Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Valley Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to submit required PBJ staffing data to CMS. During record review, the PBJ/CASPER report showed the quarterly submission had not been filed, and the ADM confirmed the delay was due to corporate computer issues. By the end of the survey, the facility could not provide evidence of compliance with the PBJ reporting requirement.
Survey Results Not Readily Accessible to Residents: A resident council interview found residents did not know where to find the facility’s most recent survey results. The survey binder was not on the usual shelf near the front entrance, the Adm said it had been moved into a closed cabinet after decorations were put away, and there was no posted notice showing where the binder was kept.
A facility failed to maintain two shared resident bathrooms in a clean, homelike condition. Surveyors observed strong urine odors, brown staining on the flooring, black staining behind one toilet, and what appeared to be fecal matter on a toilet tank, seat, and rim; the same conditions were still present on a later observation. The DON reviewed photos and confirmed the bathrooms appeared unsatisfactorily unclean and the flooring stained.
Incorrect Administration of Tiotropium Inhaler: A resident with COPD and multiple chronic conditions did not receive tiotropium inhalation medication according to the manufacturer’s instructions. An LPN handed over the inhaler without giving the required breathing directions, and the resident inhaled without first breathing out or holding the medication in the lungs as directed. The nurse and DON both confirmed the inhaler was not administered correctly per policy and the product instructions.
A resident with chronic kidney disease and intact cognition went more than 14 hours without documented urination, yet staff did not recognize or act on this lack of urine output in a timely manner. The last recorded void was late one evening, and no further output was documented before the resident was transferred to the hospital the following afternoon. The transfer form completed by an LN did not note the absence of urine output, although a later communication to the physician stated there had been no urine since the previous day. At the hospital, catheterization drained 2,000 mL of urine, far above normal bladder capacity. The DON acknowledged that nursing staff did not recognize the prolonged absence of urination across two shifts, that an order for intermittent catheterization could have been obtained but was not, and that the facility lacked a urinary retention policy.
A gastroenteritis outbreak occurred, with multiple residents experiencing vomiting and diarrhea over several days. The facility's policy required reporting such outbreaks to CDPH within 24 hours, but notification was delayed despite clear evidence of an outbreak. The delay was confirmed by the IP and DON during interviews and record review.
Three residents with Foley catheters did not have their urine output documented as required by facility policy and physician orders. Despite complex medical conditions and explicit instructions to monitor and record urinary output every shift, staff failed to document this information in the residents' records. The DON confirmed that this documentation was not completed for any of the affected residents.
A resident's representative was not informed of a change in the resident's condition requiring oxygen administration, as per facility policy. The resident, with poor decision-making skills, was given oxygen due to low saturation levels. The oversight was confirmed by staff and acknowledged by the DON, with no documentation of notification to the representative.
A resident with severe cognitive impairment received oxygen without a physician's order, contrary to the facility's medication administration policy. The resident, with a history of metabolic encephalopathy and severe malnutrition, had an oxygen saturation of 88%, prompting a nurse to administer oxygen at 2 liters by nasal cannula. Both the nurse and DON confirmed that oxygen requires a physician's order, highlighting a breach in protocol.
A resident with bipolar disorder did not receive their prescribed Depakote due to unavailability, and the facility failed to notify the physician as required by policy. Despite multiple missed doses documented in the MAR and progress notes, there was no evidence of communication with the physician. Interviews with LVNs and the DON revealed a lack of awareness and documentation, leading to a significant lapse in care.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their assessments and care plans. A resident was incorrectly noted to use restraints, while another's CPAP use was not documented. Two residents with serious mental health conditions requiring Level II PASRR were not accurately reflected in their MDS assessments. The MDS Coordinator and DON acknowledged these oversights, emphasizing the importance of accurate documentation.
The facility failed to accurately complete PASRR Level I screenings for two residents, resulting in deficiencies in documenting their mental health diagnoses. One resident's PASRR did not reflect their bipolar disorder, depression, and anxiety, while another's omitted similar diagnoses and psychotropic medication use. The MDS Coordinator acknowledged the inaccuracies, and the DON expected accurate documentation, which was not met.
The facility failed to include essential elements in the care plans of two residents, leading to deficiencies. One resident's care plan omitted the use of a CPAP machine despite its documented use, while another resident's care plan lacked the inclusion of a Level II PASRR and its recommendations. Staff interviews confirmed these omissions, highlighting a lapse in adhering to the facility's care planning policy.
A resident's CPAP equipment was not cleaned or stored properly, as required by facility policy. Observations showed the CPAP machine on the nightstand with debris in the mask and an empty humidifier chamber. Staff interviews confirmed the equipment was not maintained according to policy, which required cleaning and storage in a bag for infection control.
