Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Samarkand Skilled Nursing Facility during CMS and state inspections, most recent first.
Failure to Timely Report Resident Fall With Fracture: A resident with dementia, OA, and unsteadiness on feet fell and sustained a nondisplaced distal R femur fracture, but the event was not reported to CDPH within the facility’s required timeframe. The admin acknowledged the unusual occurrence should have been reported per policy and was not submitted until much later.
Inaccurate daily nurse staffing postings were observed when the posted Direct Care Staff Report contained missing dates and census information and did not match a separate sign-in sheet showing RN coverage that differed from the posted staffing record. The DON, CSC, and Administrator reviewed the documents and confirmed the inaccuracies, and the DON stated the inconsistencies could be misleading and cause confusion to residents and visitors.
The facility did not have a process to check the operational status, battery life, or cleanliness of Wander Guard bracelets for two residents at risk for wandering. Staff were unaware of procedures to verify device functionality, and the DON confirmed the absence of documentation or protocols for maintenance, despite manufacturer guidelines and facility policy referencing the use of these devices.
Two residents' assessments were completed using SBAR forms that were either unsigned or signed only by an LVN, without RN validation or co-signature. The DON and administrator confirmed that these forms are considered assessments and should have been completed or validated by an RN, in accordance with professional standards.
The facility failed to follow food safety standards by not labeling food items with preparation and expiration dates, resulting in expired food in the kitchen. Additionally, the concentration of sanitizing solution in red buckets was below the recommended level, compromising sanitation effectiveness. The Dietary Manager confirmed these issues during interviews.
A facility failed to protect the privacy of two residents' electronic health records when a nurse left a computer screen open on a medication cart, exposing sensitive information to the public. The facility's policies require that such information be kept confidential, in line with HIPAA regulations. The Director of Nursing acknowledged the breach of privacy rights.
The facility failed to transmit MDS records for two residents to CMS iQIES within required timeframes. A resident's discharge assessment was not transmitted within 14 days, and another resident's quarterly assessments were delayed by 28 and 39 days. Additionally, the MDS for a deceased resident was not submitted within 14 days. An LPN could not recall the reasons for these delays.
A facility failed to develop a care plan for a resident with a urinary catheter, despite the resident's history of UTIs and recent hospitalization. The resident was observed with a catheter but no care plan was documented, contrary to the facility's policy requiring comprehensive care plans.
A resident experienced a fall resulting in a hospital stay and was diagnosed with a septic joint, requiring intravenous antibiotics. Upon returning to the facility, the care plan was not updated to reflect these changes, despite facility policy requiring revisions as the resident's condition changes. The DON acknowledged the oversight, which increased the risk of recurring falls due to the lack of an updated plan for staff to follow.
A resident did not receive prescribed eye drop medication for glaucoma for two days due to a supply issue. The facility's policy and the pharmacist's recommendation on the disposal of eye drops conflicted, leading to the medication not being administered. The DON was unaware of the pharmacist's recommendation, contributing to the oversight.
The facility failed to follow physician orders for two residents, leading to unnecessary medication administration. One resident received Acetaminophen instead of Tramadol for severe pain and was given blood pressure medication despite low readings. Another resident was administered Oxycodone without prior pain assessment. The DON acknowledged these oversights, and the facility's policies on medication administration were not followed.
The facility failed to justify the continued use of psychotropic drugs for a resident and did not monitor another resident for side effects and sleep hours when administering trazodone. The lack of physician documentation for extending Ativan and Lorazepam use beyond 14 days and the absence of monitoring for trazodone administration were acknowledged by the DON, contrary to facility policies.
Expired medical supplies and medications were found in the medication storage areas of a facility, including an IV start kit, a filter needle, and anti-diarrheal medication. Interviews with staff confirmed the oversight, and facility policies require expired items to be removed and disposed of, which was not adhered to.
The facility failed to ensure that a resident's post-fall assessment and other assessments were performed by an RN, as required by professional standards. Instead, these assessments were conducted by an LVN without RN validation or co-signature, which is outside the LVN's scope of practice.
