Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Bend Nursing Center during CMS and state inspections, most recent first.
A resident with non‑traumatic intracerebral hemorrhage and H. pylori gastritis had an order for metronidazole 500 mg via PEG tube every 6 hours, but two scheduled doses were not administered. MAR review showed missed doses, and administration notes documented that the medication was pending pharmacy delivery. During surveyor interviews, the IP confirmed the doses were not given and identified that metronidazole was available in the medication e‑kit, which staff did not use. The DON stated the nurse should have used the ordered medication from the e‑kit, contrary to the facility’s medication administration policy requiring timely administration as prescribed.
The facility did not ensure that call light systems accommodated the needs of several dependent residents. Two residents with severe mobility impairments, including contractures and quadriplegia, were given standard call lights placed on their chests despite being unable to use them, and the DON stated the facility did not assess for or provide accessible call light options. Three additional residents, including individuals with respiratory failure, anoxic brain injury, and Parkinson’s disease, were observed in bed with their call lights on the floor and out of reach, which staff acknowledged as a safety concern. These practices conflicted with the facility’s own policy requiring that call lights be accessible to residents in bed.
A resident with hypotension and impaired cognition did not receive prescribed Midodrine HCl on several occasions when their SBP was below the ordered threshold. Nursing staff failed to administer the medication as ordered and did not notify the physician of the omissions, contrary to facility policy and expectations.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Residents lost the ability to perform ADLs without a documented medical reason, and the facility did not provide evidence that the decline was unavoidable due to a medical condition.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance to complete these tasks.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of environmental safety measures and insufficient supervision led to the identification of this issue.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Surveyors identified that an open container of glucometer test strips lacked an open date, and an eye drop medication in the medication room refrigerator had an illegible open date, making it unclear if it was still safe for use. Additionally, keys to controlled substance cabinets and the refrigerator were found unsecured, allowing unauthorized access. These findings were confirmed by nursing staff and were not in accordance with facility policy requiring secure storage and proper labeling of medications.
The facility failed to protect residents from scabies when three residents tested positive, and a recommended second round of treatment was not completed. Despite initial treatments, the Director of Nursing decided against a second round for all residents and staff, contrary to public health recommendations. This decision was made despite guidelines emphasizing comprehensive treatment to control outbreaks.
A resident's care plan was not updated in a timely manner after their skin condition worsened to a Stage 4 pressure ulcer. Despite physician orders for new interventions, the care plan was not revised until over a month later, contrary to facility policies. The DON acknowledged the change but did not see the need for additional interventions.
A resident with multiple diagnoses, including epilepsy, had electrodes placed for an EEG, but the facility failed to obtain follow-up care instructions, resulting in a missed appointment for electrode removal. The Director of Nursing removed the electrodes without proper guidance, causing scalp injuries. Communication lapses and lack of documentation contributed to the deficiency.
A resident with parkinsonism did not receive their prescribed Rytary medication on time due to a delay in delivery, leading to worsening symptoms. Interviews with staff and the resident highlighted concerns about medication availability, and the facility's policies on timely pharmacy services were not followed.
The facility compromised resident privacy by discarding meal tray tickets containing sensitive information into the general kitchen trash. A dietary aide was observed throwing these tickets away, which included resident names, room numbers, diet orders, and other personal details. The District Kitchen Supervisor confirmed this practice, acknowledging that the tickets should be shredded to maintain confidentiality, as per the facility's policy on resident rights.
The facility's kitchen staff lacked the necessary knowledge and competencies, leading to several deficiencies. A cook was unable to read freezer temperatures correctly, and a dietary aide could not state dishwashing machine temperatures. Additionally, a cook prepared pureed foods without a recipe, and incorrect scoop sizes were used for food portions, potentially affecting residents' nutrition and safety.
The facility failed to follow the prescribed recipe for pureed food for three residents on a pureed diet. A kitchen staff member used incorrect scoop sizes, leading to improper portion sizes for pureed potatoes and cream style corn. This error was identified during an observation and interview, with the staff member unaware of the correct scoop sizes. The District Kitchen Supervisor and Registered Dietitian emphasized the importance of following recipes and using proper measurements to ensure residents receive adequate nutrition.
The facility failed to prepare pureed bread according to a standardized recipe, affecting 20 residents on pureed diets. A cook was observed using unmeasured ingredients, resulting in a thick and sticky consistency. The Dietary Supervisor and Registered Dietitian confirmed the importance of following recipes to ensure nutritional adequacy and consistency, as outlined in the facility's policies.