A resident with bipolar disorder did not receive their prescribed Depakote in a timely manner, resulting in multiple missed doses. Despite facility policy requiring timely medication receipt, interviews with LVNs revealed inconsistent actions and communication failures. The Medical Director and DON were unaware of the issue, and the Medical Records Supervisor confirmed a lack of documentation regarding physician notification.
A facility failed to notify a physician of pharmacy consultant recommendations for a resident receiving escitalopram for depression. The consultant pharmacist suggested evaluating the therapy for a possible dose reduction or discontinuation, but there was no documentation of follow-up. The DON acknowledged the lapse in following up on the recommendations.
Two residents experienced falls, but their care plans were not updated as required by the facility's policies. Despite the facility's procedures mandating care plan updates after falls, the care plans for these residents were not revised. Interviews with LNs and the DON confirmed the oversight, highlighting a lapse in following established protocols.
The facility failed to ensure proper infection control procedures in COVID-19 positive rooms. LVN A and RN B were observed not wearing appropriate eye protection, with LVN A not using an eye shield and RN B using prescription glasses instead. The IP confirmed the need for reeducation on PPE protocols.
The facility did not follow its abuse policy by failing to submit the results of an abuse investigation to the State Survey Agency within five working days. This involved two residents, one with high blood pressure and anxiety, and another with memory loss due to a stroke. The interim Assistant Director of Nurses confirmed the absence of the required report, and the interim Administrator acknowledged the oversight by the previous Administrator.
A resident with severe cognitive decline and a history of elopement was not adequately monitored or protected by the facility. Despite being identified as an elopement risk, the resident was able to leave the facility unsupervised and was found at a nearby park. The facility failed to follow its policies for monitoring the resident's wander guard and did not update the care plan to address specific elopement triggers or schedule regular activities.
The facility did not report the results of an abuse investigation involving two residents to CDPH within the required timeframe. Although the incident was initially reported, the follow-up report detailing findings and corrective actions was not submitted, as confirmed by the ADON during a review. This failure to comply with state law and facility policy could leave residents at risk of continued abuse.
A resident's mail was not delivered within 24 hours and was opened by facility staff without permission, violating the facility's policy. The resident, who had intact cognition, reported the delay and unauthorized opening of her package. The Social Service Director and Assistant Director of Nursing confirmed the breach of protocol, noting that the resident was capable of handling her own mail.
A resident with a surgical wound was admitted to the facility but refused to have the wound assessed by staff. The facility waited two weeks for an orthopedic follow-up to obtain wound care orders, despite policies requiring a skin assessment upon admission. The resident, who was cognitively intact, insisted the brace should not be removed, and the facility did not assess the wound until after receiving orders from the follow-up appointment.
A resident was not provided with an activities schedule or newsletter for two months, leaving them uninformed about facility activities and news. The resident, with conditions including epilepsy and depression, expressed frustration over the lack of information. The facility administrator acknowledged that during a period without an activities director, these materials were not distributed.
A facility failed to respect a resident's dignity when a CNA did not stop moving her despite her request, causing fear due to her PTSD. The resident, with a complex medical history and weighing 470 pounds, required extensive assistance for bed mobility. The CNA, unfamiliar with the resident and unprepared for her size, attempted the task alone, contrary to the care plan's requirements. The facility's Administrator highlighted the expectation for CNAs to communicate and seek help when needed.
A CNA at a LTC facility failed to provide adequate assistance during incontinence care for a resident with mobility issues and morbid obesity, leading to the resident's discomfort. The CNA, unfamiliar with the resident's needs, attempted to reposition the resident without a second person, despite the resident's protests. The facility lacked proper communication and training, as the CNA was not informed of the required assistance level, and the Director of Staff Development was absent.
The facility failed to provide meals and conduct necessary pre, during, and post-dialysis assessments for residents requiring dialysis. A resident did not receive meals before, during, or after dialysis, and assessments were not consistently documented for four residents. This oversight was confirmed through staff interviews and record reviews.
Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate Payroll Based Journal (PBJ) direct care staffing information to CMS based on payroll and other verifiable and auditable data. During a concurrent interview and record review, the PBJ/CASPER report for fiscal year Quarter 1, 2026 (October 1 through December 31) was reviewed and showed that the report had not been submitted for that quarter. The Administrator confirmed the report was not submitted because the corporation had computer issues and the facility could not submit the PBJ report on time. By the end of the survey, the facility was unable to provide evidence that it had complied with the requirement to submit PBJ data and reports to CMS.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility did not protect residents’ right to access and review the results of the most recent recertification survey and any plan of correction in a place readily accessible to residents. Review of the facility policy titled, Resident [NAME] of Rights, dated 5/2011, stated that a resident has the right to examine the results of the most recent survey and any plan of correction, and that the facility must make the results available for examination in a readily accessible place and post a notice of their availability. During a Resident Council meeting interview, attendees stated they did not know where in the facility to find the survey results. During a concurrent observation and interview, the Receptionist stated there was no survey binder on the shelf on the north side of the front entrance door where it was usually kept and said the Administrator might have had it. The Administrator confirmed the survey binder was not on that shelf and stated it had been moved to a closed cabinet inside the shelf when decorations were put away after a celebration. During a later observation and interview, the Administrator confirmed there was not a notice posted where the survey binder was kept.
Unclean Shared Resident Bathrooms
Penalty
Summary
The facility failed to maintain a clean, homelike environment in two shared resident bathrooms serving up to three residents each. During observation, the bathroom between rooms [ROOM NUMBERS] was highly malodorous with a strong urine odor, brown staining in the vinyl flooring around the front of the toilet, and what appeared to be fecal matter adhered to the toilet tank, seat, and rim. The toilet base also had dried, gummy urine around the bolt area and white cap covers. A second bathroom between rooms 19 and 20 was observed to have a strong urine smell, brown staining on the linoleum in front of the toilet, and black staining spreading behind the toilet. On a later observation, both bathrooms still looked and smelled the same as before. The DON reviewed the surveyor’s photos and confirmed the bathrooms appeared unsatisfactorily unclean and the flooring stained, which was not conducive to a healthy, homelike environment.
Incorrect Administration of Tiotropium Inhaler
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 33, received tiotropium inhalation medication in accordance with the manufacturer’s instructions. Resident 33 was admitted with multiple diagnoses including COPD, heart disease, high blood pressure, diabetes, heart failure, epilepsy, major depressive disorder, and malignant melanoma. The resident’s most recent MDS indicated no cognitive problems, with a BIMS score of 14 out of 15. Resident 33 had an active order for Tiotropium Bromide Monohydrate Capsule 18 mcg to be inhaled once daily for COPD, with instructions to rinse the mouth after use. During observation, Licensed Nurse B administered the inhalation medication but did not provide the correct steps for use to the resident, who was capable of following instructions. The nurse handed the inhaler to the resident and did not instruct the resident to breathe out before using the inhaler. The resident inhaled one puff without blowing out first and did not hold the medication in the lungs for 10 seconds. The nurse did not instruct the resident to hold the medication in as long as possible after inhaling. During interview and record review, the nurse confirmed the manufacturer’s step four was not followed and that no breathing directions were provided. The DON also confirmed the medication was not administered correctly per the facility’s medication policy and the manufacturer’s instructions for use.
Failure to Recognize and Manage Urinary Retention Leading to Delayed Treatment
Penalty
Summary
The deficiency involves the facility’s failure to appropriately recognize and manage urinary retention for one resident, resulting in delayed treatment. The resident had chronic kidney disease and was cognitively intact with a BIMS score of 15, indicating he could make his own decisions. Facility documentation showed that his last recorded urination occurred at 11:32 p.m. on 12/8/25, and there was no further documented urine output for over 14 hours prior to his transfer to the hospital on 12/9/25 at 2:08 p.m. The facility’s own intermittent catheterization policy stated that intermittent catheterization would be used when medically necessary, and nationally recognized resources cited in the report indicated that acute urinary retention can be life-threatening and that treatment involves draining the bladder with a urinary catheter. Despite this, the SNF/NF to Hospital Transfer Form completed by LN A did not mention that the resident had not urinated for over 14 hours. A subsequent communication note with the physician at 2:39 p.m. documented that the resident had no urine output since the previous day. At the hospital, a urinary catheter was inserted and 2,000 mL of urine was drained, significantly exceeding normal bladder capacity as described in the National Library of Medicine reference. During interviews, the DON acknowledged there was no documentation of urination for over 14 hours, that LN A could have obtained an order for intermittent catheterization but did not realize the resident had not urinated until later, and that the lack of recognition occurred over two shifts. The DON also stated that the facility did not have a urinary retention policy.
