Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Salinas Valley Post Acute during CMS and state inspections, most recent first.
The facility failed to consistently follow infection control practices during resident care and daily activities. Staff did not use PPE appropriately for a resident on EBP, used the same tissue for both eyes during eye drop administration, and did not perform hand hygiene between contaminated and clean wound care tasks or between residents while serving meals. Unlabeled wash basins were found in shared bathrooms, respiratory equipment was left unlabeled or uncovered when not in use, an uncovered suction yankauer was observed in a resident’s room, the Water Management Plan was outdated, and there was no documentation of surveillance monitoring for hand hygiene, PPE use, or other infection control practices.
Multiple residents had bed rails observed in use even though their bed rail and entrapment risk assessments documented no bed rail use, and RN/DON interviews confirmed the documentation was inaccurate. In addition, an RN applied zinc oxide to a resident’s wound peri-wound area without a physician order, despite the active wound order not including zinc oxide.
Dietary staff failed to cover facial hair while working over exposed food during tray line service. A dietary aide and a dietary cook were observed with visible facial hair and no beard restraints while plating and checking meal trays, and both later acknowledged the issue. The RD stated that staff working in direct food prep or plating should wear hair and beard nets, and the facility policy required hair restraints, including beard restraints, to prevent hair from contacting food.
Loss of Resident Personal Property: A resident reported missing clothes and shoes, but staff did not respond to the report and no grievance or theft/lost process was documented. Review of the resident’s inventory and the DON’s search confirmed missing clothing and slippers, while the SSA and SSD were unaware of the issue.
A resident with depression and unspecified anxiety disorder had a PRN Seroquel order for breakthrough agitation with no stop date. The DON reviewed the order and confirmed it had been active for more than 14 days, while the facility P&P limited PRN psychotropic orders to 14 days and required prescriber evaluation before renewing PRN antipsychotics.
The facility inaccurately coded MDS assessments for three residents. One resident’s dental status was not coded to reflect missing teeth, another resident’s edentulous status was not accurately recorded, and a third resident’s MDS incorrectly showed a physician-prescribed weight-loss regimen despite no supporting documentation and PCP confirmation that none was approved. The facility also failed to accurately code a resident’s insulin orders for DM2, including insulin glargine and Humalog sliding scale insulin.
A resident with paranoid schizophrenia and psychosis had an incomplete PASARR Level 1 screening in the record, and no Level II evaluation had been obtained. The MDSC confirmed the screening was incomplete during interview and record review, despite the facility policy requiring PASARR screening for MD, ID, or related disorders and referral for Level II when indicated.
A facility failed to develop and implement comprehensive, person-centered care plans for a resident with bipolar disorder, two residents with missing or broken teeth, and a resident receiving O2 therapy. Records showed the residents had relevant diagnoses, assessments, or orders, but the care plan documentation did not include the required diagnoses or treatments, and the DON and MDSC confirmed the omissions.
A resident with repeated falls had a fall care plan that was not updated despite multiple IDT notes documenting new interventions, and another resident with repeated falls also had no care plan revisions after additional falls and related IDT interventions. A third resident’s smoking care plan was not revised even though staff observed the resident keeping a lighter in his pocket and refusing to surrender it for storage, contrary to the smoking safety plan and the DON’s confirmation that the plan was not updated.
Facility staff failed to follow electrical and smoking safety procedures when a long charging cord was left on the floor in a resident room, a resident used a non-hospital-grade power strip on his bed to charge multiple devices, and another resident kept a cigarette lighter in his pocket while smoking. The resident using the power strip had moderately impaired cognition, and the smoking resident’s care plan and smoking assessment indicated staff were to control smoking supplies and light cigarettes for him.
Expired brimonidine and latanoprost eye drops were found in Medication Cart AA during an inspection with RN I. RN I confirmed both bottles had passed their expiration dates, yet they remained in active stock. The DON stated expired medications in the cart should be taken and disposed, and facility policy required checking expiration dates and discarding opened multi-dose vials within the applicable timeframe.
Failure to timely offer the flu vaccine to a resident with DM and HTN. Record review showed no documentation that the resident was offered or received the flu vaccine during the 2025 season, and the IP confirmed the resident was only offered and received the vaccine later, with no explanation for why it was not offered earlier. The facility policy stated the flu vaccine shall be offered between October 1 and March 31.
A resident with a high fall risk experienced multiple unwitnessed falls without proper post-fall monitoring, care plan development, or interdisciplinary team review. Additionally, the responsible party was not notified after two falls due to incorrect documentation, contrary to facility policy. These deficiencies were confirmed by the DON during interviews and record reviews.
A resident with hemiplegia and muscle weakness experienced a fall and developed a pressure injury, but these incidents were not accurately documented in the MDS. The MDS nurse confirmed the omissions during a review.
The facility failed to follow its policy on advance directives and POLST forms for nine residents, as revealed by interviews and record reviews. The social service director and director of nursing confirmed that there was no documentation of discussions or assistance regarding advance directives, despite the facility's policy requiring such actions upon admission. This oversight could lead to medical services being provided against residents' wishes.
The facility failed to obtain informed consent and develop care plans for the use of bed rails for several residents. Two residents lacked signed informed consents, while another had an incomplete consent form. Additionally, three residents used side rails without corresponding care plans, contrary to facility policy. The DON confirmed these deficiencies during interviews and record reviews.
The facility failed to ensure safe medication management and disposal, with discrepancies in controlled drug records for two residents, improper labeling of insulin pens, and inadequate disposal of hazardous drugs. Controlled drugs were signed out but not documented on the MAR, insulin pens were mislabeled, and hazardous drugs were not properly segregated for disposal.
