Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rossmoor Post Acute during CMS and state inspections, most recent first.
Ice Machines Not Cleaned per Manufacturer Instructions: Four ice machines were not maintained in safe operating condition. Surveyors observed black specks, sludge, and residue inside Scotsman and Hoshizaki units used for resident drinking water, beverages, water pitchers, and ice packs. The FD stated he cleaned the machines every four months, but there was no yearly cleaning log for the Hoshizaki units, and he did not remove internal components as required by the manufacturer.
Failure to maintain oxygen humidifier bottles: two residents receiving O2 via nasal cannula were observed with humidifier bottles that were labeled but completely empty. An LVN stated one bottle should have been changed on the weekly schedule, and another LVN stated she had not checked the bottle. The residents had severe cognitive impairment, and one had asthma while the other had COPD and respiratory failure. Facility policy required weekly humidifier bottle changes with tubing and periodic water-level checks.
A resident with dementia and severely impaired cognition was ordered PRN lorazepam for anxiety for 66 days, but the record contained no MD documentation supporting the extended duration. The CP noted federal rules for the PRN stop date, the MD acknowledged the issue, and the facility policy limited PRN psychotropic orders to 14 days.
Failure to Notify LTC Ombudsman of Discharge: The facility did not ensure a copy of a discharge notice was sent to the LTC Ombudsman for a resident who was discharged to a respite home. The LTC Ombudsman stated they learned of the discharge from another source, while the CM was unsure whether notification occurred and the ADM could not find documentation showing the Ombudsman was informed.
Failure to assess and document after an unwitnessed fall. A resident with a history of falls and difficulty walking fell while standing beside the bedside table, hit the back of the head on the roommate's bed, and remained on the floor until staff helped her up. The resident reported right wrist pain, but the LVN confirmed there was no documented post-fall assessment, including pain, skin, ROM, or physician notification.
The facility failed to ensure the person responsible for day-to-day dietary operations met CA requirements. The RD stated she oversaw the kitchen, but she worked on-site only two days per week and remotely three days per week, while the Dietary Mgr confirmed she handled daily operations. Record review showed the Dietary Supervisor/Manager role required direct supervision of the Dietary Dept, but facility records did not show the designated person met the qualifications under HSC 1265.4, and the AD acknowledged the findings.
SB6 diet meals were not prepared according to the facility menu and recipe. A kitchen staff member said the same sized beef would be used for regular and SB6 diets, and a tray for a resident on SB6 contained meat pieces about 1 inch in size with thin gravy separated from the meat. The DM confirmed the SB6 beef should be 1/2 inch diced, tender, and moistened so liquid and solids do not separate, but the meat observed was too large, tough, and chewy.
Improper Hair Restraints in Food Prep Area: Kitchen staff were observed using disposable face masks as facial hair coverings while working in food prep areas, and hair was not fully restrained or covered. The Dietary Manager stated this was not acceptable, and the RD confirmed that disposable face masks did not meet hair restraint requirements. Facility policy required approved hairnets that fully cover the hair and beard nets for facial hair.
Unsafe handling of visitor-brought food for a resident on neutropenic precautions. A family member brought salads and other foods from home in insulated containers with cold packs, despite a posted sign indicating no raw fruits or vegetables. The family member said no staff had given instructions on food safety, labeling, dating, or what foods were appropriate, and the dietary manager was unaware of any process for giving visitors safe food handling guidance or for applying the resident’s dietary restrictions.
Improper Disposal and Containment of Refuse: The facility failed to properly contain refuse when a large mound of trash bags was observed on the ground in the outdoor disposal area, with the garbage compactor out of service and no secured lid covering the waste. The recycling dumpster lid was also not covering the container, and cardboard boxes and other recyclable materials were placed on the ground next to it. The Administrator stated the compactor became inoperable earlier that day and staff had no way to contain the waste until temporary roll-off containers were delivered.
Failure to Report Resident Fracture: A resident with normal cognition developed persistent wrist pain and was sent to the ED, where x-rays confirmed fractures of the radius and ulna. The Adm could not provide documentation that the fracture had been reported to the State Agency, despite facility policy requiring reportable unusual occurrences to be submitted within 24 hours.
Arbitration Agreement Not Adequately Explained: Multiple residents with moderate or intact cognition stated they signed admission documents on a tablet or electronic device without understanding the arbitration agreement, and some did not receive a copy or know about the 30-day rescission period. The Admissions Coordinator said understanding was assessed only by asking whether the resident or family had questions.
Infection control practices were not followed when oxygen tubing for two residents was left on the floor, a visitor entered a resident’s room on neutropenic precautions without PPE, an oxygen concentrator was stored in a bathroom next to a toilet with tubing in a trash container, and three shared pill crushers were found dirty with dried residue. Staff stated the tubing, PPE use, oxygen storage, and pill crusher cleanliness were all important to prevent contamination.