A facility failed to meet food safety standards, affecting 54 residents. Issues included improper food labeling, expired items, inadequate storage temperatures, and structural and equipment deficiencies. Observations revealed unlabeled and expired food, improper storage temperatures, and a lack of air gaps in the produce sink. A chipped can opener blade and a staff member without a beard restraint were also noted, posing contamination risks.
A LTC facility failed to follow proper infection control practices, including a respiratory therapist not performing hand hygiene, an uncovered isolation trash can, improperly labeled oxygen equipment, a dirty air fan, and open trash containers in the dining room. These deficiencies were confirmed by staff and posed potential infection risks.
The facility failed to maintain a reach-in freezer in safe operating condition, with temperatures recorded at 16 and 20 degrees Fahrenheit, contrary to the policy requiring 0 degrees or below. The Dietary Supervisor confirmed the issue, noting the freezer might be broken and lacked scheduled maintenance. This failure risked bacterial growth and foodborne illness for 54 residents consuming facility-prepared meals.
The facility failed to provide a safe, clean, and comfortable environment, with issues such as missing window blind slats, non-functioning bulbs, and open trash containers in the dining room. A resident with PTSD and blindness was found in an unsanitary state, with a strong odor and a dirty room. Staff confirmed these deficiencies, which were not addressed due to communication lapses and lack of parts.
The facility failed to ensure that two contracted CNAs received the required in-service training, including dementia management and abuse prevention. The Director of Staff Development and the Director of Nursing could not provide documentation verifying the completion of the mandatory 12 hours of annual training. The facility relied on a staffing agency, which did not maintain records of training completion, leading to a potential compromise in the quality of care provided to residents.
The facility failed to uphold dignity and privacy for two residents, impacting their well-being. A resident with PTSD and depression experienced a breach of privacy when maintenance staff entered without knocking or identifying themselves. Another resident with PTSD and blindness was found neglected, with a strong body odor and a disheveled appearance, expressing feelings of being left in filth. These actions were contrary to the facility's policy on resident rights.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident with PTSD experienced distress from loud door noises, which was not addressed despite complaints. Another resident with Alzheimer's and anxiety had no care plan for activities, resulting in isolation. The facility's policy requires timely care plan development, but this was not followed, posing potential risks to residents' well-being.
The facility failed to update care plans for two residents, one requiring an adaptive device for nutrition and another needing pain management. A resident with stroke and dysphagia did not have their care plan revised to include a two-handled cup, leading to the use of an incorrect sippy cup. Another resident with pain issues did not have their care plan updated to include a new Tramadol prescription, resulting in unmanaged pain. These oversights were confirmed by staff and highlighted a lack of adherence to the facility's policy on care plan revisions.
Two residents in an LTC facility were found with deficiencies in personal hygiene and grooming care. A resident with PTSD and blindness was observed in a disheveled state with a strong odor, despite not rejecting ADL assistance. Another resident with respiratory failure and traumatic brain injury had long, jagged fingernails, which were not trimmed as per facility policy. Staff acknowledged these issues, which were contrary to the facility's policies on maintaining hygiene and grooming.
Two residents did not receive scheduled in-room activity visits, leading to potential isolation and depression. One resident with cerebral infarction and quadriplegia had no documented visits despite a care plan for thrice-weekly visits. Another resident with Alzheimer's and anxiety disorder had only one documented visit since admission. The Activities Director confirmed the lack of visits, contrary to facility policy.
A facility failed to obtain necessary physician's orders and informed consent before using bed rails for a resident with memory impairment and other medical conditions. Observations confirmed the use of bed rails without proper documentation, violating the facility's policy on bed safety.
The facility failed to accurately document narcotic administration for two residents, leading to discrepancies between the Controlled Drug Record and the Medication Administration Record. This failure involved missing documentation for Norco and Oxycodone tablets, increasing the risk of narcotic diversion. The Director of Nursing confirmed the discrepancies and highlighted the importance of accurate documentation to ensure medication safety.
A resident with no cognitive impairment was served cream of wheat for breakfast despite requesting oatmeal, as indicated on their meal tray ticket. The Dietary Supervisor confirmed the error, acknowledging that the resident should have received oatmeal. The facility's policy requires alternate meal options, which was not followed in this case.
Two residents were not provided with necessary adaptive eating equipment as ordered by their physicians, potentially impacting their well-being. One resident, with a history of stroke and dysphagia, was given a sippy cup instead of a two-handled cup. Another resident, with encephalopathy and dysphagia, was given metal silverware instead of plastic utensils. The facility's policy emphasizes the need to evaluate and provide adaptive devices.