The facility failed to implement the consultant pharmacist's recommendations during monthly medication regimen reviews for several residents. For one resident, there was no monitoring for behaviors or side effects of psychotropic medication, and another resident's medication was not administered as recommended. Additionally, the facility did not act on recommendations to discontinue unnecessary medications for a resident, nor did it review an indefinite antibiotic order for another resident.
Two residents received unnecessary psychotropic medications without proper monitoring or informed consent. One resident was given pimavanserin and Seroquel without specific behavior monitoring or lipid panel checks, while another was prescribed Remeron without monitoring for side effects. The facility's policy on psychotropic medication use was not followed, leading to potential adverse reactions.
A facility was found to have a medication error rate of 11.11%, with errors including administering medications without food, failing to provide prescribed oral care due to medication unavailability, incorrect dosage of vitamin D, and improper insulin pen use. These incidents involved multiple residents and staff, indicating a lack of adherence to medication protocols.
The facility failed to properly store and label medications, leading to potential medication errors. Inspections revealed improperly stored Lovenox syringes, unlabeled insulin pens, and expired eye drops being used. Nursing staff confirmed these discrepancies with facility policies, highlighting risks of incorrect administration and ineffective treatments.
The facility failed to maintain sanitary conditions in the kitchen, with observations of dust and grease buildup on floors, improper placement of cleaning cloths, unlabeled food containers, and unclean equipment. Cleaning logs showed inconsistencies, and staff interviews confirmed incomplete cleaning tasks due to unavailability.
A survey identified infection control deficiencies in an LTC facility, including the use of a blood pressure cuff and glucometer on multiple residents without disinfection, and unlabeled personal care items in shared bathrooms. Staff acknowledged these oversights, which violated the facility's infection control policies.
The facility failed to accurately code MDS assessments for two residents regarding tracheostomy care. One resident, who required ongoing tracheostomy care, was not coded for it, while another resident, who had their tracheostomy removed months ago, was incorrectly coded as receiving tracheostomy care. These inaccuracies were confirmed by the MDS coordinator and the respiratory therapist.
The facility failed to complete and submit PASRR screenings for two residents with mental disorders. One resident was admitted with diagnoses including psychosis and anxiety, but the PASRR was for a different facility. Another resident, admitted with psychosis and depression, did not have a new PASRR submitted after 30 days as required. Staff interviews confirmed the screenings were not completed, despite facility policy requiring such screenings for new admissions.
The facility failed to ensure the proper functioning of Wander Guard devices for two residents, did not follow care plan interventions for a resident after a fall, and left cleaning supplies unsecured in a shared bathroom. These actions compromised resident safety and supervision.
A facility failed to follow its policy for G-tube care when an RN did not verify the placement of a G-tube before administering a water flush to a resident. The RN stated that the tube feeding was running continuously, which is why the placement was not checked. The DON confirmed that staff are expected to verify tube placement before any medication or water flush, as per facility policy.
The facility failed to provide proper respiratory care for five residents, including administering oxygen without physician orders and not following infection control practices for oxygen tubing. Observations confirmed the absence of necessary orders and documentation, and nasal cannulas were found undated and uncovered. Staff interviews acknowledged these lapses, and the facility's policies on oxygen administration and infection control were not adhered to.
The facility failed to accommodate the food preferences of two residents, as identified through observation and interviews. One resident was served bite-size cut Polish sausage instead of ground meat, while another received meat without the requested extra sauce. Staff interviews confirmed the oversight in adhering to meal tray card notes, which are crucial for ensuring resident preferences are met.
A resident's MDS was inaccurately completed, with discrepancies in weight and continence documentation. The resident's most recent weight was not correctly recorded, and their continence status was misrepresented, potentially affecting care interventions. The inaccuracies were confirmed by the MDS Coordinator.
A resident with COPD and respiratory failure, who had a laryngectomy, was non-compliant with keeping a larytube in place. Despite staff awareness and documentation of the issue, the facility failed to develop a care plan to address this non-compliance, as required by their policy.
A resident with polyneuropathy was unable to receive her prescribed PRN oxycodone due to an unsigned physician order. The order remained pending for several days, and nursing staff did not attempt to obtain the physician's signature remotely, despite the facility's policy requiring timely medication administration.
The facility failed to notify the Ombudsman office of hospital transfers for two residents, as required by AFL 17-27. One resident with a fracture and laceration was transferred without notification, and another with a subarachnoid hemorrhage was also transferred without notifying the Ombudsman. Social services staff confirmed the lack of documentation for these notifications.
A facility failed to provide and document skin treatments as ordered by a physician for a resident, risking further skin breakdown. The resident's treatment administration record showed missing documentation for Calmoseptine and Triad Cream applications on multiple occasions. The DON confirmed the lack of documentation indicated the treatments were not done, violating the facility's charting policy.
Infection Control Practices Not Implemented Consistently
Penalty
Summary
The facility failed to implement infection prevention and control practices during multiple observed resident care activities. During insulin administration to a resident on enhanced barrier precautions, an RN touched the resident’s abdomen without gloves before returning to get PPE. During eye drop administration to another resident, an LVN used the same tissue to wipe both eyes after instilling medication. During wound treatment for a resident with sacral and right groin wounds, the treatment nurse handled contaminated items and then continued care without performing hand hygiene between dirty and clean tasks, including after glove removal and after touching a soiled dressing. Additional infection control lapses were observed with resident care items and respiratory equipment. Multiple unlabeled wash basins were found in shared bathrooms used by more than one resident. For one resident using oxygen, the nasal cannula was not labeled with the date it was changed, and the nebulizer face mask was left uncovered in a nightstand drawer when not in use. For another resident, an uncovered suction yankauer was left between the bed rail and bed frame when not in use. Staff also did not perform hand hygiene between residents while serving lunch trays in the dining room, and the infection preventionist stated staff should have provided hand hygiene between residents and tasks. The facility’s Water Management Plan was not updated; the plan had expired, the water flow diagram page was blank, and it still referenced a decorative fountain that the maintenance director confirmed was no longer present. In addition, there was no documentation of surveillance monitoring or audits showing staff compliance with hand hygiene, PPE use, or other infection control practices. The infection preventionist and DON stated there was no surveillance log documenting monitoring of staff infection control practices, despite the infection control nurse job description and facility policy describing routine monitoring and reporting of staff adherence to infection prevention processes.