A resident with intact cognition and diagnoses including polyneuropathy and chronic pain was given a notice of transfer/discharge listing the discharge location as TBD, which she understood to mean to be determined. She refused to sign because she had nowhere to go and reported feeling distressed and anxious. The OMB said the resident needed a minimum 30-day written notice, while the family member denied receiving a meaningful discharge discussion. Facility notes and staff statements were inconsistent, and the discharge care plan had not been updated since 2021 despite active discharge planning.
Lack of Qualified Dietary Oversight: The facility did not maintain a qualified DM or full-time RD oversight of kitchen operations during two separate periods. Staff interviews showed the prior CDM had left, the replacement had not yet started, and the facility planned to split kitchen supervision among the ADM, Sous Chef, and other staff. In a later period, the RD coverage was part time or remote, with staff stating the RD did not oversee the kitchen and another RD was only present for a mock survey.
Incomplete and inaccurate controlled substance documentation was found for multiple residents. The facility could not locate some narcotic Shipping Manifests and one resident’s CDR was missing. In other cases, CDR entries were incomplete or did not match MAR documentation for oxycodone and hydrocodone/acetaminophen. The DON acknowledged the documentation gaps, and the consultant pharmacist reports reviewed did not identify these irregularities.
Infection Control Lapses During Food Handling and Tray Line Service: A dietary staff member handled ready-to-eat foods with contaminated gloves, a maintenance staff member entered the kitchen and took fruit without hand hygiene, and the same dietary staff member handled raw fish and then returned to the tray line without changing gloves or cleaning hands before touching ready-to-eat items used to garnish resident meals. The food cart was later sent to the Medbridge unit with trays already passed out to residents.
A resident with severe cognitive impairment, whose daughter was listed as the emergency contact and responsible party, was found with significant bleeding from injuries to the elbow and thumb, requiring EMS transfer to a hospital. Nursing documentation described the bleeding, wound care, and transfer, but there was no documentation that the resident’s representative was notified of the change in condition or the transfer. The DON confirmed the absence of notification and change-of-condition documentation, despite facility policy requiring prompt notification of the resident representative for injuries and hospital transfers.
A facility failed to accurately complete a PASARR for a resident with bipolar and anxiety disorders. The resident's Level I PASARR incorrectly indicated no serious mental disorder or psychotropic medication use, leading to a negative result and no Level II screening. The DON acknowledged the inaccuracy and stated that PASARRs should be reviewed for accuracy upon admission.
A facility failed to maintain infection control by not discarding a used IV catheter for a resident with dehydration risk. The catheter, dislodged during care, was left attached to IV tubing on an IV pole, posing a risk for bloodborne infections. Staff interviews revealed a lack of communication and adherence to proper disposal protocols.
The facility failed to secure resident-identifiable information when medication bubble packs with resident details were left on treatment carts in a hallway, accessible to staff, residents, and visitors. Interviews revealed non-compliance with facility policies on handling confidential information, with staff acknowledging the need for secure disposal and storage of such materials.
A resident, dependent on staff for most ADLs, fell out of bed during after-shower care due to inadequate supervision and staffing. The resident, who required substantial assistance, was being assisted by three staff members, including a registry CNA unfamiliar with her care needs. The bed moved slightly during repositioning, causing the resident to fall and sustain a head laceration and ankle contusion, necessitating emergency care.
A resident with acute respiratory failure and sleep apnea was inaccurately assessed on the MDS, as it failed to reflect the use of a BIPAP machine. The MDS Coordinator and DON confirmed the error, which did not accurately represent the resident's health status, potentially affecting care delivery.
A resident experienced discomfort and anxiety due to the facility's failure to provide a timely replacement for a missing BIPAP mask connector. The resident had to use an ill-fitting mask, leading to interrupted sleep and skin breakdown. Despite ordering the part, shipment delays were not communicated to the resident, exacerbating the situation.
A resident using an oxygen concentrator did not have the required oxygen safety signage posted on their room door, as observed during a survey. The facility's policy mandates such signage to ensure safety, given the flammable nature of oxygen. Staff interviews confirmed the oversight, highlighting a failure to adhere to safety protocols.
A facility failed to report a suspicion of sexual abuse involving a resident within the required regulatory timeframe. The incident was initially reported by a CNA during a care conference, but the MSW did not submit the necessary reporting form, believing the facility had done its part in the investigation. The resident had a history of Alzheimer's Disease and was dependent on others for toileting hygiene. The facility's policy requires immediate reporting of suspected abuse, but this was not followed.
