Average — CMS composite of the measures below.
The next survey window likely opens around February 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 San Joaquin Nursing Center And Rehabilitation Cent during CMS and state inspections, most recent first.
Unsanitary food storage, equipment cleaning, and food handling: A DD and CDM observed wet sheet pans and plastic bins stored upside down with residue, a dirty food cart stored in the walk-in refrigerator, bread labeled with the wrong use-by date, a floor mixer and can opener with buildup, a meal slip touching the gravy pan during tray line, and fruit salad left out for 37 minutes before being returned to refrigeration at 43 F. The DD stated several items were unclean or improperly handled, and the fruit salad was discarded.
RN staff failed to verify a resident’s identity before giving IV medication and did not label the IV medication or tubing, while the resident’s PICC dressing was overdue and catheter measurements were not documented. In separate events, an LPN signed a MAR for a Lacosamide dose that was not given, a resident received oxygen without a current MD order, oxygen tubing and humidifier were left unlabeled, and no RN assessment was documented for a resident with complex medical needs.
A CNA failed to perform hand hygiene and did not wear a gown while providing high-contact care to a resident on EBP, and also did not clean her hands before and after repositioning another resident. An LVN used ABHR instead of soap and water after caring for a resident with C. difficile, then reused an uncleaned medication tray in another resident’s room on EBP, creating cross-contamination concerns.
Failure to Notify Ombudsman of Hospital Transfer: A resident was transferred to the hospital for respiratory complications, but the record did not show that the Ombudsman was notified. SS stated she was responsible for notifying the Ombudsman of all resident transfers and discharges and that the notification should have been documented in the resident’s record. The facility later stated it had no record of notifying the Ombudsman of the transfer.
Failure to Care Plan for Anticoagulation Therapy: A resident admitted with cerebral infarction and prescribed Rivaroxaban for atrial fibrillation had no care plan addressing anticoagulation therapy. The DON confirmed the medication was a high-risk blood thinner with a black box warning, and the care plan did not include interventions to monitor or prevent bleeding or measurable objectives and timetables for this problem area.
A resident’s care plan still listed anticoagulant therapy with apixaban even though there was no current order and the resident was no longer taking the medication. The DSD and DON both stated the care plan should have been closed and updated so staff had a current plan of care, and the facility policy stated care plans are revised as resident conditions change.
Failure to Maintain Current Physician Order for Oxygen Therapy: A resident was observed receiving O2 via NC at 4 L/min, while the care plan listed continuous O2 at 3 L/min and staff found no current physician order for oxygen therapy. The resident had been on oxygen for shortness of breath, and both an LVN and the DON stated an order should have been in place to guide the safe O2 rate.
Incomplete Nursing Hour Posting: The facility failed to post the facility name and the correct number of staff and actual hours worked for RNs, LPNs/LVNs, and CNAs on the daily Census and Nursing Hour Posting. During review with the DSD, the posting was found to be missing the facility name and to have incorrect staffing numbers and hours for the AM, PM, and NOC shifts.
Two ointment medications in a treatment cart were found without pharmacy labels during observation with the TLN. The unlabeled items were collagenase ointment and silver sulfadiazine cream, while other medications in the drawer were in clear bags with resident labels. The TLN said the items were for residents but did not know whose they were, and the DON stated resident-specific medications should have a pharmacy label.
Inaccurate MAR Documentation for Lacosamide: A resident’s MAR showed both scheduled doses of Lacosamide were given, but staff stated the morning dose was not administered and had been signed in error. Review of the medication record and interview with an LPN confirmed only the evening dose was actually given, making the MAR inaccurate and not reflective of the care provided.
The facility failed to keep the smoking area free of accident hazards when a gap in the pavement repeatedly caught the wheels of residents’ wheelchairs. Multiple alert and oriented wheelchair users reported that their chairs became stuck on the gap, with one describing it as a speed bump and another calling it a fall hazard. During an on-site observation, the Director of Maintenance measured the gap at 0.75 inches wide, and the Activities Director, who is responsible for monitoring residents in the smoking area, acknowledged the need to ensure wheelchairs do not get caught. This condition conflicted with the facility’s written policy to keep the environment as free from accident hazards as possible.
A resident who was admitted after neck surgery did not have a required follow-up appointment with their surgeon scheduled, despite clear instructions in the medical record and care plan. Staff interviews and record reviews confirmed that social services did not coordinate or document the referral as required by facility policy, resulting in a delay in post-surgical care.