Failure to Administer Ordered Antibiotic When Available in Emergency Kit
Penalty
Summary
The facility failed to administer a prescribed antibiotic in accordance with professional standards and physician orders for one resident. The resident had been admitted with diagnoses including non‑traumatic intracerebral hemorrhage and H. pylori gastritis. The hospital After Visit Summary dated 3/17/26 showed metronidazole 500 mg every 6 hours, with the last hospital dose given at 12:12 p.m. The facility’s Order Summary Report starting 3/17/26 ordered metronidazole 500 mg via PEG tube every 6 hours for H. pylori gastritis. Review of the March 2026 MAR showed that the resident did not receive the scheduled metronidazole doses on 3/17/26 at 6 p.m. and 3/18/26 at 12 a.m. During interviews and concurrent record review, the Infection Preventionist confirmed that the medication had not been given, as documented in Administration Notes on 3/17/26 at 7:45 p.m. and 3/18/26 at 12:32 a.m., which indicated the medication was pending pharmacy delivery. In a medication room observation, the Infection Preventionist checked the emergency medication kit (e‑kit) and found it contained metronidazole, and stated the nurse should have used the e‑kit to administer the scheduled antibiotic if available. The DON also stated that the nurse should have used the ordered medication from the e‑kit. The facility’s undated “Administering Medications” policy stated that medications are to be administered in a safe and timely manner, as prescribed, and in accordance with prescribed orders, including any required time frame.
Failure to Provide Accessible and Reachable Call Lights for Dependent Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences related to call light accessibility for multiple residents. Two residents with significant physical limitations, including one with bilateral hand contractures and another with quadriplegia, were assessed as dependent in activities of daily living. During observation, both residents had standard call lights placed on their chests despite their mobility issues, and a licensed nurse acknowledged not knowing how they would be able to use the call lights if they needed help. The DON confirmed that these residents were not provided with accessible call light systems and stated that the facility did not conduct assessments for accessible call lights, asserting that such residents could not press them anyway. The facility did not provide a policy or procedure for call light accessibility when requested, although its Resident Rights policy referenced residents’ right to a dignified existence. Additional deficiencies were identified for three other residents whose call lights were not within reach. One resident with respiratory failure and another with an anoxic brain injury were observed lying in bed with their call lights on the floor; the licensed nurse present confirmed the call lights were not within reach and acknowledged that call lights on the floor were a safety issue. Another resident with Parkinson’s disease was also observed in bed with the call light on the floor, and the respiratory therapist confirmed the call light was out of reach and that the resident would not be able to use it to get help. These observations were inconsistent with the facility’s written policy on answering call lights, which required that call lights be accessible to residents when in bed.
Failure to Administer Antihypotensive Medication as Ordered
Penalty
Summary
A resident with a history of hypotension and impaired cognition was admitted to the facility and had a physician's order for Midodrine HCl, an antihypotensive medication, to be administered twice daily when systolic blood pressure (SBP) was less than or equal to 120. Review of the Medication Administration Record (MAR) for February 2025 showed that the resident did not receive the prescribed medication on multiple dates when the SBP was below the threshold, as required by the physician's order. The medication was omitted without documentation of physician notification or clinical justification. Interviews with the DON and a licensed nurse confirmed that the expectation was to follow physician orders and to notify the physician if a medication was not administered. The licensed nurse acknowledged that the resident's SBP was below 120 on the missed dates and that the medication should have been given. Facility policy required medications to be administered as prescribed and for the prescriber to be contacted if there were concerns about the appropriateness of a dosage. These actions and inactions resulted in a significant medication error for the resident.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning, as required, and did not provide evidence that any decline in ADL abilities was unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not show appropriate justification for the decline in ADL performance.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for a resident who was unable to do so independently. The report notes that the required support for ADLs was not given to a resident in need, indicating a lapse in the provision of necessary care and assistance as required for residents unable to perform these tasks on their own.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. This lapse in maintaining a safe environment and providing necessary oversight directly contributed to the deficiency cited by surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. An open container of glucometer test strips was found on a medication cart without an open date, despite manufacturer instructions requiring use within six months of opening. The nurse present confirmed the omission and was unable to state the allowable usage period after opening. Additionally, an eye drop medication (latanoprost) stored in the medication room refrigerator was labeled with an open date that was not legible and predated the refill date, making it impossible to determine if it was still safe for use. The Assistant Director of Nursing confirmed that the medication should be used within six weeks of opening and that the observed container had exceeded this period. Further, keys to the controlled substance cabinets and refrigerator were found unsecured, hanging in a plastic bag on the wall of the medication storage room. A nurse confirmed that these keys provided access to controlled substances and were not secured as required. The Director of Nursing acknowledged that these practices did not comply with facility policy, which mandates that all drugs and biologicals be stored in locked compartments and that only authorized personnel have access to them. The policy also requires proper labeling of all medication containers and the return or destruction of outdated or improperly labeled drugs.