Inaccurate bed rail assessments and unauthorized wound treatment
Penalty
Summary
The facility failed to document bed rail use accurately for multiple residents whose beds were observed with two side rails up. For Residents 72, 52, 1, and 83, room observations showed partial bed rails up at the head of the bed, while their bed rail and entrapment risk assessments documented that bed rails were not in use. CNA staff confirmed the rails were in use and stated the residents had been using them since admission, and the DON confirmed the assessments should have documented bed rail use as yes. Similar inaccurate documentation was identified for Residents 73, 7, 8, 91, 47, and 9. Each of these residents had physician orders for side rails as an enabler to assist with mobility and non-restraint use, and each had assessments that documented bed rails were not currently in use. However, during room observations, each resident’s bed was seen with two side rails up. RN I confirmed these residents had side rails in use and had been using them for a while, and the DON confirmed the assessments should have documented yes rather than no. The facility also failed to follow the physician’s order for Resident 92’s wound care. The active order for the right genital/groin wound included cleansing, packing, dressing, and securing the wound, but did not include zinc oxide. During wound treatment observation, TN C applied zinc oxide to the peri-wound area without a physician’s order. TN C confirmed there was no order before applying it, and the DON confirmed zinc oxide was not included in the facility’s standing orders and required a physician order before use.
Dietary Staff Failed to Wear Beard Restraints During Tray Line
Penalty
Summary
The facility failed to ensure dietary staff covered facial hair while working over exposed food in the kitchen. During an observation of the meal tray line, a dietary aide and a dietary cook were seen with visible facial hair and were not wearing beard restraints while plating and checking meal trays over exposed food items during tray line service. In interviews, the dietary aide stated he was only checking the food and not handling it, while the dietary cook acknowledged that his beard was long and that he needed to wear a beard restraint. The Registered Dietitian stated that staff working in direct food preparation or plating food should wear hair and beard nets, and the DM stated that both staff members should have worn beard nets during tray line because exposed food was present. The facility policy stated that food and nutrition services staff wear hair restraints, including beard restraints, so hair does not contact food.
Loss of Resident Personal Property
Penalty
Summary
The facility failed to ensure free from loss of personal property for one resident. During room rounds, the resident stated that his clothes and shoes were lost in the facility and that he had informed staff, but no staff responded back to him about the missing items. Review of the resident’s face sheet showed admission to the facility on 12/26/2025, and the inventory of personal effects listed clothing, shoes, and slippers among the resident’s belongings. Review of the facility’s grievance and theft/lost logs for December 2025, January 2026, and February 2026 showed no documented evidence of the resident’s missing clothes and shoes. A CNA stated the resident had reported losing clothes and shoes the prior week. The SSA confirmed there was no grievance or theft report and no lost-item process had been initiated, and the SSD was not aware of the missing items. The DON later searched the resident’s belongings and confirmed one gray pant, one gray shirt, and one gray slipper were missing from the documented inventory of personal effects.
Unnecessary PRN Antipsychotic Order Without Stop Date
Penalty
Summary
The facility failed to ensure one of four residents, Resident 9, was free from unnecessary psychotropic medication when Seroquel was ordered as needed with no stop date. Resident 9 was admitted with diagnoses including depression and unspecified anxiety disorder. The physician's order reviewed for Resident 9 included Seroquel Oral Tablet 25 mg, give 1 tablet by mouth every 6 hours as needed for paranoid schizophrenia breakthrough agitation, dated 11/27/25. During a concurrent interview and record review on 2/12/26 at 1:00 p.m., the DON reviewed the order and confirmed there was no stop date for Seroquel and that it had been ordered more than 14 days. The DON stated it should be discontinued. The facility policy titled Psychotropic Medication Use, revised February 2025, stated PRN psychotropic medication orders are limited to 14 days and that PRN orders for antipsychotics cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.
Inaccurate MDS Coding for Dental Status, Weight Loss, and Insulin Orders
Penalty
Summary
The facility failed to code minimum data set (MDS) assessments accurately for three sampled residents. For Resident 6, the admission and readmission evaluations documented broken and missing natural teeth, and an LVN later confirmed several missing upper and lower teeth; however, the MDS oral and dental status was coded as having no natural teeth or tooth fragments. Resident 49’s nursing admission evaluation documented that the resident did not have teeth or dentures, but the MDS dental status was also coded inaccurately instead of reflecting that the resident was edentulous. The facility also coded Resident 6’s weight loss status inaccurately. The MDS indicated the resident was on a physician-prescribed weight-loss regimen, but the clinical record did not contain documented evidence of such a regimen, and the PCP confirmed he did not approve a planned weight-loss regimen and had treated the resident for fluid retention instead. In addition, Resident 1’s MDS inaccurately coded insulin orders; the resident had diabetes type 2 and orders for insulin glargine and Humalog sliding scale insulin, but the assessment did not accurately reflect the insulin regimen.