Ice Machines Not Cleaned or Maintained per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain four of four ice machines in safe operating condition by not cleaning, sanitizing, and maintaining them according to manufacturer instructions. During observation and interview, the Facilities Director stated he cleaned each ice machine every four months, but the facility did not maintain a yearly cleaning log for the Hoshizaki machines and he was unsure when those machines were last cleaned. The facility had two Hoshizaki ice machines and two Scotsman ice machines located in the Legacy Nursing Unit, Westbridge Nursing Station, MedBridge Nursing Unit, and the Resident Dining Hall, and ice from these machines was used for resident drinking water, beverages, water pitchers, and ice packs. Surveyors observed black specks inside the MedBridge Scotsman ice machine, black sludge and residue inside the Legacy Scotsman ice machine, and black specks and black residue inside the Westbridge Hoshizaki ice machine. The Infection Preventionist/Director of Staff Development reviewed photographs and confirmed sludge and residue were present inside the Scotsman machine. The Facilities Director stated he used Simple Green, a hand-labeled sanitizer, and Scotsman Clear 1 solution to clean the machines and did not remove internal machine components during cleaning. The Hoshizaki manual required removal of internal parts, cleaning with Hoshizaki nickel-safe cleaner, and sanitizing with an NSF-listed no-rinse sanitizer, and the facility’s sanitation policy required ice machines and ice storage containers to be drained, cleaned, and sanitized per manufacturer instructions.
Failure to Maintain Oxygen Humidifier Bottles
Penalty
Summary
The facility failed to ensure respiratory therapy equipment was changed weekly for two residents receiving oxygen therapy. During an initial tour, one resident was observed receiving oxygen at 2 LPM via nasal cannula attached to an oxygen humidifier bottle that was labeled with an open date of 6/28/26 and was completely empty. During a concurrent observation and interview, an LVN stated the humidifier bottle should not be empty because it increases the risk of nosebleeds and infection, and stated it should have been changed on 7/5/26 in accordance with the weekly replacement schedule. The first resident had diagnoses including asthma and a BIMS score of 7, indicating severe cognitive impairment. A monthly physician order dated 7/9/26 directed oxygen at 2 liters if oxygen saturation was less than 91% every shift. During an interview, the ADON stated that oxygen humidifiers should be replaced before running empty to prevent nasal dryness. A second resident with diagnoses including COPD and respiratory failure, and a BIMS score of 7, was observed receiving oxygen at 2.5 LPM via nasal cannula with a humidifier bottle dated 6/28/26 that was also completely empty. An LVN stated she was not aware the humidifier bottle was empty because she did not check it, and later stated humidifiers are important to prevent drying of mucus membranes and nasal irritation, and that there is risk of infection when the humidifier is not changed per facility policy. The facility policy required the humidifier bottle to be changed weekly with the tubing or when the water reached the minimal fill line, and also required the water level to be checked and re-checked when in use.
Unnecessary PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 7, was free from unnecessary psychotropic medication use when the resident had no documented rationale for continued PRN lorazepam beyond 14 days. Resident 7 was admitted with diagnoses including dementia, and the MDS dated 5/8/26 indicated severely impaired cognition. During an observation on 7/6/26 at 10:33 a.m., Resident 7 was resting in bed, calm and quiet. A physician order dated 7/9/26 showed lorazepam 0.5 mg by mouth every 4 hours PRN for anxiety with a start date of 5/27/26 and an end date of 8/1/26, resulting in a PRN duration of 66 days. Review of the medical record found no documentation by the MD of a clinical rationale for the extended PRN lorazepam order. The CP stated the facility should follow federal regulations for the stop date for PRN lorazepam, and the MD stated the facility would implement a 14-day discontinuation period for PRN lorazepam moving forward. The facility policy titled Psychotropic Medication Use, revised February 2025, stated PRN orders for psychotropic medications are limited to 14 days.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a copy of the discharge notice was sent to the Long-Term Care Ombudsman for Resident 144. The report states that Resident 144 was admitted to the facility on [DATE] and was discharged on 7/2/26 to a respite home. During an interview on 7/8/26 at 12:00 p.m., the LTC Ombudsman stated the facility did not notify them about the resident’s discharge or the new location and that they learned of the discharge from another source rather than from the facility. During interviews, the Case Manager stated on 7/8/26 at 12:59 p.m. that Resident 144 had been discharged to a respite home and that they were not sure whether the LTC Ombudsman had been informed. Later that day, the Administrator stated at 4:02 p.m. that they could not find documentation showing the LTC Ombudsman was notified of Resident 144’s discharge. The facility’s policy and procedure for Transfer or Discharge Notices, revised March 2025, states that residents or resident representatives are notified of an impending transfer or discharge and that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.
Failure to Assess and Document After Unwitnessed Fall
Penalty
Summary
Facility failed to provide timely nursing assessment and evaluation after an unwitnessed fall involving a resident admitted with diagnoses of history of falls and difficulty walking. The resident had a BIMS score of 15 out of 15 on the MDS dated 6/12/26, indicating normal thinking and memory. During an interview, the resident stated that on 3/21/26 she was standing beside her bedside table when she lost balance, fell, and hit the back of her head on the roommate's bed. The resident stated the roommate called staff for help while she remained on the floor, and that nursing staff, including LVN 4, assisted her up but did not assess her for pain or injuries. The resident also stated she experienced pain in her right wrist after the fall. During a concurrent interview and record review, LVN 4 confirmed there was no documentation showing an assessment was completed after the unwitnessed fall. LVN 4 stated that after a fall the nurse should ask what happened, perform a pain assessment, check the skin, assess range of motion for injury, and inform the physician, and that these assessments must be documented in the progress notes. The facility's policy on charting and documentation stated that all services provided to the resident and any changes in condition shall be documented in the medical record to facilitate communication among the interdisciplinary team.