A resident with impaired cognition and a need for assistance with personal care was observed with long, dirty fingernails and multiple skin scratches. Staff confirmed that the resident's care plan required nails to be kept short and clean to prevent infection and injury, but this intervention was not followed, contrary to facility policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
A CNA and a housekeeping staff member did not wear required PPE when entering the room of a resident on contact precautions for ESBL and VRE, despite posted instructions. Additionally, an LVN failed to perform hand hygiene between glove changes during suprapubic catheter care for a resident, contrary to facility policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with moderately impaired cognition was found to have a low air loss mattress installed incorrectly, with air hose connectors at the head of the bed, resulting in the resident being struck in the head. The resident also used a facility-provided wheelchair with cracked and peeling arm rests, one of which was covered in duct tape, making proper sanitation impossible. Staff confirmed both the improper mattress setup and the unsanitary condition of the wheelchair.
Wound treatments were not completed as ordered for three residents, with multiple missed treatments and incomplete documentation on the TAR. Additionally, two residents did not receive required weekly wound assessments, with several assessments missing measurements or left incomplete. Staff interviews confirmed that treatments and assessments were not performed as required, and facility policies for wound care documentation and assessment were not followed.
A background check for an LVN was not completed prior to employment, as required by facility policy. The check was finalized more than a month after the hire date, and this was confirmed by the DSD during record review and interview.
The facility failed to follow CDC infection control practices, as a CNA entered a resident's room under Enhanced Barrier Precautions without PPE and did not perform hand hygiene. Additionally, two residents did not receive hand hygiene assistance before meals, contrary to facility policy.
The facility failed to follow physician orders for several residents, including not conducting necessary blood work for a resident with epilepsy, not providing compression stockings for a resident at risk of DVT, and administering IV medications at incorrect rates for multiple residents. These oversights could lead to significant health risks.
A registered nurse in a facility failed to maintain competency in calculating IV medication flow rates, leading to incorrect infusion rates for several residents. The nurse relied on the internet for calculations and had not received recent competency training. The Director of Nursing confirmed the lack of specific training for IV flow rate calculations, despite the facility's policy requiring accurate regulation of medication flow.
The facility failed to follow its medication handling and security procedures, as observed with LVNs discarding medications improperly and leaving a medication cart unlocked. Additionally, Controlled Drug Records lacked necessary nurse signatures, indicating a lapse in documentation and handling of controlled substances.
A resident was found to be self-administering eye drops without a physician's order or an IDT assessment to determine his capability to do so safely. The resident had been using the eye drops for five years post-surgery, with some nurses aware of this practice. However, there was no documentation in the medical records or care plan, and the facility's policy on self-medication administration was not followed.
The facility failed to ensure an advance directive was offered and completed for a resident. During a review, the MDS Coordinator could not find the resident's completed AD in the medical record, despite acknowledging it should be there. The facility's policy requires that residents are informed of their rights to make medical decisions, including formulating advance directives, and that care plans align with these preferences. The absence of the AD indicates non-compliance with this policy.
The facility failed to notify the ombudsman of hospital transfers for two residents, as required by their policy. The Social Services Director confirmed the lack of documentation for these notifications, which could result in the residents not having an advocate to inform them of their rights and options.
A facility failed to accurately assess and document urine output for a resident with a urostomy, resulting in the physician being unaware of accurate measurements. The resident self-catheterizes as needed, but documentation was inconsistent, with zero totals recorded for urine output over several days. The facility lacked a policy for urine intake and output, leading to inadequate documentation procedures.
The facility failed to complete discharge summaries accurately for two residents, potentially impacting their follow-up care and safety. One resident, with multiple diagnoses including Parkinsonism and COPD, lacked essential information in their discharge summary, such as physician and pharmacy contact details, and an assessment of their ability to perform care at home. Another resident, admitted with a femur fracture and other conditions, also had an incomplete discharge summary missing similar critical information and was not signed by the resident.
A resident did not receive appropriate foot care, as their thick and yellowish toenails were not referred to podiatry despite observations by staff. The facility's policies required such referrals, but there was no documentation of a referral or physician notification, leading to a deficiency.
The facility did not complete required Performance Evaluations for two CNAs, as per their policy. CNA 1 and CNA 5, hired in early 2023, lacked evaluations in their files, contrary to the policy requiring annual reviews. This oversight could leave staff unaware of necessary improvements in patient care.
The facility failed to maintain a medication error rate below 5%, with errors involving incorrect IV antibiotic flow rates for several residents. The flow rates were set higher than prescribed, leading to faster infusion rates. RN 1 and the DON acknowledged the discrepancies, and the facility's policies emphasize adherence to prescriber orders, which was not followed.