Failure to Timely Report Resident Fall With Fracture
Penalty
Summary
The facility failed to follow its policy and procedure for reporting unusual occurrences to the State Agency when Resident 1 experienced a fall with fracture on 2/28/26 and the event was not reported to CDPH until 4/30/26. Resident 1 was a [AGE]-year-old female admitted with diagnoses including dementia, osteoarthritis, and unsteadiness on feet. A review of the resident note entry dated 3/2/26 indicated that the resident had a fall on 2/28/26 and x-ray imaging showed a nondisplaced fracture of the distal end of the right femur. The facility policy titled Unusual Occurrence Reporting stated that reportable events affecting resident health, safety, or welfare are to be reported by telephone within 24 hours and followed by a written report within 48 hours. During interview, the administrator agreed the fall with fracture should have been reported according to facility policy and was not reported until 4/30/26.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information accurately reflected the actual staff on duty. During a concurrent observation and interview on 1/20/26 at 11:12 a.m. with the DON and the CNA/Scheduler Coordinator, the posted Direct Care Staff Report was reviewed and found to contain inconsistencies and inaccuracies, including entries with missing dates and census information on 11/22/25, 11/23/25, 1/1/26, 1/7/26, 1/17/26, and 1/18/26. The review also identified that on 12/20/25, the posted staffing report showed a census of 59 with no RN scheduled or assigned to work for 24 hours, while a separate sign-in sheet for that date showed RN coverage for only 4 hours instead of the required 8 hours. The DON and CSC reviewed the documents and confirmed the entries, and the CSC stated that the dates and census were forgotten. During later interviews, the DON stated the inconsistencies could be misleading and cause confusion to residents and visitors, and the Administrator and DON confirmed that all facility documentation should be accurate and complete.
Failure to Maintain Wander Guard Bracelets in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that Wander Guard bracelets, which are used to monitor residents at risk for wandering or elopement, were maintained in safe operating condition for two of three sampled residents. Specifically, the facility did not have a process in place to check the operational status or battery life of the Wander Guard bracelets, nor did they have a regimen for cleaning and disinfecting the devices. Interviews with a licensed nurse revealed that while staff were trained to check the placement of the bracelets, they were unaware of any procedures to verify if the devices were functioning or had sufficient battery power. The Director of Nursing confirmed that there was no documentation or process to ensure the Wander Guards were operational, had adequate battery life, or were being cleaned as recommended by the manufacturer. A review of the manufacturer's manual indicated that the bracelets require weekly battery testing and periodic cleaning and disinfection, with specific instructions for how this should be done. The facility's own policy referenced the use of Wander Guards as an intervention for residents at risk of wandering or elopement but did not include procedures for maintaining the devices. As a result, the lack of maintenance and monitoring of the Wander Guard bracelets created a deficiency in ensuring the safety and security of residents identified as at risk for wandering.
Assessments Not Performed or Validated by RN
Penalty
Summary
The facility failed to ensure that assessments for two sampled residents were performed by a registered nurse (RN) as required by professional standards and the facility's comprehensive care plan. Specifically, review of the residents' records revealed that several SBAR Communication Forms, which are used to evaluate residents across ten body systems, were either unsigned or signed only by a licensed vocational nurse (LVN) rather than an RN. In some instances, the signature area was left blank, and in others, the forms were completed and signed solely by an LVN without RN validation or co-signature. The director of nursing (DON) and administrator confirmed that these forms are considered assessments and acknowledged that they were not completed or validated by an RN as required. The report references the Nursing Practice Act and the Scope of Vocational Nursing Practice, which clarify that while LVNs may contribute to data collection, only RNs are qualified to analyze, synthesize, and make clinical judgments necessary for comprehensive assessments. The failure to have RNs complete or validate these assessments means that the facility did not meet the professional standards of quality required for resident care planning and assessment. The DON and administrator acknowledged these findings during the surveyor's review.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On April 8, 2025, DON assessed resident #1 after notification by nurse that the X-ray result showed a closed nondisplaced fracture of the right ilium, unspecified fracture morphology. IDT reviewed the occurrence of injury of unknown source on April 8, 2025. On 2/11/2025, the IDT reviewed the fall occurrence of resident #2 the same day. Both residents did not sustain significant changes after occurrences. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents had the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur On April 17, 2025, DON initiated in-services for licensed nurses for completion and signing of the SBAR and Scope of Practice of LVNs. On May 21, 2025, DON initiated in-service for licensed nurses to write clinical notes or progress notes detailing observations after an incident of fall. The findings will be communicated with the physician. The DON also continued the discussion about the role of LVN and RN that was initiated on the April 17, 2025, in-service. How the corrective action(s) will be monitored to ensure the deficient practice will not recur; i.e., what quality assurance programs will be put into place DON or designee will review the fall incidents, including documentation, care plans, new interventions, and notifications. This review will take place during the daily Interdisciplinary Team (IDT) meetings, held on business days. Findings from weekly audits for 12 weeks will be presented by the DON to the QAPI committee monthly for 3 months. Date by which systemic corrections will be completed: May 31, 2025
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional food safety standards by not labeling food items with preparation and expiration dates, leading to the presence of expired food in the kitchen. During an observation, several food items, including a pack of ground beef, bags of potato wedges, hamburger buns, and dinner rolls, were found to be beyond their expiration dates or unlabeled. Additionally, bags of grapes brought from the independent living kitchen were unlabeled, with one bag showing signs of mold. The Dietary Manager confirmed these findings during interviews. Furthermore, the facility did not maintain the recommended concentration of sanitizing solution in red buckets, which is crucial for effective sanitation. Observations revealed that the concentration of the sanitizing solution in two red buckets was 170 ppm, below the recommended level as per the facility's policies and procedures. The Dietary Aide and Dietary Manager acknowledged the discrepancy, indicating that the solution was not as effective at the observed concentration. The facility's policy requires testing the sanitizer solution when buckets are filled and maintaining a concentration of a specified ppm, which was not met in this instance.
