.11 was cited as requiring hair restraints, including beard restraints, to keep hair away from food and equipment. Additional kitchen observations showed approximately 21 cheese sandwiches in Refrigerator #1 that were unlabeled and undated, and an open plastic bag of chicken breasts in Freezer #1 that was also unlabeled and undated. Two seasoning containers, including sage and an unlabeled container of dried green herbs, were found with use-by dates of 11/27/25. Boxes labeled Mashed Potatoes, received 11/26/25, were stored directly on the floor in the dry storage area. A manual can opener was later observed with metal worn off the tip of the blade and food build-up above the tip, and the Dietary Manager agreed the blade looked worn and could pose a possible infection control problem.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and offer written information regarding Advance Directives to 9 residents out of a census of 83, despite the requirement to provide residents or their representatives with information about the facility’s Advance Directive policy upon admission and to document whether an Advance Directive had been issued. The deficiency involved Residents 45, 2, 67, 76, 6, 73, 16, 53, and 84, and the record review found no documented evidence that written or verbal information about Advance Directives was communicated to them or their responsible parties upon admission or afterward. Record review showed that several residents had no Advance Directive on file, including Residents 45, 2, 6, and 73. For Residents 67, 76, 16, and 53, the POLST forms reflected CPR or treatment preferences, but Section D regarding Advance Directive status was left blank. Resident 84’s EMR indicated no Advance Directive or POLST on file, and there was no documented evidence that staff informed or offered the resident or responsible party information regarding an Advance Directive. During interviews, the DON stated that a POLST is not the same as an Advance Directive and said the SSD should have a conversation with residents about Advance Directives upon admission and document it in the EMR. The SSD stated she offered Advance Directives to residents and families when they arrived and often gave them a blank form to complete, but she did not document these conversations because she felt it was an emotional issue to discuss death or incapacitation. The facility policy stated that upon admission the company will provide written information regarding its Advance Directive policy and document in a prominent part of the clinical record whether the resident has issued an Advance Directive.
Failure to Hold Quarterly IDT Care Conferences
Penalty
Summary
The comprehensive care plan was not developed, reviewed, and revised by a complete interdisciplinary team for four sampled residents, and quarterly care conferences were not documented as required. Resident 5 was admitted with diagnoses including cerebral infarction, unspecified dementia, hemiplegia affecting the right dominant side, and aphasia; a later MDS showed a BIMS score of 2, and a physician note stated the resident did not have capacity to make health care decisions. Care plans initiated between 6/20/25 and 9/30/25 had not been revised, and there was no documented evidence of care conferences or IDT meeting notes in the record. Resident 76 was admitted with adult failure to thrive, community acquired pneumonia, and severe protein calorie malnutrition, but the record showed care conferences only on 6/13/23 and 9/14/23, with no documented evidence for 4th quarter 2022, 1st quarter 2023, 4th quarter 2023, all quarters of 2024, or all quarters of 2025 to date. Resident 67, admitted with hemiplegia and hemiparesis following cerebral infarction, repeated falls, and PTSD, had care conferences only on 2/17/25 and 5/8/25, with no documented evidence for the 3rd and 4th quarter to date. Resident 3, admitted with vascular dementia, had one care conference on 7/18/25, with no documented evidence of care conferences for the 3rd and 4th quarter to date. The Social Services Director stated she was behind on care conferences for long-term residents by about a month or two across the board, and the MDS Coordinator stated quarterly IDT meetings usually consisted of the Social Worker, the MDS Coordinator, and other team members when available.
Food Not Served in a Palatable or Appetizing Manner
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and appetizing for 6 sampled residents who reported dissatisfaction with the meals. Residents stated the food was horrible, awful, pathetic, so-so, and forgettable, and one resident on a pureed diet said the meals were not clearly identified and were served in different colored dishes. Another resident reported the meat was sometimes too hard to chew, and a resident on a pureed diet said the food had lumps and was not very tasty. During a lunch tray observation, the regular tray was noted to be bland, and the cheese sauce on the broccoli lacked detectable flavor. The pureed tray was observed to be unappetizing in appearance, lacking in taste, and the pasta had a gummy texture that adhered to the roof of the mouth during sampling. At a Resident Council meeting, attendees stated meat was often overcooked, baked chicken was like jerky, and pizza was like cardboard. The RD stated palatability was a concern because it could reduce intake and cause unplanned weight loss. The facility's undated Food Handling Practices policy stated that good food preparation should serve foods that are attractive, palatable, and in the form best tolerated and accepted by residents.