A resident expressed discontent after receiving peanut butter and jelly sandwiches for every meal over seven days due to the facility's failure to evaluate and accommodate his food preferences. Despite the resident's requests for alternatives, no changes were made, and the Certified Dietary Assistant had not assessed the resident's preferences. The Registered Dietitian updated the preferences, but the facility did not provide an updated meal ticket, violating the policy on menu alternatives.
A facility failed to document a resident's edema in their medical records, as observed during a survey. The resident's swollen legs and feet were not recorded in the Weekly Nursing Summary over several weeks, and the Minimum Data Set Coordinator confirmed the absence of documentation. Staff interviews indicated that changes in condition should be included in the summary, but this was not done. The facility's policy requires complete and accurate documentation, which was not adhered to in this case.
The facility failed to document verbal acknowledgment of the Binding Arbitration Agreement (BAA) from family representatives of two residents, as required by its policy. Interviews confirmed that while the representatives claimed to understand the BAA, the facility did not document this verbal acknowledgment in the medical records, contrary to policy requirements.
The facility failed to maintain an effective QAPI Program, with staff unaware of the plan and process improvement projects. The Administrator and DON could not provide evidence of data-driven interventions for rehospitalization, and the facility lacked documentation and specific quality indicators.
A resident was readmitted with a pressure injury (PI) on the right buttock, but the facility failed to develop a care plan for this condition. Despite having a physician's order for daily application of Medihoney wound gel, there was no documented care plan. Interviews with the DON and TN confirmed the oversight, which was against the facility's policy requiring a baseline care plan upon admission.
A resident admitted with pain due to an orthopedic prosthetic device and osteoarthritis did not receive appropriate pain management. The resident's Lidocaine patch was not administered as it was unavailable, and although Acetaminophen was given, the pain level increased. The LVN did not contact the physician for additional pain management, contrary to the facility's policy, which requires immediate communication if pain is not controlled.
The facility did not complete baseline care plans within 48 hours for three residents. The Social Services and Rehabilitative Services sections were delayed, with one resident's Activities section completed 21 days post-admission. The DON confirmed the requirement for completion within 48 hours, as per facility policy.
A resident in the facility exhibited behaviors such as refusal of care, yelling, and grabbing, but did not receive necessary behavioral health services. The Social Services Director was unaware of these behaviors, and there was no documentation of services provided. The facility's policy requires behavioral health services based on a comprehensive assessment, but this was not followed.
A resident's right to receive a phone call was violated when a facility receptionist refused to transfer a call due to lack of caller information, citing HIPAA. The resident, needing assistance and using a wheelchair, had no phone in her room. The facility lacked a protocol for handling such calls, despite policies ensuring phone access and privacy.
A facility failed to ensure a resident received necessary services for pressure injuries due to non-compliance with turning and repositioning. Despite the resident's understanding of the risks and benefits, the treatment nurse documented the non-compliance but did not ensure it was included in the active care plans. The Director of Nursing confirmed the absence of a non-compliance care plan, contrary to the facility's policy on comprehensive care plans.
A resident frequently pulled out his G-Tube, requiring multiple emergency room visits for re-insertion. Despite the resident's diagnosis of Gastrostomy Status, the facility did not develop an individualized care plan or hold an interdisciplinary team meeting to address the issue, contrary to their policy requiring a comprehensive care plan within seven days of the MDS assessment.
A resident, who was cognitively intact, reported neglect due to delayed medication administration and called the police. Despite the serious allegation, the facility did not investigate or report the incident to the CDPH, contrary to their policy. The DON stated no investigation was needed as the police found nothing.
A resident accused the facility of neglect, claiming she was not cared for or given medication. The Social Services Designee failed to follow up or provide psychosocial monitoring after the incident, as required by the facility's job description, potentially causing distress to the resident.
A resident was not informed of a room change during a hospital transfer, despite having a paid bed hold agreement. The facility converted the resident's room into a female room and moved his belongings without prior notice. Upon return, the resident was unaware of the change and expressed dissatisfaction. The facility's policy requires advance notice for room changes unless medically necessary, which was not followed in this case.
A resident with moderate cognitive impairment was not allowed to return to his previous room after a hospital stay, despite having signed a Bed-Hold and Return Agreement. The resident's belongings were packed, and he was moved to a different room without his consent, leading to feelings of distress and disrespect.