Breach of Resident Privacy Due to Unattended Computer
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of two residents' electronic health records. During an observation, a Registered Nurse left a medication cart unattended with an open computer screen displaying the electronic health records of two residents. This exposure occurred at the Garden Court station, where the records were visible to the public as two individuals passed by the cart. The nurse acknowledged the oversight and confirmed that the electronic medical records should have been closed to protect the residents' privacy. The facility's policies and procedures emphasize the importance of maintaining confidentiality and privacy of residents' health information, in compliance with HIPAA regulations. The policies require that electronic information about residents should not be exposed or posted publicly. The Director of Nursing acknowledged that the residents' rights to privacy and confidentiality were not upheld in this incident, as per the facility's established guidelines.
Failure to Transmit MDS Records Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) records for two unsampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) within the required timeframes. Specifically, the discharge assessment MDS for Resident 31 was not transmitted within 14 days of their discharge date, as required. During an interview, a licensed nurse (LN1) confirmed that the transmission date for Resident 31's discharge assessment was unavailable because it had not been transmitted. For Resident 37, the facility also failed to transmit MDS assessments within the required timeframes. The MDS quarterly assessment for Resident 37 was transmitted 39 days after the assessment reference date (ARD), and another quarterly assessment was transmitted 28 days after the ARD. Additionally, the MDS for Resident 37, who was discharged with a status of deceased, was not submitted within 14 days of the death in the facility. LN1 was unable to recall the reasons for these delays.
Failure to Develop Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident with a urinary catheter, which is a flexible rubberized tube inserted into the urinary tract to drain urine. This deficiency was identified during an observation where the resident was seen in bed with a urinary catheter connected to a urine bag. A subsequent review of the resident's clinical record revealed that there was no care plan in place for the urinary catheter, despite the resident having a history of urinary tract infections (UTI) and being readmitted to the facility after hospitalization for a UTI. The facility's policy and procedure for comprehensive person-centered care plans, dated March 2022, requires the interdisciplinary team to develop and implement a care plan that reflects recognized standards of practice for problem areas and conditions. However, the licensed nurse acknowledged that no care plan was in place for the resident's urinary catheter, which could potentially lead to further complications such as UTIs, dislodgement, and other bladder issues.
Failure to Update Care Plan After Resident's Fall
Penalty
Summary
The facility failed to review and update the care plan for a resident after a fall, which was identified during an interview and record review. The resident, referred to as Resident 18, experienced a fall two weeks prior to the interview, resulting in a week-long hospital stay. During the hospital stay, the resident was diagnosed with a septic joint and began intravenous antibiotic treatment. Upon returning to the facility, the care plan was not updated to reflect these changes, despite the facility's policy requiring care plans to be revised as the resident's condition changes. The Director of Nursing acknowledged that the care plan for falls was not updated when the resident returned from the hospital. The interdisciplinary team notes indicated that the care plan would be updated to include resident teaching on using the call button for assistance, but the last update to the fall care plan was dated prior to the resident's hospital admission. This oversight placed the resident at a higher risk for recurring falls due to the lack of an updated plan for staff to follow and implement for prevention.
Failure to Administer Glaucoma Medication Due to Supply Issues
Penalty
Summary
The facility failed to provide an eye drop medication for glaucoma as ordered by the physician for one of the residents, identified as Resident 12. This failure occurred when the supply of the medication ran out, and the medication was not administered on two consecutive days, 12/17 and 12/18/2024. During a medication pass observation, a registered nurse indicated that the eye drop medication would not be administered as it was being reordered. The physician's order dated 7/10/2024 specified that Resident 12 was to receive Timolol Maleate 0.5% eye drops daily for glaucoma. The facility's policy and procedure on medication administration indicated that multi-use eye drops should be disposed of 28 days after initial use, while the pharmacist's recommendation suggested discarding them after two months from the open date. The Director of Nursing was unaware of the pharmacist's recommendation and acknowledged the conflicting information between the pharmacist's guidance and the facility's policy. This lack of awareness and conflicting information contributed to the non-administration of the medication to Resident 12 for two days.