Unqualified dietary supervisor responsible for daily kitchen operations
Penalty
Summary
The facility failed to ensure that the person designated to manage the day-to-day operations of the dietary department was qualified under California regulations. Survey findings showed that the Registered Dietitian stated she was responsible for daily oversight of the kitchen serving the skilled nursing facility, while also stating that the kitchen supervisor was not qualified. She reported that she was a full-time employee who worked on-site two days per week and remotely three days per week. The Dietary Manager confirmed that the RD was responsible for the day-to-day operations of the dietary department and worked on-site two days per week and remotely three days per week. During record review, the RD’s offer letter identified the position as full time but stated that on-site hours would be around 12-16 hours per week on average, and Human Resources confirmed that the RD worked on-site Mondays and Wednesdays. Review of the Dietary Supervisor/Manager job description showed that the position was required to provide supervision for the Dietary Department and direct and assist meal preparation and service, while the Registered Dietitian job description described monitoring responsibilities rather than day-to-day supervision. Facility records for the Dietary Supervisor/Manager did not show evidence that the person met the qualifications required under California Code, Health and Safety Code section 1265.4. The Administrator acknowledged these findings.
SB6 Diet Meals Not Prepared to Required Texture
Penalty
Summary
The facility failed to provide mechanically altered foods according to the menu for the Soft and Bite Sized (SB6) diet. During meal preparation, the kitchen staff member stated that the same sized beef would be used for both the regular diet and the SB6 diet. During tray line observation, a SB6 meal tray prepared for Resident 186 contained meat pieces that were about one inch in size and served in thin gravy that was separated from the meat, and the RN confirmed the tray matched the meal ticket for an SB6 diet. The Dietary Manager reviewed the facility's Diet Extensions and the Beef Rib Bites with Teriyaki Sauce recipe and confirmed that SB6 meat should be 1/2 inch diced, tender cooked, and moistened with enough sauce so liquid and solids do not separate. When the beef rib bites were observed on the steam table and later tested on a SB6 tray, the meat pieces were found to be too large, tough, and chewy, and the gravy had separated from the meat. The facility's diet spreadsheet listed the SB6 lunch meal as chicken noodle soup, beef rib bites with teriyaki sauce, brown rice, soft and bite sized carrots, and a pureed baked roll, and the diet manual stated SB6 foods must be soft, tender, moist, and chopped in 1/2 inch pieces.
Improper Hair Restraints in Food Prep Area
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when kitchen staff were observed using disposable face masks as facial hair coverings while working in food preparation areas. During the observation, hair was not fully restrained or covered. The deficiency was identified during an observation on 07/07/26 at 10:15 a.m., and the Dietary Manager later stated that staff had been observed using disposable face masks as facial hair coverings and that this was not acceptable. The Dietary Manager also stated that hair not fully restrained in hairnets did not meet facility requirements. During a phone interview on 07/07/26 at 4:15 p.m., the Registered Dietician stated that disposable face masks were not allowed as hair coverings and did not meet hair restraint requirements. Facility policy review showed that food service areas are to be kept clean, refrigerated foods are to be covered, labeled, and dated, dry foods are to be stored to maintain packaging integrity, kitchen areas are to be kept clean, utensils and equipment are to be maintained in good repair, cutting boards are to be washed and sanitized between uses, and all staff entering food preparation areas are to wear approved hairnets that fully cover the hair, with beards covered by beard nets and only approved hair restraint devices used.
Unsafe handling of visitor-brought food for a resident on neutropenic precautions
Penalty
Summary
The facility failed to ensure safe and sanitary handling and consumption of food brought into the facility by family or visitors for one resident on neutropenic precautions. During observation, a sign posted on the resident’s door indicated neutropenic precautions, including a pictogram stating no raw fruits or vegetables, while a family member was observed bringing salads and other food items from home for the resident. During interview, the family member stated the resident had only one salad since arrival, so salads were brought from home, along with other foods and drinks in insulated containers with cold packs. The family member said no staff member had provided instructions or guidelines about food safety, labeling, dating items, or what foods were appropriate for the resident’s neutropenic condition. The dietary manager stated he was not aware of procedures for providing visitors with safe food handling information, could not identify who was responsible for communicating the policy to residents, families, or visitors, and stated he had not been trained on assisting residents with food brought in by visitors or on applying dietary restrictions associated with neutropenic precautions. The facility policy titled Foods Brought by Family/Visitors stated staff were to explain safe food handling practices and that food brought by family or visitors was to be labeled, dated, and stored in re-sealable containers with tight-fitting lids.