Failure to Provide Hot Beverages Consistent With Resident Preferences
Penalty
Summary
The facility failed to provide drinks consistent with resident preferences for six sampled residents when hot beverage service was unavailable for more than two weeks. Residents 21, 29, 33, 43, 69, and 74 each stated during interviews that they had not been served coffee or, in the case of Resident 69, hot water for tea for several weeks, and each identified the lack of hot beverages as a problem. Resident 33 stated he drank coffee every day at home, Resident 29 stated he liked coffee, and Resident 69 stated hot tea was one of her preferred beverages, especially during the winter. Resident 21 stated her only issue with food service was that she had not been served coffee. The Dietary Manager stated the facility coffee maker broke down before Thanksgiving and a temporary machine was installed, but the water and coffee were too hot to serve. The Administrator decided the temporary machine would not be used to provide hot beverages for residents after the Activities Director reported the temperature was too hot during the coffee social. The Dietary Manager stated the company representative did not return to adjust the machine, and residents repeatedly asked when coffee would be served and stated they were not happy they did not get any coffee. Facility menus for two weeks listed coffee or tea at every breakfast, lunch, and dinner, and the facility policy stated resident food preferences would be assessed upon admission and communicated to the Interdisciplinary Team.
Failure to Care Plan Oxygen Therapy
Penalty
Summary
Nursing staff failed to develop a care plan for Resident 53's oxygen therapy. Resident 53 was admitted to the facility on 8/23/25 with diagnoses that included COPD, pleural effusion, and atelectasis. The physician order report showed an order for supplemental oxygen at 2-3 LPM and for licensed nurses to check the resident's pulse at least once during every shift starting on 9/18/25. A review of Resident 53's care plans dated 9/18/25 to 9/25/25 did not include a care plan for oxygen therapy. During an observation on 12/2/25 at 10:30 a.m., Resident 53 was sitting up in bed awake and alert, wearing a nasal cannula, and the oxygen concentrator was set at 2 liters of humidified oxygen. During an interview on 12/4/25 at 4 p.m., LN 6 confirmed there was no care plan for Resident 53's oxygen therapy. The facility's Care Plan Essentials policy stated that respiratory information is included in the resident-specific care plan and that a new CPE is initiated when an update in any section is indicated.
Failure to Provide Translation Services for Mandarin-Speaking Resident
Penalty
Summary
Facility staff failed to provide communication services to a resident whose primary language was Mandarin Chinese. The resident was admitted with diagnoses of tubulo-interstitial nephritis and malignant neoplasm of the breast, and the face sheet listed Chinese as the preferred language without identifying a specific dialect. During an observation, the resident was lying in bed, gesturing toward the wall and pointing at the bedside table, but would not speak and only grunted when attempting to communicate. The resident’s responsible party stated the resident spoke very little English and became frustrated with the limited ability to communicate with staff, including when trying to discuss inability to sleep because of a roommate and current pain. A nurse stated he often tried to communicate nonverbally and sometimes used a translation application on his personal cell phone, but was unsure of the resident’s dialect and unsure whether the facility offered translation services. Another nurse stated she also used a translation application on her phone and was unaware of any facility translation services. The administrator pointed to a translation services flyer and stated translation services were reviewed during orientation, while invoice review showed Mandarin translation services were used twice for a total of 9 minutes during the review period.
Failure to Complete Trauma-Informed Care Screening
Penalty
Summary
Facility staff failed to ensure that Resident 67 was screened for a need for trauma-informed care upon admission. Resident 67 was admitted with diagnoses including hemiplegia, hemiparesis following a cerebral infarction, and PTSD. His care plans documented behavioral problems with verbal outbursts, agitation, and anxiety, with staff directed to remove him from triggering environments, place him in a calm and quiet area with supervision, and identify and attempt to remove anxiety triggers. During observation, Resident 67 was pacing in his room with a seated walker and stated that he did not feel safe in the facility. He said he felt threatened by another resident and wished he had a gun to protect himself. Staff interviews indicated that he was often assigned to an LPN who was unsure what triggered his behavior, and described incidents in which loud singing caused him to slam his door and scream, and another where he believed he was being followed by another resident. The SSD stated the facility used a Trauma Informed Care screening form on admission and confirmed that the screening was not completed for Resident 67, despite understanding it would have helped formulate his care plan for trigger mitigation or elimination.