Failure to Implement Comprehensive Scabies Prophylaxis
Penalty
Summary
The facility failed to protect residents from acquiring scabies, a contagious skin infestation caused by mites, when three residents tested positive for scabies and facility-wide prophylaxis was not completed as recommended by public health authorities. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow through with the recommended second round of treatment for all residents and staff, which was advised to prevent further spread of the infestation. Resident 1, admitted in March 2023 with multiple diagnoses including cerebral infarction, ventilator dependence, tracheostomy, and heart failure, tested positive for scabies on December 13, 2024, and was treated with permethrin cream as ordered. Resident 2, admitted in September 2012 with respiratory failure, quadriplegia, seizures, and heart failure, also tested positive for scabies and received the prescribed treatment. Similarly, Resident 3, admitted in October 2022 with respiratory failure, paraplegia, pressure ulcer stage 4, and amputation of both legs above the knee, was treated for scabies following a positive test result. Despite these treatments, the facility did not implement a second round of prophylaxis for all residents and staff, as recommended by the Yolo County Public Health Officer. Interviews with facility staff, including the Nursing Supervisor, Infection Preventionist, and Director of Nursing, revealed that while initial treatments were administered, the decision not to conduct a second round of treatment for all residents and staff was made by the Director of Nursing, who deemed it a recommendation rather than a mandate. This decision was made despite the public health officer's strong recommendation for a second round of treatment to prevent recurrence and further spread of scabies within the facility. The facility's policy on infection prevention and control, as well as guidelines from the California Department of Public Health and Los Angeles County Public Health, emphasize the importance of comprehensive treatment to control outbreaks, which was not fully adhered to in this case.
Failure to Update Wound Care Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to update and revise the wound care plan in a timely manner for a resident whose moisture-related skin condition deteriorated into a Stage 4 pressure ulcer. The resident, who had been admitted with conditions including respiratory failure, muscle wasting, diabetes, and reduced mobility, was found to have a Stage 4 pressure ulcer on the sacrococcyx during a skin integrity review. Despite the reclassification of the wound from a shear injury to a pressure injury by a wound MD, and subsequent physician orders for specific wound care interventions, the care plan was not revised until over a month later. The care plan, initially created in May, was not updated to reflect the significant change in the resident's condition or the new interventions ordered by the physician on two separate occasions in September and October. The Director of Nursing acknowledged the change in the resident's condition but did not believe additional interventions were necessary at the time. This oversight was contrary to the facility's policies, which require care plans to be revised when there is a significant change in a resident's condition.
Failure to Follow Up on EEG Appointment Leads to Resident Injury
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident who had electrodes placed for an EEG machine. The facility did not obtain instructions for follow-up care, resulting in a missed appointment for the removal of the electrodes. This oversight had the potential to cause scalp skin injuries when the electrodes were eventually removed at the facility. The resident, who had multiple diagnoses including dysphagia following a stroke, quadriplegia, and epilepsy, was admitted to the facility in June 2013. The resident was sent out for an EEG appointment, and upon return, there was no documentation or paperwork regarding follow-up care. The EEG department contacted the facility to request the return of the EEG machine, and the Director of Nursing removed the electrodes without proper instructions, leading to skin damage on the resident's scalp. Interviews with facility staff revealed a lack of communication and documentation regarding the follow-up appointment. The resident's family member had informed staff about the appointment, but this information was not conveyed to the appropriate personnel to arrange transportation. The facility's failure to ensure proper follow-up care and communication resulted in the resident developing pressure injuries on the scalp.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to maintain timely and appropriate pharmaceutical services for a resident diagnosed with parkinsonism, fibromyalgia, muscle wasting, atrophy, and difficulty walking. The resident was prescribed Rytary, an extended-release medication for parkinsonism, to be taken two capsules three times a day. However, the medication was unavailable for administration as ordered by the physician, leading to the resident experiencing worsening tremors, increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose. Interviews with the resident and facility staff revealed that the resident was concerned about running out of medication, and the pharmacy had not delivered the medication on time. The resident missed the scheduled dose, and the Director of Nursing acknowledged the failure to administer the medication as prescribed. The facility's policies and procedures emphasized the importance of providing routine and timely pharmacy services and ensuring medications are administered within one hour of their prescribed time, which were not adhered to in this case.