Improper Disposal and Containment of Refuse
Penalty
Summary
The facility failed to ensure proper disposal and containment of refuse when the outdoor garbage compactor area was observed with a large mound of trash bags placed directly on the ground. During the tour of the outdoor premises on 07/06/2026 at 3:24 p.m. with the Administrator, the trash bags were not contained in a dumpster or compactor with a secured lid, and a strong sour odor was present. The garbage compactor in the area was observed to be out of service. The recycling dumpster was also observed with its lid not covering the container, and overflowing cardboard boxes and other recyclable materials were placed on the ground next to the dumpster rather than inside it. During interview on 07/06/2026 at 3:29 p.m., the Administrator stated the trash compactor became inoperable earlier that day and staff had no way to compact or contain the waste until temporary roll-off containers could be delivered by the contracted trash vendor.
Failure to Report Resident Fracture
Penalty
Summary
The facility failed to report a right wrist fracture sustained by one of three sampled residents, Resident 150, to the State Agency after the resident was sent to the emergency department for evaluation of right wrist pain. Resident 150 was admitted to the facility on an unspecified date and had an MDS dated 6/12/26 showing a BIMS score of 15 out of 15, indicating normal thinking and memory. On 3/29/26, Resident 150 reported persistent right wrist pain and requested transfer to the emergency department. Record review of the emergency department provider notes dated 3/29/26 showed closed fractures of the right radius and right ulna. During interviews, the Administrator stated that unusual occurrences such as a major injury like a fracture must be investigated and reported by fax or email according to state requirements, but was unable to provide documentation that the incident had been reported. The ADON stated that fractures must be reported so the State Agency can review the care plan, visit the facility, investigate, and help improve care areas that the facility did not identify or catch. The facility policy on unusual occurrence reporting stated that reportable events affecting resident health, safety, or welfare are to be reported to appropriate agencies within 24 hours or as otherwise required.
Arbitration Agreement Not Adequately Explained
Penalty
Summary
The facility did not ensure that the binding arbitration agreement was explained to and understood by residents or their personal representatives for Residents 26, 38, 187, and 188. During interviews, Resident 26, who had a BIMS score of 13/15 and whose daughter was present as the personal representative, stated that a staff member had the resident sign multiple documents on an electronic device, that no copy was provided, and that the resident did not know what arbitration was. Resident 38, who had a BIMS score of 12/15, stated that the resident and family member signed on a tablet, did not understand the meaning of arbitration, and did not know there was a 30-day window to rescind the agreement. Resident 187, who was observed with the son and spouse present and had a BIMS score of 12/15 in one record review and 15/15 in another, stated the resident did not remember signing an arbitration agreement and recalled only commotion in the room, adding that the resident would remember signing something giving up rights. Resident 188 stated the resident vaguely remembered signing documents but not an arbitration agreement and did not recall the 30-day rescission period, and believed all documents had to be signed for admission because no one said it was optional. The Admissions Coordinator stated that understanding was determined by asking the resident or family member if they had any questions about the document.
Infection Control Lapses With Oxygen Equipment, PPE, and Shared Pill Crushers
Penalty
Summary
The facility failed to follow infection control prevention practices related to oxygen equipment and shared resident-care items. During observation, Resident 3’s oxygen tubing was seen on the floor at the bedside, and staff stated it should be secured and not touch the floor to prevent infection. The same issue was observed again in Resident 3’s room during a later observation, when a CNA stated the tubing should not be on the floor because of infection risk. Resident 72 was observed in a room posted for neutropenic precautions, and a visitor was at the bedside without the required PPE. Oxygen tubing was also observed on the floor at the bedside. The RN stated Resident 72 was on neutropenic precautions to protect the resident from infection, that people without appropriate PPE present a risk to immunocompromised individuals, and that oxygen tubing is contaminated once it is on the floor and should be replaced. Resident 88 had an order for oxygen at 2 LPM via nasal cannula as needed for shortness of breath or chest pain. During observation, the resident’s oxygen concentrator was stored in the bathroom next to the toilet, with the power cord on the floor and parts of the tubing inside a garbage container. The IP/DSD stated the concentrator was not supposed to be stored in the bathroom and should be kept at the bedside or in the designated oxygen storage room. In addition, three shared pill crushers on medication carts were observed with dried residue and crusted debris, and staff stated the pill crushers were dirty and could contaminate medications given to residents.