Delayed Reporting of Gastroenteritis Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to report an outbreak of gastroenteritis to the California Department of Public Health (CDPH) in a timely manner. According to the facility's records, multiple residents began experiencing symptoms of gastroenteritis, including vomiting and diarrhea, over several days. Specifically, two residents vomited on one day, three more on another, and five more on a subsequent day, with a total of 12 residents showing symptoms between the first and fifth of the month, and an additional seven residents experiencing symptoms in the following week. The facility's policy required that unusual occurrences, such as suspected outbreaks, be reported to the appropriate agencies within 24 hours. However, the CDPH was not notified until several days after the initial cases were identified. The Infection Preventionist confirmed that the line list documented the progression of symptoms among residents, and the Director of Nursing acknowledged that the suspicion of a gastrointestinal outbreak was not reported promptly. This delay in reporting was identified during interviews and record reviews, where it was confirmed that the facility did not adhere to its own policy or state guidelines regarding timely notification of communicable disease outbreaks. The failure to report the outbreak in a timely manner had the potential to allow the infection to spread among residents, staff, and the community.
Failure to Document Foley Catheter Output per Policy and Orders
Penalty
Summary
The facility failed to monitor and document the output of Foley catheters for three residents as required by both facility policy and physician orders. The policy specified that nursing staff must assess urinary drainage for signs and symptoms of infection, including cloudiness, color, sediment, blood, odor, and the amount of urine, and document these findings every shift. Physician orders for each of the three residents also required staff to document the amount of urine output from the Foley catheter every shift. Record reviews revealed that for all three residents, there was no documentation of urine output on their Intake and Output records or Bladder reports during their respective stays. The Director of Nursing confirmed that no output was documented for these residents, despite the presence of physician orders and facility policy mandating this documentation. The lack of documentation was acknowledged as a failure to follow both the facility's catheter care policy and the specific physician orders for these residents. The residents involved had significant medical histories, including obstructive and reflux uropathy, atrial fibrillation, metabolic encephalopathy, urinary retention, congestive heart failure, benign prostatic hyperplasia, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, irritable bowel syndrome, and constipation. Despite these complex conditions and the presence of Foley catheters, the required monitoring and documentation of urinary output was not performed for any of the three residents.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to inform the representative of a resident about a change in the resident's condition, which required the administration of oxygen. The facility's policy mandates that licensed nurses notify family or surrogate decision-makers of any changes in a resident's condition as soon as possible. However, in this case, the resident's representative was not informed when the resident was given oxygen due to low oxygen saturation levels. The resident, who had poor decision-making skills and memory recall, was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, and severe protein-calorie malnutrition. The deficiency was identified during a review of the resident's medical records and interviews with the resident's representative and facility staff. The resident's medication administration record indicated that oxygen was administered, but there was no documentation of notification to the resident's representative. The licensed nurse on duty confirmed the oversight, and the Director of Nurses acknowledged the lack of documentation regarding the notification of the resident's representative.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility administered oxygen to a resident without a physician's order, which is a violation of their medication administration policy. The policy, dated January 1, 2012, clearly states that medication, including oxygen, should only be administered by a licensed nurse upon the order of a physician or licensed independent practitioner. However, on December 28, 2024, a licensed nurse administered oxygen to a resident at a rate of 2 liters by nasal cannula due to an oxygen saturation level of 88%, which is below the normal range of 92 to 100%. The nurse confirmed that no physician's order was obtained prior to administering the oxygen, considering it an acceptable nursing intervention for immediate treatment. The resident involved had a severe impairment in memory and decision-making ability, as indicated by a Brief Interview for Mental Status score of 2 out of 15. The resident's medical history included diagnoses of metabolic encephalopathy, urinary tract infection, and severe protein-calorie malnutrition. During a review of the resident's Medication Administration Record and Physician's Orders for December 2024, both the licensed nurse and the Director of Nurses confirmed that oxygen is considered a medication and requires a physician's order for administration. This oversight in following the facility's policy had the potential to lead to negative clinical outcomes for the resident.