Incomplete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate PASARR screening for one resident with diagnoses of paranoid schizophrenia and psychosis. Review of the resident’s clinical record showed a PASARR Level 1 screening form dated 2015 that was incomplete, and during interview and record review the MDS Coordinator confirmed that the Level 1 screening in the record was incomplete and that no Level II evaluation had been obtained. The resident’s record also documented the mental health diagnoses, and the facility policy stated that new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders through the Medicaid PASARR process, with referral for Level II screening when the Level 1 screen indicates possible criteria.
Missing Comprehensive Care Plans for Behavioral, Dental, and Oxygen Therapy Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with target symptoms, measurable objectives, and interventions for four sampled residents. Resident 47 was admitted with bipolar disorder and thrombocytopenia and had a physician order for Valproate sodium oral solution for bipolar disorder, but the clinical record showed no comprehensive care plan for the bipolar diagnosis. During review with the DON, the absence of a bipolar disorder care plan was confirmed. Resident 49’s admission evaluation documented that the resident did not have teeth or dentures, yet the care plan record contained no documented care plan for missing teeth. Resident 6’s admission and readmission evaluations documented own broken teeth and broken natural teeth, but the care plan record also lacked documentation for broken or missing teeth. In interviews, the MDSC and DON confirmed that care plans should have been initiated for the residents’ dental conditions and that no such care plans were present. Resident 72 was observed using oxygen via room air concentrator and communicated that oxygen was used on and off for shortness of breath. The resident’s diagnoses included chronic respiratory failure, and the order summary included oxygen therapy at 2 liters titrated to maintain oxygen saturation at or above 93% as needed. The care plan record contained no documented care plan for oxygen therapy, and the MDSC and DON confirmed that no oxygen care plan had been developed or implemented.
Care Plans Not Updated After Falls and Smoking Non-Compliance
Penalty
Summary
The facility failed to keep comprehensive person-centered care plans updated and revised for three residents after changes in condition and events. Resident 9, who had diagnoses including depression and anxiety disorder, had a fall risk care plan last updated on 7/10/25 even though the record showed multiple falls, including falls on 10/18/25, 10/19/25, 11/21/25, 1/30/26, and 2/10/26. The interdisciplinary team notes documented interventions such as redirection, re-orientation, supportive care, music therapy, positive reinforcement, dim lighting, social service visits, pain management, neuro checks, frequent safety checks, notifying the MD, reminding the resident to use the call light, and keeping the call light within reach, but there was no documentation that these new fall interventions were added to the care plan. Resident 25, who had diagnoses including metabolic encephalopathy and diabetes, had a fall care plan dated 8/20/25 that included PT and OT consults and keeping the bed in low position. The record showed multiple falls, including on 9/11/25, 9/17/25, and 12/11/25. IDT notes documented interventions such as pain management, notifying the MD of changes, neurological checks, 72-hour charting, and PT and OT evaluations, but there was no documentation that the fall care plan was revised after those falls. During interview, the DON confirmed that new interventions were not in the resident’s fall care plan and that the plan should have been updated with new interventions. Resident 88’s smoking care plan dated 1/29/26 stated that smoking supplies were kept by activity staff during the day and in the west wing med room at night, and the smoking assessment indicated staff should light the cigarette for smokers. During observation, the resident was seen with a lighter in his pant pocket, used it to light his cigarette, returned it to his pocket, and left the smoking area with the lighter still on him. Activity staff and the AD confirmed the resident kept the lighter and refused to give it to staff for storage, and the DON confirmed the smoking care plan had not been updated to reflect this non-compliance with smoking material storage.
Electrical and Smoking Safety Failures
Penalty
Summary
The facility failed to follow its electrical safety policy when a long cell phone charging cord was observed on the floor in room [ROOM NUMBER], running from a wall outlet across the area between two beds to a tray table next to one resident’s bed. A certified nursing assistant confirmed the cord was on the floor and stated it should have been off the floor for safety reasons. The maintenance director later stated the cord should have been off the floor to prevent a tipping hazard and potential injury for anyone entering the room. The facility also failed to follow its electrical safety and smoking safety procedures for two residents. Resident 52, admitted on 8/23/2025 and assessed with a BIMS score of 12/15 indicating moderately impaired cognition, was observed using an ungraded power strip on his bed with six electronic devices charging next to his pillow. The resident stated the power strip was his own and that staff were aware of its use. Resident 88, admitted on 1/28/2026, was observed in the designated smoking area with a cigarette lighter in his pant pocket, used it to light his cigarette, and then returned it to his pocket before leaving the area and going back inside the facility. The resident’s smoking assessment stated staff should light cigarettes for smokers, and the care plan stated smoking supplies were to be kept by activity staff during the day and in the west wing med room at night. Activity staff and the activity director confirmed the resident kept the lighter with him and was not compliant with the facility’s smoking material storage process.
Expired Eye Drop Medications Left in Active Cart Stock
Penalty
Summary
The facility failed to ensure proper medication storage and labeling for one of two medication carts, Medication Cart AA, when expired brimonidine eyedrop and latanoprost eyedrop medications remained in the cart’s active stock. During an inspection of Medication Cart AA with RN I, a bottle of brimonidine eyedrop was found with an open date of 1/7/26, and RN I confirmed it expired on 2/6/26. A bottle of latanoprost eyedrop was also found with an open date of 12/27/25, and RN I confirmed it expired on 2/7/26. During interview, the DON stated that any expired medications in the cart should be taken and disposed. The facility’s policy titled Medication Labeling and Storage stated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a different date. The facility’s policy titled Administering Oral Medications stated to check the expiration date on the medication and return any expired medication to the pharmacy.
Failure to Timely Offer Flu Vaccine
Penalty
Summary
The facility failed to offer the influenza vaccine timely for one sampled resident who was admitted with diagnoses including DM and hypertension. Review of the resident’s clinical record and Immunization Audit Report showed no documentation that the resident received or was offered the flu vaccine in 2025. During interview, the infection preventionist confirmed the resident was admitted in March 2025 and stated the resident was offered and received the flu vaccine on 2/11/26, but was not sure why that was the only time the resident was offered the vaccine. The facility policy, Influenza Vaccine, dated 3/2022, stated that between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees.