Inadequate discharge planning and communication for facility-initiated discharge
Penalty
Summary
Facility failed to ensure that a facility-initiated discharge for one resident was accompanied by adequate discharge planning and communication that met the resident’s needs and preferences and prepared the resident for a safe discharge. The resident had been admitted with multiple diagnoses including polyneuropathy and chronic pain, and a BIMS score of 15 out of 15 indicated intact cognition. Despite this, the resident reported that the SSD gave her a Notice of Transfer/Discharge stating she would be discharged with the location listed as TBD, which she understood to mean to be determined, and she refused to sign because she had nowhere to stay. The resident stated she believed she would be required to leave the facility on the stated discharge date and felt very distressed about being discharged with nowhere to go. The OMB stated she notified the facility that the resident required a minimum 30-day written notice for discharge. The resident’s family member stated the resident called her and said she was going to be discharged and was frightened because she had nowhere to go, while the family member’s phone records showed only a missed call from the SSD and no voicemail or direct discussion about the discharge. Facility documentation showed conflicting and incomplete discharge communication. The SSD’s social service note stated she met with the resident and spoke with the resident’s sister about the discharge notice, but the family member denied any phone conversation with the facility. The SSD later stated discharge planning was still in process and the resident would be discharged when everything was set up, while the resident stated no one had spoken with her about whether she was actually being discharged and that she felt upset and anxious. The resident’s discharge care plan had not been updated since 11/23/21 and still stated the resident did not show potential for discharge to the community and was a long-term resident, despite the facility’s active discharge planning and notice of transfer/discharge.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to ensure adequate kitchen oversight when it did not have a qualified Dietary Manager and the Registered Dietitian did not provide full-time oversight of the kitchen for two separate periods. During an interview with Human Resources, it was stated that the previous Certified Dietary Manager’s last day was 8/21/25 and that another dietary manager would not start until 9/4/25. Registered Dietitian 1 stated that the dietary manager was responsible for supervising day-to-day kitchen activities, while the dietitian’s role was limited to resident assessments, weight monitoring, tube feeding management, care conferences, and occasional random checks or walkthroughs of the kitchen. During an observation and interview in the kitchen, the surveyor entered without a hairnet and the Sous Chef stated that a hairnet was not required in the kitchen. The Sous Chef also stated they were not a certified dietary manager and that their primary duties were cooking and ordering supplies. Registered Dietitian 1 later stated that a dietary manager needed to be qualified to understand food safety and infection prevention. At an interview with the Administrator and Director of Nursing, the facility’s plan was reviewed showing that kitchen responsibilities would be split among the Administrator, the Sous Chef, and other staff, and the Administrator stated the facility did not plan or attempt to find a temporary certified dietary manager. In a separate period, staff interviews and record review showed there was again no full-time registered dietitian oversight of the kitchen. The Dietary Manager stated Registered Dietitian 1 was no longer working at the facility and had been gone for about a week, while Registered Dietitian 4 was starting that day. The Sous Chef stated Registered Dietitian 2 worked part time in the evening on clinical dietitian work and did not oversee the kitchen. Human Resources confirmed that Registered Dietitian 1 had been working part-time and remotely, and Registered Dietitian 2 was part time. Records showed Registered Dietitian 1 worked 5.75 hours over three days remotely, and Registered Dietitian 2 worked 25 evening hours over ten days. Registered Dietitian 4 stated they were starting full time that day and that Registered Dietitian 3 had been overseeing the kitchen, while the Dietary Manager and Administrator 2 stated Registered Dietitian 3 was only present for two days to conduct a mock survey and present results to staff.
Incomplete and Inaccurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure that controlled medication records were complete and accurate for multiple residents. During record review and interviews, the Record Director stated that narcotic Shipping Manifests were stored onsite, but the facility could not locate the Shipping Manifests for the period reviewed. The Registered Nurse described the narcotic accountability process as including pharmacy delivery, nurse signature on the Shipping Manifest, placement of the narcotic and CDR in the medication cart, documentation of removal on the CDR, and completion of the MAR if the drug was administered. For one resident, the facility could not find the CDR for oxycodone 5 mg tablets. For another resident, the CDR showed two tablets removed, but the required fields for date, time, amount used, and administered by were left blank. The DON acknowledged that the required fields were not completed. The DON also acknowledged multiple instances in which CDR removals for several residents did not have corresponding MAR documentation on the dates and times listed in the record review, including oxycodone and hydrocodone/acetaminophen entries across several residents. The DON acknowledged the issues with the scheduled medication record system, including Shipping Manifests, CDRs, and MARs, and stated that it was the facility’s expectation that narcotic tracking documents be complete and accurate. The Consultant Pharmacist summary reports for February through August documented no irregularities observed and did not identify issues with incomplete or inaccurate scheduled medication records, despite the deficiencies found during survey review. The facility policy stated that controlled substance inventory is monitored and reconciled to identify loss or potential diversion and that the system includes records of personnel access and usage, MARs, declining inventory records, and destruction, waste, and return-to-pharmacy records.