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician when a medication, Depakote, was not available for administration to a resident diagnosed with bipolar disorder. The resident was admitted to the facility with a history of bipolar disorder and was prescribed Depakote to be administered at bedtime. However, the medication was not available on multiple occasions, as documented in the Medication Administration Record (MAR) and progress notes, spanning from late September to mid-October 2024. Despite the facility's policy requiring the prescriber to be contacted when a medication is unavailable, there was no evidence that the physician was notified about the unavailability of Depakote for the resident. Interviews with several Licensed Vocational Nurses (LVNs) revealed that they were aware of the protocol to notify the physician via fax or phone call and document it in the resident's medical record. However, none of the LVNs recalled notifying the physician, and the Medical Records Supervisor confirmed the absence of any faxes regarding the issue. The Director of Nursing (DON) and the Administrator were also unaware of the situation, indicating a breakdown in communication and documentation. The Medical Director, who receives numerous faxes daily, did not recall receiving any notification about the resident's missed doses of Depakote. This lack of communication and documentation led to the resident missing several doses of a critical medication, which was not addressed in a timely manner by the facility staff.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments and care plans. Resident #8 was admitted with a history of heart failure and diabetes, among other conditions. The MDS inaccurately indicated the use of physical restraints, which was not observed during multiple assessments. The MDS Coordinator admitted to mistakenly entering this information, highlighting a lack of accuracy in the assessment process. Resident #44, with a history of sleep apnea and oxygen dependence, was not accurately coded for the use of a CPAP machine on their MDS. Despite having an order for CPAP therapy and evidence of its use, the MDS did not reflect this, indicating a failure to accurately capture the resident's care needs. The MDS Coordinator acknowledged the oversight, emphasizing the importance of accurate MDS coding for effective care planning. Residents #25 and #52 both had serious mental health conditions requiring Level II Preadmission Screening and Resident Review (PASRR), which were not accurately reflected in their MDS assessments. Despite having documentation supporting the need for specialized services, the MDS for both residents failed to include their PASRR status. This oversight was confirmed by the MDS Coordinator and the Director of Nursing, who both stressed the critical nature of accurate MDS documentation in reflecting the residents' needs and guiding their care plans.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in the documentation of their mental health diagnoses. Resident #6 was admitted with a medical history of bipolar disorder, major depressive disorder, and generalized anxiety disorder. However, the PASRR Level I Screening indicated no serious mental illness, which was inaccurate. The MDS Coordinator acknowledged that the PASRR should have been updated to reflect the resident's psychiatric diagnoses, but this was not done. The Director of Nursing (DON) and the Administrator both expected accurate documentation, which was not met in this case. Similarly, Resident #18's PASRR Level I Screening was also found to be inaccurate. The resident had a history of bipolar disorder, major depressive disorder, and anxiety disorder, but the PASRR screening did not document these mental illnesses or the use of psychotropic medications. The MDS Coordinator admitted that the PASRR was incomplete and should have triggered a Level II PASRR, which was not conducted. The DON reiterated the expectation for accurate PASRR documentation, which was not fulfilled for Resident #18. Interviews with the Business Office Manager (BOM) and the MDS Coordinator revealed a lack of clarity regarding the responsibility for ensuring PASRR accuracy. The BOM was unsure who was responsible for checking the PASRR, while the MDS Coordinator stated it was her responsibility to ensure all diagnoses were included and accurate. Despite this, the necessary updates to the PASRRs were not made, resulting in deficiencies in the residents' documentation.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for two residents, leading to deficiencies in their care. For one resident, who had a medical history of obstructive sleep apnea and was dependent on supplemental oxygen, the care plan did not include the use of a non-invasive mechanical ventilator, specifically a CPAP machine. Despite having an order for CPAP therapy and documentation of its nightly use, the care plan only mentioned oxygen therapy. Interviews with staff, including the MDS Coordinator, LVNs, and the Director of Nursing, confirmed that the use of a CPAP machine should have been included in the care plan. Another resident, with a medical history of anxiety disorder, depression, PTSD, and bipolar disorder, had a Level II PASRR that was not included in their care plan. The PASRR report contained individualized recommendations for specialized services, such as increased family contact and addressing weight concerns, which were not reflected in the care plan. The MDS Coordinator acknowledged the oversight and stated that the Level II PASRR and its recommendations should have been care planned. The facility's policy on care planning emphasizes the need for person-centered, comprehensive, and interdisciplinary care plans that meet residents' health, safety, psychosocial, behavioral, and environmental needs. However, the failure to include critical elements such as the CPAP machine and Level II PASRR recommendations in the care plans of the two residents indicates a lapse in adhering to this policy. Interviews with facility staff, including the Administrator, highlighted an expectation for care plans to include all necessary information to guide staff in providing appropriate care.