Failure to Implement Fall Management and Notification Procedures
Penalty
Summary
The facility failed to implement appropriate fall management interventions for a resident with a high risk for falls, as evidenced by multiple lapses in monitoring, care planning, interdisciplinary team (IDT) involvement, and notification of the responsible party. The resident, who had diagnoses including unspecified fall, muscle weakness, gait abnormalities, and cellulitis, experienced five unwitnessed falls during their stay. After each fall, licensed nurses did not document monitoring of the resident every shift for 72 hours as required, and there was no evidence that the IDT met to discuss three of the falls. Additionally, after the resident's first fall, no care plan was developed to address the incident and prevent further falls. Further review revealed that the resident's responsible party, identified as the resident's son, was not notified after two of the falls, despite facility policy requiring such notification. Documentation incorrectly indicated the resident was self-responsible, leading to a failure in communication with the designated responsible party. These deficiencies were confirmed by the Director of Nursing during interviews and record reviews, and were not in accordance with the facility's policies on change in condition and care planning.
Inaccurate MDS Documentation for Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, which compromised the ability to develop appropriate care plans and interventions. The resident, who was admitted with diagnoses including hemiplegia/hemiparesis, difficulty in walking, and muscle weakness, experienced an unwitnessed fall on 8/22/24. However, the MDS dated after this incident was incorrectly coded to indicate that the resident had not fallen during the specified time frame. During an interview, the MDS nurse confirmed that the fall should have been recorded in the MDS, but it was not. Additionally, the resident developed an open wound on the left arm due to pressure from a splint, which was treated from 11/28/24 to 12/17/24. Despite this, the MDS was inaccurately coded to show that the resident did not have any unhealed pressure injuries. The MDS nurse confirmed that the pressure injury should have been documented in the MDS but was omitted. These inaccuracies in the MDS documentation were identified during a review of the resident's medical records and interviews with the MDS nurse.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives (AD) and the completion of physician orders for life-sustaining treatment (POLST) forms for nine residents. The deficiency was identified through interviews and record reviews, revealing that the facility did not discuss, offer, or assist in executing advance directives for these residents. The residents involved were admitted between 2018 and 2024, and their POLST forms either indicated 'No Advance Directive' or were incomplete, with no documented evidence of any discussion or assistance provided by the facility. The social service director (SSD) confirmed during an interview that there was no documentation of discussions or assistance regarding advance directives for the nine residents. The SSD acknowledged that the social service staff should have verified, discussed, offered, and assisted in executing advance directives as needed. Similarly, the director of nursing (DON) stated that the social service staff should have engaged in these discussions and that the nursing staff should have completed all sections of the POLST form, particularly for one resident whose form was left blank. The facility's policy, last revised in December 2016, requires the social service director or designee to inquire about the existence of advance directives upon a resident's admission. If a resident has not established advance directives, the facility staff is supposed to offer assistance, and nursing staff should document the offer and the resident's decision. The failure to follow this policy could lead to unnecessary or inappropriate medical services being provided against the residents' wishes, as the facility did not ensure that residents' preferences were documented and respected.
Failure to Obtain Informed Consent and Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper use of side rails for six residents, compromising their rights to make informed decisions and potentially putting them at risk for entrapment or serious injury. For two residents, there were no signed informed consents for the use of side rails, as confirmed by the Director of Nursing (DON) during an interview and record review. The facility's policy requires informed consent before using bed rails, but this was not adhered to for these residents. Another resident had an informed consent form on file that was missing a signature, indicating that the consent process was incomplete. The resident, who was self-responsible for decision-making and had intact cognition, did not recall giving consent for the use of bed rails. The DON acknowledged that the nursing staff should have obtained the resident's signature before using the bed rails. Additionally, three residents were using side rails without having care plans in place to address their use. The facility's policy requires comprehensive, person-centered care plans based on resident assessments, but this was not followed. The DON confirmed that these residents did not have care plans for the use of side rails, despite having physician orders recommending their use for mobility and positioning.