Dirty Oxygen Concentrator Not Maintained
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not ensure respiratory equipment was clean and in a usable state for one resident. Resident 76 was admitted with diagnoses of Community Acquired Pneumonia and Adult Failure to Thrive, and had a physician order for oxygen 2-4 L via nasal cannula for saturation less than 90%. During observation, an oxygen concentrator in Resident 76's room was seen against the wall near the bed with visible debris on the front of the machine. The filter used to clean and purify the air was black and needed to be changed, and the vents near the filter had accumulated dust build up. The DON stated the oxygen concentrators were rented and maintenance was responsible for daily checks, while the MNT stated housekeeping checked them daily and acknowledged the concentrator was not clean and in a usable condition. The IP stated a dusty oxygen concentrator with a dirty filter placed the resident at risk and could blow particles into the resident's lungs, and the ADM stated the facility was responsible for maintaining cleanliness of the equipment and had not been following its policy.
Unsafe discharge to an ILF without needed assistance
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who needed assistance with ADLs and was discharged to an ILF that did not provide assistance. The resident was admitted with sepsis and infection/inflammatory reaction related to a left hip prosthesis. His care plan stated he wanted to return to the community safely, and facility staff were expected to identify a safe discharge location, provide community resource information and assistance, and complete a welfare check after discharge. Records showed the resident used a wheelchair, could ambulate only with a front wheeled walker and contact guard assist, needed help with meals, and required one-person physical assist with bathing. The PT discharge summary listed the discharge location as a group home with morning and evening caregiver support, but progress notes documented that he was discharged to an ILF. The MDS also showed he required supervision or touching assistance with bathing, transfers, and multiple walking tasks. During interviews, the SSD stated she believed the ILF and the assisted living locator company that helped find placement would provide help for the resident, and later said it was a bad choice. The ADM stated he was heavily involved in the discharge because the resident owed the facility money. The ECA stated ILFs provide lodging, not assistance with daily needs, and denied telling the SSD the ILF would provide ongoing help. The ILF manager stated the resident arrived unable to walk, the facility was not wheelchair accessible, and the bathroom was not accessible; he said he would not have accepted the resident if he had known he could not walk. The resident stated he asked whether the discharge location could assist him, trusted the SSD when told it would, and reported he did not eat between discharge and hospital arrival because he could not cook and needed help setting up his food.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident, also with severe cognitive impairment. According to interviews and record reviews, one resident was struck on the left cheek by another resident as he wheeled past her in the dining room. The incident was witnessed by a staff member, who observed that the resident's cheek was slightly reddened but she did not cry out in pain. The event was reported to a licensed nurse, who assessed the resident and confirmed the redness but noted no complaints of pain. The facility's Social Services Director acknowledged awareness of the incident and agreed that the resident had suffered abuse, confirming the facility's responsibility to ensure resident safety. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse. The report documents that the facility did not ensure this right for the resident involved in the incident.
Failure to Notify Responsible Party of Resident Falls Due to Incorrect Contact Information
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident following two separate fall incidents. The resident, who was admitted in April 2025, experienced falls on consecutive days. Nursing progress notes indicated that attempts were made to contact the RP by calling the number listed on the resident's face sheet and leaving voicemails, but there was no response. It was later discovered that the contact number on the face sheet was incorrect, and the RP did not receive the notifications. The correct number was only updated on the day of the resident's discharge, at which point the RP was informed of the falls. Interviews with licensed nursing staff and the Director of Nursing confirmed that the facility was responsible for ensuring the accuracy of contact information for RPs and for promptly notifying them of changes in condition, such as falls. The staff acknowledged that the failure to update and verify the RP's contact information resulted in the RP not being made aware of the resident's falls in a timely manner. Facility policy required immediate notification of the RP and physician in the event of an accident or change in condition, which was not followed due to the incorrect contact information.
Failure to Provide Baseline Care Plan Summary to Responsible Party
Penalty
Summary
The facility failed to provide a summary of the baseline care plan (BCP) to the responsible party (RP) of a resident within 48 hours of admission, as required by facility policy. A review of the resident's face sheet confirmed the presence of an RP, and the BCP was completed on 4/14/25. However, there was no documentation indicating that the BCP summary was given to the RP. This was verified during an interview and record review with a licensed nurse, who acknowledged the absence of documentation showing the RP received the BCP summary. Further confirmation came from the Director of Nursing (DON), who reviewed the BCP and also found no evidence that the summary was provided to the RP. The facility's policy states that both the resident and their RP should receive a summary of the BCP, and documentation should be maintained in the electronic health record. The lack of documentation indicated that the required communication with the RP did not occur.