Improper Cleaning and Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of non-invasive mechanical ventilation equipment for a resident with obstructive sleep apnea and dependence on supplemental oxygen. The facility's policy required CPAP equipment to be cleaned and stored in a plastic bag or container labeled with the resident's name when not in use. However, observations revealed that the CPAP machine was left on the resident's nightstand with the tubing and mask attached, and dried debris was found in the mask. Additionally, the humidifier chamber was found empty on multiple occasions, contrary to the order that specified it should be filled with distilled water every night. Interviews with staff, including LVNs and the Director of Nursing, confirmed that the CPAP equipment was not being cleaned or stored according to the facility's policy. Staff members acknowledged that the equipment should be stored in a bag for infection control and cleaned after each use. The Director of Nursing stated that the CPAP mask should be cleaned daily, the headgear weekly, and the filter changed every two weeks. The Administrator deferred to the Director of Nursing on care-related subjects but acknowledged that staff should follow facility policies and procedures.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure that medications were received from the pharmacy in a timely manner for a resident diagnosed with bipolar disorder. The resident, who had intact cognition, was admitted to the facility with a care plan that included the use of psychotropic medications. The medication administration record indicated that the resident's prescribed Depakote was not available on multiple occasions, leading to missed doses over several days. Interviews with various Licensed Vocational Nurses (LVNs) revealed a lack of consistent action in addressing the unavailability of the medication. While some LVNs attempted to locate the medication within the facility or contact the pharmacy, there was no evidence of consistent communication with the physician or the Director of Nursing (DON) regarding the missed doses. The facility's policy required timely receipt of medications, but this was not adhered to, resulting in the resident missing critical doses of their mood stabilizer. The Medical Records Supervisor confirmed the absence of documentation regarding communication with the physician about the medication issue. The Medical Director was unaware of the situation and noted the potential impact on the resident's mood stability. The Pharmacy Representative indicated that the medication was delivered upon request, but there was no record of earlier orders. The DON and Administrator were not informed of the ongoing issue, highlighting a breakdown in communication and protocol adherence within the facility.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the physician of pharmacy consultant recommendations for a resident reviewed for unnecessary medications. The facility's policy required that all findings and recommendations from the consultant pharmacist be reported to the director of nursing, the attending physician, the medical director, and the administrator. However, the facility did not follow this policy for a resident who had been receiving escitalopram for depression. The consultant pharmacist's report recommended evaluating the therapy to determine if a lower dose or discontinuation was appropriate, but there was no documentation that the prescriber had signed or dated the report, indicating a lack of follow-up on the recommendation. The resident in question had a history of major depressive disorder and was receiving escitalopram daily. The resident's care plan included monitoring the effectiveness and side effects of the antidepressant medication. Despite the consultant pharmacist's recommendation for a gradual dose reduction or discontinuation, the facility did not document any follow-up actions. Interviews with the Director of Nursing revealed that the follow-up for the pharmacy recommendations was not found, indicating a lapse in the facility's process for addressing pharmacy consultant recommendations.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update care plans for two residents after they experienced falls, as required by their policies. The facility's policy on Fall Prevention and Management Program, revised on 8/1/14, mandates that care plans be initiated or updated following a resident's fall. Additionally, the Comprehensive Person-Centered Care Planning policy, revised on 11/1/18, requires updates to the care plan based on the resident's assessed needs. However, the care plans for Residents 2 and 7 were not updated after their falls, which was confirmed during interviews with Licensed Nurses (LNs) and the Director of Nursing (DON). Resident 2, who was admitted with diagnoses including dementia and epilepsy, had a fall on 10/14/24, but no Actual Fall care plan was initiated. Similarly, Resident 7, who had a history of syncope and amputation, fell on 10/2/24, yet their care plan was not updated to reflect this incident. Interviews with LN A and LN C revealed that LNs were responsible for initiating or revising care plans after a fall, using a fall packet checklist. The DON confirmed the absence of updated care plans for both residents, acknowledging that the necessary updates were not made as per the facility's procedures.
Inadequate PPE Usage in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed in COVID-19 positive resident rooms. During an observation, it was noted that eight rooms had isolation signs indicating the need for specific personal protective equipment (PPE) including gowns, N95 masks, eye protection, and gloves. However, two staff members were observed not adhering to these requirements. Licensed Vocational Nurse (LVN) A was seen exiting an isolation room wearing an N95 mask but without an eye shield, despite acknowledging the presence of COVID-19 positive residents in the room. LVN A admitted to not wearing an eye shield because she did not believe it was necessary. Similarly, Registered Nurse (RN) B was observed leaving another isolation room wearing an N95 mask and her own prescription glasses, which had slid down her nose, instead of proper eye protection. RN B confirmed the room was for COVID-19 isolation but mistakenly thought her glasses sufficed as eye protection. The Infection Preventionist (IP) later clarified that prescription glasses do not qualify as eye shields and expressed the need to reeducate staff on the correct PPE protocols for isolation rooms.