Infection Control Lapses During Food Handling and Tray Line Service
Penalty
Summary
The facility failed to ensure infection control practices were followed during food service activities when [NAME] 1 handled ready-to-eat foods with contaminated gloves and did not perform hand hygiene between tasks. During observation on 8/27/25 at 4:21 p.m., [NAME] 1 was measuring temperatures of foods at the tray line while wearing gloves, adjusted their glasses with a gloved hand, removed an alcohol wipe from their pants pocket with the same gloved hand, and then continued taking temperatures of chicken patties and fish patties without performing hand hygiene or changing gloves. The facility also failed to prevent cross-contamination in the kitchen and on the dinner tray line. On 8/27/25 at 3:37 p.m., a maintenance staff member entered the kitchen and took a banana from the fruit container near the tray line without performing hand hygiene. On 8/27/25 at 4:25 p.m. and 4:50 p.m., [NAME] 1 handled a plate of raw fish, placed it into the oven, then returned to the tray line without hand hygiene or changing gloves and used the same gloved hand on chopped green onions that were used to garnish chicken entrees. The Sous Chef confirmed the fish in the oven was raw, and the food cart had been sent to the Medbridge unit where trays were already passed out to residents.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition and transfer to an acute care hospital. The resident had severe cognitive impairment, with a BIMS score of 2/15, and was care planned as confused and exhibiting cognitive loss. The care plan included a goal to discuss concerns regarding overall status and health with the resident and family as needed. The admission record listed the resident’s daughter as the first emergency contact and responsible party. A progress note documented that in the early morning hours, the resident was found bleeding from injury sites on the left elbow and right thumb, with the gown and bedding soaked in blood. The RN documented that the wounds were cleaned, dressings applied, and emergency responders were called to transfer the resident to the hospital for further evaluation, and that the resident left the facility on a gurney with EMTs. During interviews and record review, the RN who wrote the note did not recall the specific incident or the transfer but stated that they usually notify family by phone and leave a voicemail if unable to reach them. The DON confirmed there was no documentation that the resident’s responsible party was notified of the change in condition or the transfer to the hospital, and also noted there was no separate change-of-condition documentation regarding the bleeding episode. The facility’s policy on “Change in a Resident’s Condition or Status” requires prompt notification of the resident, attending physician, and resident representative of changes in medical or mental condition or status, including when the resident is involved in an accident or incident resulting in injury or when it is necessary to transfer the resident to a hospital. Despite this policy and the resident’s documented cognitive impairment and identified responsible party, there was no evidence that the responsible party was informed of the bleeding incident or the hospital transfer.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate preadmission screening and resident review (PASARR) for a resident with mental health diagnoses. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process. The resident in question was admitted with a medical history of bipolar disorder and generalized anxiety disorder. However, the Level I PASARR screening inaccurately indicated that the resident did not have a serious mental disorder and was not prescribed psychotropic medications for such conditions. The Director of Nursing acknowledged that the Level I PASARR did not reflect the resident's mental illness diagnoses or the use of psychotropic medication, leading to a negative result and the absence of a Level II screening requirement. This discrepancy was identified during an interview, where the DON stated that all PASARRs should be reviewed for accuracy upon admission. The failure to accurately complete the PASARR screening resulted in the deficiency noted in the report.
Failure to Properly Dispose of IV Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices, leading to a deficiency in the handling of an intravenous (IV) catheter for Resident #313. The resident, who was admitted with a medical history of encephalopathy and altered mental status, was at risk for dehydration and required IV fluids. On 02/09/2025, the resident's IV catheter became dislodged, and the used catheter was not immediately discarded as required. Instead, it was left attached to the IV tubing and hanging from an IV pole in the resident's room, posing a risk for bloodborne infections. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and the Director of Nursing (DON), revealed a lack of clarity and communication regarding the proper disposal of the used IV catheter. The staff members acknowledged that the catheter should have been discarded immediately in a sharps container to prevent potential infection transmission. The Director of Staff Development, who also served as the Infection Preventionist, confirmed that the failure to discard the catheter promptly posed a risk for bloodborne infection transmission to residents or staff who might come into contact with the items.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality and security of resident-identifiable information when medication bubble packs labeled with resident information were found unsecured and accessible in public areas. During an observation, it was noted that empty medication bubble packs with resident information were placed on top of a treatment cart in a hallway, making them visible and accessible to staff, residents, and visitors. Additionally, a paper document with resident names and vital signs was visible through a plastic bag. This breach of confidentiality was further evidenced by the presence of a gray plastic wash basin on another treatment cart, which also contained an empty medication bubble pack with resident information. Interviews with facility staff revealed a lack of adherence to the facility's policies regarding the handling of confidential information. The Director of Staff Development acknowledged that medication bubble packs should not be placed in boxes for shredding and emphasized the importance of securing such information. The Medical Records staff admitted to not checking the contents of the boxes, assuming they were someone else's trash, and noted that boxes should have lids for privacy. The Administrator confirmed that the boxes should not be open and that it was the responsibility of the Medical Records staff to ensure proper handling of documents. The Director of Nursing highlighted the importance of HIPAA compliance and the responsibility of all staff to protect patient information.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate safety measures and supervision, resulting in a resident falling out of bed during after-shower care. The resident, who was dependent on staff for most Activities of Daily Living (ADLs) due to conditions such as morbid obesity, cerebrovascular accident, and schizophrenia, required substantial assistance for repositioning. Despite this, only three staff members were present to assist the resident, who typically required a three to four-person assist. During the incident, the resident was being assisted by three staff members, including a registry CNA who was unfamiliar with the resident's care needs. As the resident was being turned to complete the application of an incontinent brief, the bed moved slightly, and the resident fell, hitting her head and sustaining a seven-centimeter laceration on her forehead, a brief loss of consciousness, and a contusion on her right ankle. The resident was subsequently transported to the emergency department for evaluation and treatment. Interviews with staff revealed that the registry CNA was not adequately oriented to the resident's specific care needs, and the facility's policy on fall prevention was not effectively implemented. The incident highlighted a lack of sufficient staffing and inadequate training for temporary staff, contributing to the resident's fall and subsequent injuries.