Resident Placed in Wheelchair Without Assessment Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a history of falls was placed in a wheelchair without an assessment or care plan indicating the need or safety for wheelchair use. The resident was previously documented as ambulatory with a cane and identified as a fall risk with a history of wandering behavior. The fall care plan did not mention wheelchair use, and the physical therapy evaluation did not recommend or assess for wheelchair safety. Despite this, the resident was found sitting in a wheelchair and subsequently slid from it, landing on their buttocks. Record reviews and staff interviews confirmed there was no documentation of a wheelchair assessment or care plan for wheelchair use for this resident. Both the licensed nurse and the DON verified that the resident should not have been placed in a wheelchair, as there was no evaluation or recommendation supporting its use. The facility's fall management policy requires staff to identify interventions based on evaluations and current data, which was not followed in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Initiate Timely CPR and Emergency Response for Full Code Resident
Penalty
Summary
The facility failed to ensure that nursing staff were knowledgeable and able to correctly state and follow the facility's policy regarding the initiation of Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS). Four out of six nursing staff interviewed were unable to accurately describe the policy, and there was inconsistency among staff regarding who should initiate CPR and how to activate emergency response systems. Some staff were unsure about the use of the paging system and the process for verifying code status, leading to delays in emergency response. A resident with multiple medical conditions, including diabetes, hypertension, and heart disease, was found unresponsive, not breathing, and pulseless in her bed. Despite having a Physician Orders for Life-Sustaining Treatment (POLST) indicating a full code status and a desire for resuscitation, nursing staff delayed the initiation of CPR while attempting to verify the resident's code status. Documentation and interviews revealed that staff did not immediately begin CPR, and there was confusion about who should call 911 and how to summon additional help. The facility's policy required immediate initiation of CPR by certified staff and activation of emergency response, but these steps were not promptly followed. Additionally, the facility did not have an Automated External Defibrillator (AED) available for use during the resuscitation attempt, despite policy and best practice expectations. Only some of the licensed nurses were currently certified in CPR/BLS at the time of the incident. These failures reduced the likelihood of successful resuscitation for the resident and potentially for other residents identified as full code.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to meet professional standards of nursing care by not completing all laboratory tests as ordered by the physician for one resident. The resident, who was admitted with multiple fractures, diabetes, hypokalemia, hypertension, and atherosclerotic heart disease, had physician orders for several laboratory tests, including norovirus, C. diff, COVID, and a KUB x-ray, due to symptoms of loose stools. While documentation indicated that the orders were noted and supposed to be carried out, the norovirus test was not completed, and there was no laboratory report for this test in the resident's records. Multiple staff interviews confirmed that the norovirus test was not performed, despite being ordered and documented as carried out. Additionally, the resident had a critical low potassium value reported, prompting further orders for potassium and magnesium administration, as well as repeat labs for magnesium and a comprehensive metabolic panel (CMP) in two days. However, the repeat labs were not completed within the ordered timeframe, with documentation showing the order administration was late and required rebooking. The facility's policy requires that physician orders be followed and not discontinued without a physician's directive, but in this case, the ordered labs were not completed as required.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments for two residents and did not complete the assessments in a timely manner for two additional residents. Resident #5 was readmitted on 08/22/2024, and Resident #22 was admitted on 08/19/2024, but neither had a subsequent MDS completed after their initial assessments. The MDS Coordinator was unaware of the need for Resident #5's MDS in December 2024 and acknowledged that Resident #22's MDS for November 2024 had not been completed. The Director of Nursing (DON) and the Administrator were both informed of the late assessments and expressed expectations for timely completion. Additionally, Resident #1 and Resident #48 had their quarterly MDS assessments completed late. Resident #1's MDS, with an Assessment Reference Date (ARD) of 10/08/2024, was not signed as completed until 12/02/2024. Similarly, Resident #48's MDS, with an ARD of 10/16/2024, was also completed on 12/02/2024. The MDS Coordinator, who had been in the role since July 2024, admitted to struggling with timely completion of assessments. The DON and Administrator were unaware of the delays and expected the MDS assessments to be completed on time, noting that the MDS Coordinator was new and had not communicated the issues with completing the assessments.