Medication Management and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure the safe use and disposition of medications, particularly controlled drugs, leading to discrepancies between the controlled drug record (CDR) and the medication administration record (MAR) for two residents. For Resident 83, there were four instances where oxycodone was signed out on the CDR but not documented on the MAR, indicating a lack of evidence that the medication was administered. Similarly, for Resident 34, there were nine instances where hydrocodone/acetaminophen was signed out but not documented on the MAR. The Director of Nursing (DON) confirmed these discrepancies, and the nurse responsible admitted to forgetting to document the administrations. The facility also failed to adhere to labeling standards for insulin pens, which could lead to medication errors. During inspections, insulin pens were found with pharmacy labels on the caps instead of the body, increasing the risk of mix-ups if pen caps were switched. This practice contradicts guidelines from the Institute for Safe Medication Practices, which recommend labeling the body of the pen to prevent such errors. Additionally, the facility lacked a proper process for the disposal of hazardous drugs (HDs), as required by current standards. During observations, it was noted that all medications, including HDs, were discarded in the same bins without segregation. The DON acknowledged the absence of a separate disposal system for HDs, which is necessary to prevent exposure to hazardous substances. This deficiency was confirmed by the review of the facility's practices against the standards set by the United States Pharmacopeia 800 and the National Institute for Occupational Safety and Health.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) identified irregularities and made necessary recommendations during the monthly medication regimen review (MRR) for several residents. For Resident 72, the CP did not recommend monitoring for specific targeted behaviors, side effects, or informed consent for the use of pimavanserin, a medication for Parkinson's disease psychosis. Additionally, there was no recommendation for lipid panel monitoring for Seroquel, which is known to affect blood lipids. The Director of Nursing (DON) confirmed these oversights during an interview, acknowledging the lack of documentation and care planning specific to Resident 72's symptoms. For Resident 44, the CP recommended administering pantoprazole sodium 30 minutes before breakfast, but the medication administration record showed it was given at 9 a.m. instead. The DON claimed to have followed the CP's recommendation by adjusting the administration time, but the records did not reflect this change. This discrepancy indicates a failure to implement the CP's recommendations effectively. Resident 40's case involved the CP recommending the discontinuation of three medications to prevent polypharmacy, but the facility did not follow up with the medical doctor to act on these recommendations. The DON confirmed that the recommendations were received but not acted upon. Similarly, for Resident 2, the CP did not review or recommend changes to an indefinite order for Keflex, an antibiotic, which is typically not recommended for long-term use. These failures highlight the facility's inability to act on CP recommendations and ensure safe medication practices.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 72 was administered pimavanserin for Parkinson's disease psychosis without specific target behaviors being identified, side effect monitoring, a quarterly psychotropic review, a care plan, or evidence of informed consent for over eight months. Additionally, there was no periodic monitoring of blood lipids while the resident was on Seroquel, which is known to affect blood lipids. The Director of Nursing (DON) confirmed the lack of documentation and care planning specific to the resident's symptoms and the absence of informed consent and quarterly reviews. Resident 91 was prescribed Remeron for depression without monitoring for potential side effects. The resident's medical record lacked documentation of monitoring for adverse effects, despite the known risk of marked sedation in the elderly. The DON acknowledged that the order for monitoring side effects was not renewed when the resident returned from the hospital, resulting in over a month without monitoring. The facility's policy on psychotropic medication use requires that residents only receive such medications when necessary to treat a specifically diagnosed condition, with informed consent obtained and documented. The policy also mandates monitoring for efficacy and adverse consequences, which was not adhered to in these cases, leading to the administration of unnecessary medications and the potential for adverse reactions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.11%, exceeding the acceptable threshold of 5%. This was observed during medication administration for four out of nine residents. One incident involved a registered nurse (RN) administering calcium acetate and carvedilol to a resident without food, contrary to the prescriber's orders and manufacturer's specifications. The RN was unaware that carvedilol should be given with food to minimize the risk of orthostatic hypotension, and calcium acetate must be administered with meals to be effective. The delay in administration was attributed to the RN falling behind schedule due to other residents' needs. Another incident involved a licensed vocational nurse (LVN) who failed to administer chlorhexidine to a resident due to the facility running out of the medication. The LVN documented the unavailability in the resident's progress notes but did not ensure the medication was available for the scheduled oral care. This oversight resulted in the resident not receiving the prescribed oral hygiene treatment. Additionally, an LVN administered an incorrect dosage of vitamin D to a resident, providing only one tablet instead of the prescribed five tablets. Furthermore, the same LVN failed to prime an insulin pen before administering insulin lispro to another resident, which is a necessary step to ensure the full dose is delivered. These errors highlight a lack of adherence to medication administration protocols and insufficient knowledge of medication requirements among the nursing staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, leading to potential medication errors and ineffective treatments. During an inspection, it was found that four medications were not stored according to the manufacturer's guidance, and a discontinued medication for a resident was not discarded. Specifically, Lovenox syringes were improperly stored in a refrigerator and not removed after the resident's discharge. Additionally, brimonidine eye drops were stored at incorrect temperatures, and a tuberculin vial was not labeled with an open date and stored at room temperature instead of being refrigerated. Further inspection revealed an insulin pen without a visible resident's name, increasing the risk of it being administered to the wrong resident. Several opened medications, including an inhaler and eye drops, lacked open dates, and some eye medications were used past their discard dates. These findings were confirmed by the nursing staff, who acknowledged the discrepancies with the facility's policies and procedures, which require proper labeling and timely disposal of medications.
Sanitation Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a tour with the registered dietitian (RD). Dark black areas, indicative of dust and grease buildup, were noted on the kitchen floor near food preparation areas, under refrigerators, and in corners. The RD confirmed these areas were due to inadequate cleaning and stated that the kitchen floor should have been replaced. The facility's cleaning logs revealed inconsistencies, with missing initials for daily cleaning tasks and no records of deep cleaning for several weeks. Interviews with dietary staff confirmed that scheduled cleaning tasks were not completed due to staff unavailability. During the kitchen tour, wet cleaning cloths were found improperly placed on a vegetable sink and a food storage container. The cook admitted to leaving the cloth on the sink after cleaning food carts, acknowledging it should have been put away for cleaning. Another cloth was found on a container used for storing dry beans, with the staff unsure if it was used or unused. The RD emphasized that dietary staff should maintain clean and sanitary practices in the kitchen. Additionally, a container of sliced cheddar cheese was found without an opened date label, contrary to the facility's policy requiring all opened food items to be labeled with the date. The RD confirmed this oversight and stated that all food storage containers should be labeled accordingly. A blender was also observed with dark brown particles on its base, which the RD identified as dry food residue. The blender was not in use, and the RD stated it should have been cleaned and removed from the kitchen when not in use.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey. A registered nurse used a blood pressure cuff on two different residents without disinfecting it between uses, which was against the facility's policy that requires reusable items to be cleaned and disinfected between residents. The nurse acknowledged the oversight during an interview. Additionally, a licensed vocational nurse was observed using a shared glucometer on multiple residents without disinfecting it between uses. The nurse admitted to forgetting to use disinfectant wipes after each use, which is required to prevent the spread of infection. The Director of Nursing confirmed that the glucometer should be cleaned with Sani-Cloth wipes before and after each use, allowing a dwell time of two minutes. The survey also noted unlabeled urinals and wash basins in shared bathrooms, which were not marked with residents' names, posing a risk of cross-contamination. Certified nursing assistants confirmed the oversight and discarded the items. Furthermore, personal care items such as adult briefs, towels, toothbrushes, and razors were improperly stored or unlabeled, which was confirmed by the facility's infection preventionist as a breach of infection control practices.