Inaccurate MDS Assessment for Resident with Sleep Apnea
Penalty
Summary
The facility failed to accurately assess a resident using the Minimum Data Set (MDS), which is a critical assessment tool used to direct care. This deficiency involved a resident who was admitted with multiple diagnoses, including acute respiratory failure with hypoxia and obesity. The resident's care plan indicated a risk for respiratory impairment related to sleep apnea, and active orders included the use of a BIPAP ventilator and oxygen therapy. However, the resident's Quarterly MDS Assessment did not reflect the use of a non-invasive mechanical ventilator, such as a BIPAP or CPAP machine, which was necessary for managing the resident's sleep apnea. Interviews with the MDS Coordinator and the Director of Nursing revealed that the MDS Assessment was incorrectly coded, failing to indicate the resident's use of a non-invasive mechanical ventilator. The MDS Coordinator acknowledged being unsure about the specific machine used by the resident, despite knowing that the resident had been using such a device since admission. The Director of Nursing confirmed the error in coding, which did not accurately reflect the resident's current health status. This oversight resulted in an inaccurate assessment of the resident's condition, potentially impacting the delivery of person-centered care.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care in a timely manner for a resident who required a BIPAP machine to manage sleep apnea and acute respiratory failure. The deficiency occurred when a connecting piece of the resident's BIPAP mask went missing after the facility replaced the machine's tubing. As a result, the resident had to use an ill-fitting, temporary mask that caused discomfort, interrupted sleep, and skin breakdown on the nose bridge. The resident, who was admitted with diagnoses including acute respiratory failure with hypoxia and obesity, experienced significant inconvenience and anxiety due to the delay in receiving the correct BIPAP mask connector. Despite the Central Supply Manager (CSM) ordering the missing piece from Vendor 1, shipment delays occurred, and the resident was not informed of these delays. The resident's condition was further exacerbated by the lack of timely communication and updates from the facility staff. The facility's inaction in promptly addressing the missing BIPAP mask piece and the subsequent shipment delays led to the resident's mental and physical exhaustion. The resident had to endure ten nights of discomfort and anxiety, which ultimately prompted her to order the missing piece herself. The facility's failure to address the skin breakdown until several days later further highlights the deficiency in providing adequate respiratory care in accordance with professional standards.
Failure to Post Oxygen Safety Signage
Penalty
Summary
The facility failed to post oxygen safety signage on the door of a resident's room who was using an oxygen concentrator. This deficiency was identified during a survey where it was observed that the resident, diagnosed with acute respiratory failure with hypoxia, had an oxygen concentrator at their bedside but lacked the required signage indicating oxygen use. The absence of this signage was confirmed during an interview with the Nurse Supervisor, who acknowledged the responsibility to ensure such signage was posted. Further interviews with facility staff, including a Registered Nurse and the Assistant Director of Nursing, reinforced the importance of oxygen signage for safety reasons, as oxygen is flammable and combustible. The facility's policy and procedure on oxygen administration, dated 2021, clearly stated the requirement to place 'Oxygen in Use' signs on the room entrance door and over the resident's bed. Despite these guidelines, the necessary signage was not in place, indicating a lapse in adherence to established safety protocols.
Failure to Report Suspected Abuse Timely
Penalty
Summary
The facility failed to report a suspicion of sexual abuse involving a resident within the required regulatory timeframe. The incident was initially brought to attention during a care conference by a CNA, who reported finding the resident with a bloody discharge on her brief and her blanket partially pulled down after a visit from her spouse. Despite this, the facility's MSW did not report the incident to the appropriate authorities and instead sought guidance from the Ombudsman, who provided the necessary reporting form. However, the MSW later decided not to submit the form, believing the facility had done its part in the investigation and found no need to report the incident. The resident involved had a history of Alzheimer's Disease and failure-to-thrive, and was dependent on others for toileting hygiene. The CNA reported the suspicious circumstances to an LVN, who denied receiving such a report. The Hospice Registered Nurse also noted the suspicious behavior of the resident's spouse but did not find any signs of pain or infection during her assessment. The facility's Administrator also believed there was no reportable incident and did not initiate an abuse investigation. The facility's policy requires immediate reporting of any suspected abuse, neglect, or injuries of unknown origin to various authorities, including the state licensing agency, local/state ombudsman, and law enforcement officials. However, in this case, the facility did not follow its own policy, resulting in a failure to ensure a timely and complete investigation and to protect the resident and other residents from potential abuse.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Walnut Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Creek Skilled Nursing & Rehabilitation Cent | 0 mi | ★★★★★ | 8 | 0 |
| Tice Valley Post Acute | 0.1 mi | ★★★★★ | 16 | 0 |
| Tampico Healthcare Center | 2.5 mi | ★★★★★ | 3 | 0 |
| La Casa Via Transitional Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Moraga Post Acute | 3.5 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.