Improper Disposal of Meal Tray Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information by improperly disposing of meal tray tickets. During an observation and interview, a dietary aide was seen discarding meal tray tickets into the general kitchen trash while preparing breakfast trays. These tickets contained sensitive information, including resident names, room numbers, diet orders, food allergies, food preferences, and special dietary needs. The District Kitchen Supervisor confirmed this practice and acknowledged that the tickets should be shredded to protect resident privacy. The facility's policy on resident rights, dated December 2016, explicitly prohibits unauthorized release, access, or disclosure of resident information, underscoring the deficiency in maintaining confidentiality.
Deficiencies in Kitchen Staff Competency and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff possessed the necessary knowledge and competencies to perform dietary functions effectively. A cook was unable to correctly read the temperature in a reach-in freezer and did not know the required temperature for proper food storage, which is critical to prevent bacterial growth. Additionally, a dietary aide was unable to state the desired temperatures for a dishwashing machine and could not locate the temperature gauge, which is essential for ensuring that dishes are sanitized properly. Further deficiencies were observed when a cook prepared pureed foods without following a recipe, adding unmeasured amounts of ingredients, which could affect the nutritional content and consistency necessary for residents with swallowing difficulties. Another cook used incorrect scoop sizes to measure food portions, leading to residents receiving improper portion sizes. These actions were contrary to the facility's policies and procedures, which emphasize the importance of following standardized recipes and using correct portion sizes to ensure nutritional adequacy and consistency.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to adhere to the prescribed recipe for pureed food for three residents on a pureed diet, which was identified during an observation, interview, and record review. The deficiency was noted when a kitchen staff member used incorrect scoop sizes to measure food portions, specifically using a 3/8 scoop for pureed potatoes and a 1/4 scoop for pureed cream style corn, instead of the required #8 scoop (1/2 cup) as indicated in the facility's Diet Guide Sheet. This error in portion control had the potential to affect the nutritional intake of residents on a pureed diet, potentially leading to malnutrition and weight loss. During the investigation, it was revealed that the kitchen staff member was unaware of the correct scoop sizes, and the District Kitchen Supervisor emphasized the importance of using the proper scoop size to ensure residents receive adequate nutrition. The Registered Dietitian also confirmed that cooks should follow recipes and measure ingredients accurately. The facility's Policy and Procedure on Trayline Accuracy/Menu Compliance, dated 2010, highlighted the necessity of following menus and recipes as written to ensure adequacy and accuracy in portion control, underscoring the importance of having the correct scoops, ladles, and spoodles available for meal preparation.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that conserved nutritive value and palatability for 20 residents receiving a pureed diet. This deficiency was observed when a cook, identified as CK 2, was seen preparing pureed bread without following a recipe. CK 2 added unmeasured amounts of milk, bread, and water to a blender and then added an unmeasured amount of food thickener, relying on feel rather than a standardized recipe. This method of preparation resulted in a thick and sticky consistency of the pureed bread, which was confirmed during a test tray sampling by the Dietary Supervisor. The Registered Dietitian emphasized the importance of following recipes and measuring ingredients to ensure nutritional adequacy and consistency, especially for residents with swallowing difficulties. The facility's policy and procedure documents, including the Trayline Accuracy/Menu Compliance and Diet and Nutrition Care Manual, highlighted the necessity of using standardized recipes to maintain consistency in taste, appearance, and nutritional content. The failure to adhere to these guidelines posed a risk of inadequate nutrition and potential swallowing issues for the residents on pureed diets.