Failure to Report Abuse Investigation Results Timely
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not providing the State Survey Agency (SA) with the results of an investigation into an alleged abuse incident within the required five working days. This incident involved two residents, one with high blood pressure and anxiety, and the other with memory loss due to a stroke. The facility's policy, revised on January 8, 2014, mandates that the Administrator or their designee must submit a written report of the investigation findings to the appropriate agencies within five working days of the incident. The deficiency was identified during a review of the facility's records and interviews with staff. The interim Assistant Director of Nurses (IADON) confirmed that the file related to the alleged abuse did not contain the required 5-day investigation report. Additionally, the interim Administrator (IADMIN) acknowledged that the previous Administrator had failed to provide the SA with the necessary report. This oversight placed residents at risk for further potential abuse, as the facility did not comply with its own procedures for reporting and investigating abuse allegations.
Failure to Manage Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to adequately address the elopement risk of a resident, identified as Resident 1, who had a history of severe cognitive decline and was not his own responsible party. Despite being identified as an elopement risk after a previous incident on 7/30/24, the facility did not implement effective interventions or monitor the resident's wander guard for functionality. The resident eloped again on 9/7/24, walking to a nearby park without staff supervision, which was not documented or reported to the responsible party or state agencies as required by the facility's policies and procedures. The facility's policies and procedures for managing elopement risks were not followed. The interdisciplinary team did not review or update the care plan to address the resident's specific elopement triggers or schedule regular walks and activities as interventions. Additionally, the licensed nurses were not informed of the resident's elopement risk during shift changes, and there was no documentation of the wander guard's functionality checks or skin assessments, which were supposed to be conducted weekly. Interviews with staff revealed a lack of awareness and communication regarding the resident's elopement risk and the procedures for testing the wander guard. The interim Assistant Director of Nurses confirmed that the facility staff did not document or monitor the wander guard's functionality, and the care plan was not updated to reflect the resident's individual risks or root causes for elopement. The facility's failure to follow its policies and procedures placed the resident at an increased risk for continued elopement and potential injury.
Failure to Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an investigation into an abuse incident involving two residents to the California Department of Public Health (CDPH) within the required five working days. The incident occurred when one resident slapped another on the arm, and although the facility reported the incident itself to CDPH, they did not follow up with a written report detailing the findings and any corrective actions taken. This omission was identified during a review of the facility's policy and procedure on reporting abuse, which mandates that such a report be submitted within the specified timeframe. During an interview and record review with the Assistant Director of Nursing (ADON), it was confirmed that no follow-up report had been prepared or submitted to CDPH regarding the altercation between the two residents. The facility's policy, dated January 18, 2014, clearly states that the administrator or their designee must provide a written report of the investigation's findings within five working days if the alleged violation is verified. The lack of this report indicates a failure to comply with both state law and the facility's own policies, potentially leaving residents vulnerable to continued abuse without proper oversight.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened and within 24 hours, as per the facility's policy. The policy stated that mail should be delivered to residents unopened and within 24 hours of delivery to the premises. However, a resident reported that a package was delivered to the facility on a Friday and was not received by her until the following Tuesday. The package had been opened by facility staff before it was given to the resident, which was confirmed by the Social Service Director and the Assistant Director of Nursing. The resident involved had a diagnosis that included bone infection, anxiety, cancer, and homelessness, and her cognitive status was intact as indicated by a BIMS score of 15. The Social Service Director noted that the resident was capable of opening her own mail and that staff should not open it unless asked. Despite this, the package was opened by a Licensed Nurse who found medication inside and locked it up. There was no documentation in the resident's care plan indicating a need for supervision when opening mail, and the Assistant Director of Nursing confirmed that the package was opened without the resident's knowledge or permission.
Failure to Assess and Obtain Wound Care Orders
Penalty
Summary
The facility failed to effectively assess and obtain a wound care treatment order for a surgical wound for a resident who was admitted with a surgical wound. The resident refused to have the wound assessed by staff, and the facility waited two weeks for an orthopedic follow-up appointment to obtain an order for the resident's wound care and treatment. This inaction occurred despite the facility's policies requiring a skin assessment upon admission and the attending physician to provide routine care orders. The resident was admitted with diagnoses including osteomyelitis, cellulitis, and MRSA infection. The resident was cognitively intact and made their own decisions, as indicated by a BIMS score of 15/15. The resident was adamant that the brace on their leg should not be removed, and the facility staff did not assess the wound until after the orthopedic follow-up appointment. The resident expressed that they might have allowed the wound to be assessed if shown an order from the doctor. The facility administrator acknowledged that treatment was expected and needed, but the wound was not assessed prior to receiving orders from the follow-up appointment.