Inaccurate MDS Coding for Tracheostomy Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, which could potentially lead to inappropriate care and interventions. Resident 39, who was admitted with a tracheostomy and required ongoing tracheostomy care, was not coded for this care in the MDS assessment dated 6/14/2024. This oversight was confirmed by the MDS coordinator, who acknowledged that the assessment should have accurately reflected the resident's need for tracheostomy care. The respiratory therapist also confirmed the resident's condition and the necessity for frequent suctioning due to increased secretions. Similarly, Resident 78, who had a tracheostomy removed approximately nine months prior, was incorrectly coded as receiving tracheostomy care in the MDS assessment dated 7/5/2024. The respiratory therapist confirmed that the resident no longer had a tracheostomy, and the MDS coordinator admitted that the assessment was inaccurately coded. The Director of Nursing also stated that MDS assessments should accurately reflect the residents' clinical status. The facility's policy and procedure, as well as CMS guidelines, require that MDS assessments be completed based on current clinical information, which was not adhered to in these cases.
Failure to Complete PASRR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure the completion and submission of the Pre-Admission Screening and Resident Review (PASRR) for two residents with mental disorders. Resident 43 was admitted to the facility with diagnoses including psychosis, anxiety, obsessive-compulsive disorder, and adult personality disorder. However, the PASRR screening completed for Resident 43 was for a different nursing facility located 21 miles away, and no new Level 1 PASRR screening was conducted upon admission to the current facility. Similarly, Resident 85, who was admitted with diagnoses of psychosis and depression, had a PASRR screening under a 30-day exempted hospital discharge. The facility did not resubmit a new Level 1 screening as required on the 31st day of admission. Interviews with the medical record assistant and the MDS coordinator confirmed that the Level 1 PASRR screenings were not completed for both residents after their admission to the facility. The director of nursing acknowledged that the nursing staff was responsible for completing and submitting the Level 1 screenings to the Department of Health Care Services (DHCS) but failed to do so for these residents. The facility's policy and procedure on admission criteria indicated that all new admissions and readmissions should be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process, which was not adhered to in these cases.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the proper functioning and monitoring of Wander Guard devices for two residents, which are intended to prevent elopement. Observations revealed that the devices were not checked for functionality, and staff did not document their checks as required by the facility's policy. Interviews with nursing staff and the Director of Nursing confirmed that there were no physician orders to check the functionality of the Wander Guards, and staff relied on door alarms to indicate if the devices were working. This lack of documentation and monitoring could potentially lead to residents leaving the facility without staff knowledge. Another deficiency involved the failure to follow the interdisciplinary team's recommendation to remove wheelchair footrests for a resident who had experienced a fall. Despite the care plan indicating the need to remove the footrests to prevent future falls, observations showed that the footrests remained attached. Interviews with nursing staff and the Director of Nursing confirmed that the recommendation had not been communicated to the staff, and the necessary intervention was not implemented, leaving the resident at risk for further falls. Additionally, cleaning supplies were found unsecured in a shared bathroom, posing a risk to residents, particularly those who may be confused. Observations noted that containers of cleaning products were left on the floor, accessible to residents. Interviews with staff confirmed that cleaning supplies should be stored in a locked area to prevent accidental ingestion by residents. The facility's policy also indicated that cleaning supplies should be stored securely, separate from food storage areas.
Failure to Verify G-tube Placement Before Water Flush
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the care of a resident with a gastrostomy tube (G-tube). Specifically, a registered nurse (RN A) did not verify the placement of the G-tube before administering a water flush to Resident 20. This verification process involves injecting air into the tube and listening for gurgling sounds in the stomach with a stethoscope, as well as checking the residual. During an observation and interview, RN A admitted to not checking the placement because the tube feeding was running continuously. The Director of Nursing (DON) confirmed that the expectation is for nursing staff to verify tube placement before administering any medication or water flush, as outlined in the facility's policy titled 'Administering Medications through an Enteral Tube.' This oversight had the potential to lead to enteral feeding complications for the resident.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for five residents. For two residents, oxygen was administered without a physician's order. Observations confirmed that these residents were receiving oxygen at specific flow rates, yet their clinical records lacked documentation of any physician orders for this treatment. The Director of Nursing acknowledged the absence of necessary orders and the lack of documentation regarding the oxygen administration. Additionally, the facility did not adhere to infection control practices for oxygen tubing for two other residents. Observations revealed that the nasal cannulas were undated and left uncovered when not in use. Interviews with staff confirmed that the nasal cannulas should have been dated when changed and stored in a plastic bag to prevent infection. The facility's infection preventionist and respiratory therapist both acknowledged these lapses in standard infection control practices. For another resident, oxygen was administered without a physician's order, and the nasal cannula was undated. The Registered Nurse confirmed the oxygen flow rate and the lack of labeling on the nasal cannula. The Director of Nursing admitted that an order should have been obtained before administering oxygen. The facility's policy indicated that oxygen cannulas and tubing should be changed weekly and stored properly, which was not followed in these cases.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate food preferences for two residents, which was identified during an observation, interview, and record review. Resident 46 was supposed to receive ground meat as per their lunch tray card notes and alerts, but was instead served bite-size cut Polish sausage. This discrepancy was confirmed by a certified nursing assistant (CNA B) who acknowledged the error and rectified it by obtaining the correct meal from the kitchen. Similarly, Resident 16's lunch tray card indicated a preference for extra sauce on meats, but the resident received meat without any sauce. This was confirmed by another certified nursing assistant (CNA C), who noted the dietary staff's oversight in preparing the meal according to the resident's preferences. Interviews with the cook (CD), dietary supervisor (DS), and registered dietitian (RD) further confirmed that the dietary staff failed to adhere to the notes and alerts on the residents' meal tray cards, which are intended to ensure that food preferences are met. The facility's policy and procedure on serving foods, revised in January 2013, mandates the use of diet tray cards to ensure tray accuracy and accommodate resident preferences. The failure to follow these procedures had the potential to decrease meal intake and negatively affect the health and well-being of the residents involved.