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 54 residents who received facility-prepared meals. During an initial kitchen tour, it was observed that proper food labeling was not followed for items stored in the freezers, refrigerator, dry storage, and spice shelf. Additionally, expired food items were found in these areas, and personal milk cartons were not stored at appropriate temperatures. The kitchen's reach-in freezers contained multiple boxes of food items that were exposed and open to the freezer environment, and a plastic container of brown sugar was not sealed properly. Furthermore, frozen foods were not stored at appropriate temperatures, and a steam table pan was found stored wet. The facility's kitchen also had structural and equipment issues that could compromise food safety. No air gaps were found in the produce sink, which could lead to wastewater contaminating produce. The kitchen can opener had a chipped blade, posing a risk of physical contamination in food. Additionally, a kitchen staff member was observed not wearing a beard restraint, which is necessary to prevent hair from contacting food and clean equipment. These deficiencies were confirmed through observations and interviews with the Dietary Supervisor, Registered Dietitian, and other kitchen staff. The facility's policies and procedures, as well as the US FDA Food Code, were reviewed and indicated that the facility did not comply with the required standards for food labeling, storage, and equipment maintenance. These failures had the potential to lead to foodborne illness for the residents receiving facility-prepared meals.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. A respiratory therapist did not perform hand hygiene during a breathing treatment for a resident with chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The therapist was observed using the same gloves to handle tubing and then organizing the resident's equipment, which was confirmed as inappropriate by both the therapist and the Director of Nursing. In another instance, an isolation trash can in a resident's room was found overflowing and uncovered, exposing personal protective equipment. The licensed nurse confirmed the trash can was broken and should have been covered, a sentiment echoed by the Infection Preventionist and the Director of Nursing. Additionally, oxygen tubing and nebulizer facemasks for another resident were not properly labeled or were labeled with expired dates, which was verified by a certified nursing assistant and the Director of Staff Development. This oversight was acknowledged as a potential risk for respiratory infection by the Infection Preventionist and other staff members. Further deficiencies were noted with an air fan in a resident's room that was dirty and blowing directly towards the resident, which could lead to respiratory illness. This was confirmed by a certified nursing assistant and a licensed nurse, who acknowledged the responsibility to clean such equipment. Additionally, three trash containers in the dining room were found open and without lids during a meal, which was confirmed by a licensed nurse as a breach of infection control protocols.
Unsafe Freezer Temperatures in Facility Kitchen
Penalty
Summary
The facility failed to maintain one of its three reach-in freezers in safe operating condition, as observed during a survey. The freezer, located near the Dietary Supervisor's office, was found to be running at unsafe temperatures, with readings of 16 and 20 degrees Fahrenheit during two separate observations. The Dietary Supervisor confirmed these readings and acknowledged that the freezer should be colder. It was noted that the freezer had been last serviced in July 2024, but there was no scheduled maintenance, suggesting it might be broken. The facility's policy and procedure for food storage indicated that freezer temperatures should be maintained at 0 degrees Fahrenheit or below. Additionally, the policy for equipment maintenance required routine cleaning and maintenance in accordance with manufacturer's directions, with requests for maintenance or repair to be submitted as needed. The failure to maintain the freezer at the appropriate temperature had the potential to lead to the growth of bacteria and foodborne illness for all 54 residents consuming meals prepared by the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, clean, and comfortable environment for its residents, staff, and the public. In the dining room, several issues were observed, including missing slats on window blinds, non-functioning fluorescent bulbs, and open trash containers without lids. These deficiencies were verified by various staff members, including a Restorative Nursing Aide, a Licensed Nurse, and the Activities Director. The Maintenance staff acknowledged the issues but indicated that they were not addressed due to a lack of parts and communication from previous administration. Resident 19 was found in a concerning state, with a strong odor emanating from both the resident and the room environment. The resident, who has a history of PTSD, blindness, and anxiety, was observed to be disheveled, half-naked, and wearing a dirty incontinence brief. The room was also noted to be unclean, with disorganized sheets and a dirty floor. The resident expressed dissatisfaction with the care received, indicating neglect in personal hygiene and room cleanliness. Interviews with staff, including a Licensed Nurse and the Director of Nursing, confirmed the unsanitary conditions and the need for a clean and comfortable environment. The facility's policy on maintenance service, which emphasizes maintaining the building in good repair and following infection control precautions, was not adhered to, leading to these deficiencies.