Failure to Provide Communication Aids to Non-Verbal Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to verbally communicate due to a medical history of cerebral infarction, had access to necessary communication aids. The resident was admitted with a diagnosis that required assistance with personal care and had a care plan in place that directed staff to provide a communication board and cards for basic needs. However, during multiple observations, the surveyor noted that the communication board was not within the resident's reach, and there was no pointer available for the resident to use. Interviews with the resident and staff revealed that the resident did not always have access to the pointer, which was essential for their communication. A CNA and an RN both confirmed the absence of the pointer, and the Director of Nursing was unaware of its missing status until informed by the surveyor. The resident indicated a need for the pointer, but it was not provided, leading to a deficiency in ensuring the resident's ability to communicate effectively.
Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an elopement incident. The resident, who had severe cognitive impairment and a history of chronic pain, acute systolic heart failure, and epilepsy, was admitted to the facility and initially assessed as not at risk for elopement. However, the resident was able to exit the facility without staff knowledge on two occasions. On the first occasion, the resident attempted to leave the facility to go to the bank, but staff intervened. On the second occasion, the resident was found by the local police department strolling on a sidewalk outside the facility. The resident's room had a sliding door that provided a means of exit, which was not initially considered a risk by the facility. Despite the resident's exit-seeking behavior being noted after the first incident, the facility did not move the resident to a different room until after the second elopement. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that the facility did not anticipate the resident's exit-seeking behavior and did not take immediate action to mitigate the risk after the initial incident.
Non-Compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident rooms met the required square footage per resident, as mandated by regulatory guidelines. Specifically, seven rooms in the facility did not provide the minimum 80 square feet per resident. Measurements taken by the Environmental Services staff confirmed that the rooms ranged from 70.19 to 74.96 square feet per resident, falling short of the required space. During interviews, the Administrator acknowledged awareness of the non-compliance, while the Director of Nursing was unaware of the square footage requirement for resident rooms.
Resident Safety Compromised Due to Policy Violation
Penalty
Summary
The facility failed to ensure the safety of a resident who was allowed to leave the premises without a physician's order, contrary to facility policy. This resident, who was legally blind and used a walker, was accompanied by a staff member to a convenience store where he purchased three bottles of vodka using his personal money. The resident consumed the alcohol, became intoxicated, and attempted to leave the facility against medical advice. The incident was reported by a member of a mobile crisis team who responded to a police call regarding the resident's behavior. The facility's administrator acknowledged awareness of the incident but admitted to not investigating it or documenting the events leading to it. The administrator stated that the nurse on duty assumed the resident had a pass to leave, which was not verified. The facility's policy requires a physician's order for a resident to leave on a day pass, and the resident must be signed out and back into the facility. However, there was no documentation of the resident's departure or return, indicating a breach of protocol. Interviews with staff revealed a lack of adherence to the facility's policies regarding resident outings and alcohol prohibition. The unlicensed staff member who accompanied the resident did not ensure compliance with the policy, and the nurse failed to verify the necessary physician's order. Additionally, the resident's care plan did not address his history of alcohol dependency or the incident, highlighting a gap in the facility's management of residents with such conditions.
Failure to Report Allegation of Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe. The incident involved a resident who reported that a CNA put his hand on her face and around her mouth area. The alleged event occurred on 3/14/24 at approximately 11:00 a.m., but the report was not made to law enforcement until 3/15/24 at 11:00 a.m., and the form was faxed to CDPH at 1:07 p.m. on the same day. This delay in reporting was confirmed during an interview with the Administrator, who admitted to not realizing the required reporting timeframes as per the facility's abuse policy. The facility's Policy and Procedure titled Abuse Investigation and Reporting mandates that any alleged violation involving abuse must be reported immediately, but not later than two hours if it involves abuse or has resulted in serious bodily injury. The failure to adhere to this policy had the potential to contribute to ongoing resident physical abuse and delayed the timely investigation by authorities. The Administrator's lack of awareness regarding the reporting timeframes was a significant factor in this deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Rafael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Postacute Care | 0 mi | ★★★★★ | 34 | 0 |
| Professional Post Acute Center | 0 mi | ★★★★★ | 6 | 0 |
| Villa Marin | 0.8 mi | ★★★★★ | 11 | 0 |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 0.8 mi | ★★★★★ | 17 | 0 |
| Marin Post Acute | 1.2 mi | ★★★★★ | 26 | 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 July 2026) and official state health department websites.