Inaccurate MDS Documentation for Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for a resident, leading to discrepancies in the documentation of the resident's weight and continence status. The resident, who had a medical history including a femur fracture, sepsis, obesity, and kidney disease, was documented to weigh 231 pounds on the MDS, despite the most recent weight being 220.8 pounds as confirmed by the registered dietician. This inaccuracy was acknowledged by the Minimum Data Set Coordinator (MDSC), who confirmed that the MDS should have reflected the most recent weight as per the guidelines in the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Additionally, the MDS inaccurately indicated that the resident was always continent with both urination and defecation. However, a review of the resident's documentation showed that during a specific period, the resident was frequently incontinent with urination and always incontinent with defecation. The MDSC confirmed these findings and acknowledged that the MDS should have been coded to reflect the resident's actual continence status during the 7-day look-back period, as outlined in the RAI Manual. These inaccuracies in the MDS had the potential to compromise the facility's ability to develop and implement appropriate interventions to meet the resident's needs.
Failure to Develop Care Plan for Resident's Non-Compliance
Penalty
Summary
The facility failed to develop a care plan to address the non-compliance of a resident with keeping a laryngectomy tube in place. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease and respiratory failure, had undergone a laryngectomy and was breathing through a laryngectomy stoma. Despite the resident's non-compliance with the larytube, as noted in progress notes and confirmed by staff interviews, there was no care plan in place to address this issue. Interviews with facility staff, including a respiratory therapist and a licensed vocational nurse, revealed that the resident frequently removed the larytube and was resistant to wearing it, even with staff encouragement. The facility's policy requires a comprehensive, person-centered care plan to be developed and revised as residents' conditions change, but this was not done for the resident's non-compliance with the larytube, as confirmed by a registered nurse during a record review.
Unsigned Pain Medication Order
Penalty
Summary
The facility failed to ensure a pain medication order was signed by the physician for a resident, which compromised the ability to administer the medication when needed. The resident, who was admitted with diagnoses including polyneuropathy, reported that she was unable to receive her prescribed oxycodone over a weekend because the physician had not signed the order. The medication was ordered to be administered as needed every six hours, but the order remained pending from the date it was issued until two days later. Interviews with nursing staff revealed that the facility did not attempt to obtain the physician's signature remotely, which was possible according to the registered nurse. The licensed vocational nurse confirmed informing the resident about the inability to administer the medication due to the unsigned order but did not recall reaching out to the physician. The facility's policy required nursing staff to ensure residents have a sufficient supply of medications and to contact the pharmacy if medications are unavailable, but there was no documentation of efforts to obtain the necessary signature.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman office of hospital transfers for two residents, which is a requirement under AFL 17-27. Resident 2, who was admitted with a fracture of the left foot and a laceration on the left hand, was transferred to the hospital on 11/9/23 after a physician's examination. However, there was no documentation in the clinical record indicating that the Ombudsman office was notified of this transfer. During an interview and record review, social services staff confirmed the lack of notification. Similarly, Resident 3, who was admitted with a diagnosis of subarachnoid hemorrhage, was transferred to the hospital on 2/28/24 after showing symptoms of lethargy, paleness, and clamminess. Again, there was no documentation in the clinical record that the Ombudsman office was notified of this transfer. The social services staff confirmed this oversight during an interview and record review. The failure to notify the Ombudsman office as required by AFL 17-27 was identified as a deficiency in the facility's compliance with regulations.
Failure to Document and Administer Skin Treatments
Penalty
Summary
The facility failed to provide skin treatments as ordered by the physician for a resident, which put the resident at risk for developing further skin breakdown. The resident had a physician's order to apply Calmoseptine to the perineum every shift for 21 days, starting from a specified date. However, the treatment administration record (TAR) showed that the application of Calmoseptine was not documented as completed on multiple occasions during both day and evening shifts. Additionally, the resident had another physician's order to apply Triad Cream to the coccyx every shift for 21 days, with instructions to notify the physician if there was any worsening. The TAR also indicated that the application of Triad Cream was not documented as completed on several occasions. During an interview, the Director of Nursing (DON) confirmed that the skin treatments with Calmoseptine and Triad Cream were not documented as completed on the specified dates. The DON acknowledged that if the treatments were not documented, it indicated that they were not done. The facility's policy on charting and documentation required that all services provided to the resident be documented in the medical record, including the date of treatment and the name and title of the individual who provided the care.
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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.
Illustrative
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Nursing homes near Salinas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Coast Post Acute | 0 mi | ★★★★★ | 5 | 0 |
| Katherine Healthcare | 0.6 mi | ★★★★★ | 23 | 0 |
| Coastal Post Acute | 2.6 mi | ★★★★★ | 0 | 0 |
| Windsor The Ridge Rehabilitation Center | 2.6 mi | ★★★★★ | 13 | 0 |
| Carmel Hills Care Center | 12.7 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.