Deficiency in In-Service Training for Contracted CNAs
Penalty
Summary
The facility failed to ensure that two contracted Certified Nursing Assistants (CCNAs), identified as CCNA 15 and CCNA 16, received the required in-service training, including dementia management and abuse prevention, as mandated by the facility's policy. During interviews and record reviews, the Director of Staff Development (DSD) and the Director of Nursing (DON) were unable to provide documentation verifying that these CCNAs had completed no less than 12 hours of annual in-service training. The facility relied on a staffing agency to provide this documentation, but the agency was identified as a scheduling agency, which did not maintain records of training completion. The Administrator (ADM) confirmed that there was no way to verify if the in-service training was completed for the contracted CCNAs through the agency. The facility's policy, revised in May 2019, clearly stated the requirement for annual in-services to address specific skills and knowledge, including dementia management and abuse prevention. The lack of documentation and verification of training for CCNA 15 and CCNA 16 had the potential to significantly compromise the quality of services provided to the residents.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for two residents, impacting their emotional, mental, and psychosocial well-being. For Resident 52, who has PTSD, depression, and chronic pain, the deficiency occurred when a maintenance staff member entered the resident's room without knocking or identifying himself. This action was contrary to the facility's policy, which requires staff to knock, announce themselves, and ask for permission before entering a resident's room. Interviews with the maintenance staff and nursing staff confirmed the lack of adherence to this protocol, which left Resident 52 feeling that their dignity and privacy were not respected. Resident 19, who has PTSD, blindness, and anxiety, was found in a state of neglect, with a strong body odor and a foul-smelling environment. The resident was disheveled, half-naked, and wearing a dirty incontinence brief, with a dirty floor and disorganized sheets. Despite having moderate memory impairment, Resident 19 did not reject assistance with activities of daily living. The resident expressed feelings of being neglected and living in filth, which was verified by a licensed nurse who acknowledged the unhealthy and undignified condition. The facility's policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. Resident 52, who was admitted with PTSD, depression, and chronic pain, expressed concerns about loud door noises exacerbating her PTSD symptoms. Despite her complaints and the maintenance staff's awareness of the issue, no care plan was developed to address her emotional and environmental concerns. Interviews with staff revealed that the problem had been ongoing for months, yet no action was taken to move the resident or fix the door noise, and the Social Services Director was unaware of the issue. Resident 85, admitted with a lumbar vertebral fracture, Alzheimer's disease, and generalized anxiety disorder, did not have a care plan for activities. The resident was observed to remain in bed and not participate in activities, contrary to the initial assessment that recommended in-room visits three times a week. The Activities Director confirmed the absence of a care plan and acknowledged its importance in preventing isolation and depression. Despite the facility's policy requiring care plans to be developed within 24 hours of identifying a new issue, this was not done for Resident 85. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to develop and implement care plans for Residents 52 and 85 indicates a lapse in adhering to this policy. Interviews with the Director of Nursing and other staff highlighted the expectation for immediate care plan development, yet this was not reflected in practice, leading to potential risks to the residents' well-being.
Failure to Update Care Plans for Adaptive Device and Pain Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for two residents, leading to potential deficiencies in their care. Resident 18, who was admitted with conditions including stroke, diabetes, and dysphagia, had a nutrition care plan that was not updated to include the use of a two-handled cup as ordered by the physician. During an observation, it was noted that Resident 18 was provided with a sippy cup instead of the prescribed two-handled cup, which was confirmed by the nursing staff. The MDS Coordinator verified that the care plan did not include the necessary adaptive device, indicating a lack of revision and update. Resident 139, admitted with diagnoses such as stroke and COPD, had a pain care plan that was not updated to reflect a new medication order for Tramadol. Despite the resident expressing pain and the presence of a physician's order for pain management, the care plan lacked an intervention for the administration of the medication. Observations and interviews revealed that Resident 139 was experiencing pain and had not received the prescribed medication, with staff acknowledging the oversight in updating the care plan. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in these cases. The Director of Nursing emphasized the importance of addressing residents' needs promptly, yet the care plans for both residents were not updated to include necessary interventions, potentially impacting their well-being.
Deficiencies in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents. Resident 19, who has diagnoses including PTSD, blindness, and anxiety, was found in a disheveled state with a strong foul-smelling odor in his room. Despite having moderate memory impairment and not rejecting assistance with activities of daily living, Resident 19 was observed in a dirty incontinence brief and expressed dissatisfaction with the care provided. A licensed nurse confirmed the resident's unclean condition and acknowledged it was unhealthy to leave him in such a state. Resident 29, diagnosed with respiratory failure, traumatic brain injury, and seizures, was observed with long and jagged fingernails. When asked, the resident indicated a desire to have his nails trimmed. A licensed nurse confirmed the nails were long and should be cut on shower days to prevent potential harm. The facility's policy indicated that nail care should include daily cleaning and regular trimming, and that residents should receive appropriate care to ensure their activities of daily living do not diminish unless unavoidable due to clinical conditions.