Failure to Provide Activities Schedule and Newsletter
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the activities schedule and facility news, which is a violation of the resident's right to be informed and make decisions regarding their activities. The deficiency was identified when it was observed that the resident did not receive an activities schedule or newsletter for the months of June and July 2024. The resident, who was admitted with diagnoses including epilepsy, muscle weakness, difficulty walking, and depression, expressed that the absence of these materials left them unaware of the scheduled activities and current news within the facility. During interviews and observations, it was noted that the resident's room had a clear plastic wall sign holder that was intended to display the activities calendar, but it had been empty since June 2024. The resident mentioned that there was a new activities director, and although activities were being conducted, they were not informed about the timing or nature of these activities due to the lack of a calendar. The facility administrator confirmed that during the period without an activities director, the weekly activities room calendars and newsletters were not being produced or distributed to residents.
Failure to Respect Resident's Dignity and Assistance Needs
Penalty
Summary
The facility failed to honor the dignity and respect of Resident 2 when Certified Nursing Assistant (CNA) X did not stop moving the resident despite her request. Resident 2, who suffers from Post Traumatic Stress Disorder (PTSD), felt afraid during the incident. The resident's medical history includes depression, morbid obesity, epilepsy, PTSD, developmental delay, previous nervous system surgery, and mobility difficulties. At the time of the incident, Resident 2 weighed 470 pounds and required extensive assistance from one to two persons for bed mobility. CNA X attempted to roll Resident 2 in bed alone for incontinence care, despite the resident's request to stop and get help. CNA X, who was unfamiliar with Resident 2 and typically worked night shifts, was unprepared for the resident's size and did not know the required assistance level. The CNA's written account indicated that other CNAs were busy, and she completed the task alone. The facility's 5-Day Report acknowledged that CNA X took accountability for handling the resident insensitively. Resident 2's care plan specified the need for extensive assistance with one to two persons for bed mobility. Documentation showed varying levels of assistance required for rolling in bed, with most instances needing substantial or maximal help. The facility's Administrator stated that CNAs could access information on required assistance levels through care plans or by consulting the resident's nurse, emphasizing the expectation for CNAs to communicate and seek help when needed.
Inadequate Assistance During Incontinence Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had the necessary knowledge and assistance to provide appropriate care for a resident, resulting in the resident experiencing unnecessary discomfort. The incident involved CNA X, who was responsible for providing incontinence care to Resident 2, a resident with multiple diagnoses including morbid obesity, epilepsy, and mobility difficulties. During the care, CNA X attempted to reposition Resident 2 without the assistance of a second person, despite the resident's protests and expressions of pain. Resident 2's medical records indicated a need for substantial assistance with mobility, including rolling in bed, due to her weight and impaired range of motion. The Minimum Data Set (MDS) and Activities of Daily Living (ADL) chart documented that Resident 2 required significant help for such activities. However, CNA X, who was relatively new to the facility and unfamiliar with Resident 2, was not informed of the specific assistance requirements and attempted to perform the task alone, leading to the resident's discomfort. Interviews with facility staff revealed that CNA X was not adequately prepared or informed about the level of assistance required for Resident 2. The facility's administrator acknowledged that CNAs should refer to care plans or consult with nurses to determine the necessary assistance for residents. The absence of the Director of Staff Development, who was responsible for staff training and competencies, further contributed to the lack of proper guidance and support for CNA X.
Failure to Provide Meals and Conduct Dialysis Assessments
Penalty
Summary
The facility failed to adhere to its dialysis policy and procedure for four residents who required dialysis services. Resident 1 was not provided with meals before leaving for dialysis, during the dialysis session, or upon returning to the facility. This oversight was confirmed through interviews with staff and the resident, as well as a review of meal documentation, which showed no recorded meals for Resident 1 on the day of her dialysis appointment. Additionally, the facility did not consistently complete pre, during, and post-dialysis assessments for Residents 1, 3, 4, and 5. The facility's policy required these assessments to be documented, but reviews of electronic medical records and paper records revealed missing assessments for multiple dialysis sessions. Interviews with nursing staff and the Director of Nursing confirmed the lack of documentation for these critical assessments. The failure to provide meals and conduct necessary assessments for residents undergoing dialysis had the potential to negatively impact their health. The facility's policy outlined the need for communication between the dialysis center and the facility, as well as the responsibility of licensed nurses to perform and document these assessments, which was not consistently followed.
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 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redding Post Acute | 0.4 mi | ★★★★★ | 16 | 0 |
| Copper Ridge Care Center | 1.1 mi | ★★★★★ | 15 | 0 |
| Vibra Hospital Of Northern California D/p Snf | 1.4 mi | ★★★★★ | 0 | 0 |
| Quartz Hill Post Acute | 1.7 mi | ★★★★★ | 1 | 0 |
| Crestwood Wellness And Recovery Center | 2.2 mi | ★★★★★ | 2 | 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.