Failure to Adhere to Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by improper medication administration and lack of adherence to physician orders. Resident 54, an 82-year-old with hypertension, stroke, and fractures, was administered Acetaminophen for severe pain levels instead of the prescribed Tramadol for moderate to severe pain. This occurred on multiple occasions, and the facility's Director of Nursing (DON) acknowledged that the physician's order was not followed, with no documentation to justify the deviation or notification to the physician. Additionally, Resident 54 was given blood pressure medication despite having systolic blood pressure readings below the physician-ordered parameters. The medication was administered on two separate dates when the resident's blood pressure was recorded as 109 and 99, contrary to the order to hold the medication if the systolic blood pressure was less than 110. The DON confirmed the oversight and was unable to provide documentation supporting the decision to administer the medication or any communication with the physician regarding the deviation. Resident 57's medication administration also demonstrated deficiencies, as Oxycodone was given without prior pain assessment, contrary to the physician's order. The facility's policy required pain evaluation before administering medication, but records showed that Oxycodone was administered on several dates without such assessments. The facility's policy emphasized the importance of evaluating the effects of medications and ensuring that drug regimens are free from unnecessary medications, which was not adhered to in this case.
Failure to Justify and Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for two residents. For one resident, there was no justification from the physician for the continued use of Ativan and Lorazepam beyond 14 days. The physician's orders for these medications did not include a stop date, and the Director of Nursing acknowledged the lack of documentation for the continued use of these medications. The facility's policy requires that orders may be extended beyond 14 days only if the attending physician documents the rationale for the extended time period in the medical record. For another resident, the facility failed to monitor for side effects and hours of sleep when administering trazodone, an antidepressant medication. The resident's care plan indicated the need to monitor for side effects such as constipation, dry mouth, anxiety, agitation, headache, and falls. However, there was no documented evidence of monitoring for side effects or hours of sleep when trazodone was administered. The Director of Nursing confirmed that the monitoring was missed, which was contrary to the facility's policy on psychotropic medication use that requires adequate monitoring for efficacy and adverse consequences.
Expired Medications and Supplies Found in Medication Storage
Penalty
Summary
The facility failed to remove expired medical supplies and medications from the medication storage areas, which could potentially lead to residents receiving expired and ineffective treatments. During an observation in the Garden Court station medication room, several expired items were found, including an IV start kit, a filter needle, and an opened box of bio patch discs. Additionally, an unopened box of anti-diarrheal medication was found expired in the medication cart. Interviews with the Registered Nurse and the Director of Nursing confirmed the presence of these expired items. The facility's policy and procedure documents, which were reviewed, indicate that medications should be administered safely and timely, with expiration dates checked prior to administration. The policy also states that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, these protocols were not followed, leading to the deficiency.
Failure to Ensure RN Conducted Resident Assessments
Penalty
Summary
The facility failed to ensure that Resident 1's post-fall assessment and other assessments were performed by a registered nurse (RN) as required by professional standards of practice. According to the Nursing Practice Act, an RN is responsible for comprehensive assessments, including data collection, analysis, and making clinical judgments. However, the assessments for Resident 1 were conducted by a licensed vocational nurse (LVN) without RN validation or co-signature. This included an SBAR Communication Form and a Daily Skilled Progress Note, both of which were created by an LVN and included evaluations of the resident's body systems. During interviews, the interim assistant director of nursing (IADON) and the administrator (ADMIN) confirmed that the assessments were performed by an LVN and acknowledged that this practice was not within the LVN's scope. The IADON confirmed that the SBAR Communication Form was the only assessment done before Resident 1 was sent to the hospital emergency department. The ADMIN acknowledged the need to review and change the facility's practice to ensure compliance with professional standards of practice.
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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 Santa Barbara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Park Healthcare Center | 0.2 mi | ★★★★★ | 0 | 0 |
| The Californian | 0.6 mi | ★★★★★ | 0 | 0 |
| Valle Verde Health Facility | 1.2 mi | ★★★★★ | 7 | 0 |
| Channel Islands Post Acute | 1.4 mi | ★★★★★ | 3 | 0 |
| Buena Vista Care Center | 4.6 mi | ★★★★★ | 15 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.