Failure to Provide Scheduled In-Room Activities
Penalty
Summary
The facility failed to meet the activity needs of two residents, leading to potential isolation and depression. Resident 37, who has a history of cerebral infarction, aphasia, and quadriplegia, was supposed to receive in-room visits three times a week as per their care plan. However, upon review, it was found that no documented activity visits had occurred. The Activities Director confirmed the lack of documented visits and acknowledged the importance of activities to prevent depression and isolation. Similarly, Resident 85, diagnosed with lumbar vertebral fracture, difficulty in walking, Alzheimer's disease, and generalized anxiety disorder, was also supposed to receive in-room visits three times a week. However, the electronic health record indicated only one documented visit since admission. The Activities Director confirmed this and emphasized the resident's need for companionship to avoid feeling alone. The facility's policy requires the Activity Director to schedule and ensure assistance for residents to attend activities, which was not adhered to in these cases.
Failure to Obtain Consent and Orders for Bed Rail Use
Penalty
Summary
The facility failed to follow proper procedures before using bed rails for a resident, identified as Resident 63. The resident was admitted with medical conditions including sequelae of cerebral infarction, muscle wasting and atrophy, and dysphagia, and was noted to have memory impairment. Observations on two separate occasions revealed that the bed rails were locked and in use without the necessary physician's orders, informed consent, or care plan in place. Licensed Nurse 5 confirmed the absence of these documents in the resident's medical record, which was corroborated by another licensed nurse during a concurrent review. The facility's policy and procedure on bed safety, dated December 2007, requires obtaining consent from the resident or their legal representative before using side rails, and informing them about the benefits and potential hazards. The policy also mandates that side rails should only be used when no other reasonable alternatives can be identified. However, the facility did not attempt appropriate alternatives, nor did it obtain the required physician's orders and informed consent prior to the use of bed rails for Resident 63, leading to a deficiency in compliance with the established procedures.
Narcotic Inventory Discrepancies
Penalty
Summary
The facility failed to maintain an accurate inventory of narcotics for two residents, Resident 66 and Resident 76, which increased the potential for diversion and hindered the ability to accurately monitor medication administration. Resident 66, admitted with cancer of the head and neck, had two instances where Norco tablets were removed from the medication card but not documented as administered in the Medication Administration Record (MAR). Similarly, Resident 76, diagnosed with muscular dystrophy, had four Oxycodone tablets removed without corresponding documentation in the MAR. The Director of Nursing (DON) confirmed the discrepancies between the Controlled Drug Record (CDR) and the MAR for both residents, acknowledging the lack of signatures on the MAR that matched the narcotic sheet. The DON emphasized the importance of accurate documentation to ensure residents receive their medications and acknowledged that inaccurate documentation increases the risk of narcotic diversion. The facility's policy on medication reconciliation aims to ensure medication safety by accurately accounting for residents' medications, but this was not adhered to in these cases.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 9, who was admitted with acute and chronic respiratory failure with hypoxia, pneumonia, and muscle wasting and atrophy. Despite having a Brief Interview for Mental Score (BIMS) of 13, indicating no cognitive impairment, Resident 9's request to not be served cream of wheat for breakfast was disregarded. Instead, the resident was served cream of wheat, contrary to the meal tray ticket instructions which specified oatmeal with three butter packets. This incident was confirmed during an interview with the Dietary Supervisor, who acknowledged that Resident 9 should have received oatmeal as requested. The facility's policy and procedure titled 'Trayline Checklist' from 2010 was reviewed, which indicated that alternate meal options should be available, but this was not adhered to in this instance.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment for two residents, as ordered by their physicians, which could negatively impact their well-being and meal intake. Resident 18, who has a history of stroke, diabetes, hemiplegia, dysphagia, and muscle weakness, was not provided with a two-handled cup as specified in her care plan. During an observation, it was noted that Resident 18 was given a sippy cup instead, which was not in accordance with her meal ticket or care plan. The MDS Coordinator confirmed that the two-handled cup was not included as an intervention in the nutrition care plan. Similarly, Resident 73, who has encephalopathy, diabetes, dysphagia, and reduced mobility, was not provided with plastic eating utensils as indicated in her care plan. During a meal, Resident 73 was observed struggling to use metal silverware instead of the prescribed plastic utensils. The MDS Coordinator verified that the care plan included the use of plastic utensils, and the Director of Nursing emphasized the importance of providing adequate care and adaptive devices. The facility's policy on accommodating needs highlights the requirement to evaluate and review residents' needs for adaptive devices regularly.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 651 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer House | 2.2 mi | ★★★★★ | 22 | 0 |
| Cedarwood Post Acute | 3.2 mi | ★★★★★ | 0 | 0 |
| Mid-town Oaks Post-acute | 3.8 mi | ★★★★★ | 27 | 0 |
| Mckinley Park Care Center | 4.3 mi | ★★★★★ | 31 | 0 |
| Saylor Lane Healthcare Center | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.