The facility failed to provide oxygen as ordered for a resident and did not provide humidified oxygen for two residents on continuous oxygen. One resident was observed with an incorrect oxygen setting, and both residents lacked humidifiers, contrary to the facility's policy.
Unsanitary food storage, equipment cleaning, and food handling
Penalty
Summary
Food was not stored, prepared, and distributed in a sanitary manner in the kitchen and walk-in refrigerator. During observation with the Dietary Director (DD), 14 sheet pans were stacked upside down while wet, with water stains and food debris or sticky residue on five of them. Plastic storage bins were also stored upside down with residual moisture inside, and two bins had black speckles and sticky residue. The DD stated the pans and bins needed to be rewashed and fully air dried before storage because moisture could foster bacterial growth. In the walk-in refrigerator, a food cart was observed sticky and covered with dust and food particles, and the DD confirmed it was not clean before being stored there. Also in the refrigerator, a plastic bin containing sliced bread was labeled with an incorrect use-by date. The CDM stated bread could be stored refrigerated for up to three months, and the incorrect date could result in the bread being used past expiration. In the kitchen, a floor mixer had thick black residue at the attachment hub under the splash guard and light brown residue in the mixing bowl, and a commercial can opener had thick black buildup on the cutting blade. The DD stated the mixer had not been thoroughly cleaned and the can opener was unclean. During tray line, a meal slip fell and its corner touched the edge of the gravy pan while hot foods were being plated. The DC continued plating the gravy after briefly removing the slip, and the DD stated the gravy should have been discarded because the contact was unsanitary. In another event, fruit salad was removed from refrigeration, plated into eight bowls, left on the preparation table while the wrong scoop size was identified, and then returned to the original container after sitting out for 37 minutes. The fruit salad temperature was 43 F when checked, and the DD stated it had sat out too long, came up to temperature, and should not have been refrigerated again; the fruit salad was discarded for resident safety.
Medication, IV, oxygen, and assessment documentation failures
Penalty
Summary
RN 1 administered IV medication to Resident 121 without first verifying the resident’s identity and without labeling the IV medication or IV tubing. During the observation, RN 1 was seen cleaning the resident’s PICC line, connecting the IV tubing, and hanging the IV medication, and the medication and tubing had no label. RN 1 later stated she did not identify the right patient or the right medication, that she administered the IV medication without the resident’s label, and that she did not label the IV tubing. The DON stated the facility expected IV medications to be verified by checking resident photographs in the electronic medical record and that all IV medications and tubing were to be labeled. Resident 121 also had a PICC line dressing that had not been changed for nine days. The dressing was dated 2/23/26 and changed 3/1/26 when observed on 3/10/26. RN 1 stated it must have been overlooked and acknowledged that the dressing should be changed every 7 days and as needed. The DON stated PICC line dressings were expected to be changed every 7 days or as needed, and the facility policy stated transparent semi-permeable membrane dressings were to be changed at least every 5 to 7 days and as needed. Resident 121’s record also showed that PICC line measurements were not documented when the dressing was changed on 3/10/26. RN 1 stated she changed the dressing but forgot to document the catheter’s measurements, and she stated it was important to document the measurements to ensure the PICC line was working properly and the resident was tolerating IV medications. The order summary required catheter length to be measured with each dressing change. In addition, Resident 70’s MAR was signed for a 9 a.m. dose of Lacosamide that was not given, and LVN 5 stated the dose was not administered even though she signed the MAR. Resident 106 was observed receiving oxygen by nasal cannula, but the record review and interviews showed there was no physician’s order for oxygen therapy. Resident 118’s oxygen tubing and humidifier were observed without a date and time label, and the MDSC and DON stated the tubing and humidifier should have been labeled and changed weekly. Resident 1’s record showed no RN assessment during the stay, and the DON stated there was no indication an RN evaluated the care provided to Resident 1 despite the resident’s complex condition.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to follow infection control practices for two residents during observed care. For a resident on Enhanced Barrier Precautions with a diagnosis of metabolic encephalopathy, a CNA entered the room without performing hand hygiene, wore gloves but no gown, and changed the resident’s brief and bed sheets. The CNA’s clothing touched the bed sheets, and after placing the soiled linens in a dirty linen container outside the room, the CNA removed the gloves and did not perform hand hygiene. The CNA later stated she did not wear a gown and believed gloves were enough, while the Infection Preventionist stated gown and gloves were required for changing briefs and bed sheets for residents on EBP and that hand hygiene was imperative before, after, and between resident care. The facility also observed the same CNA repositioning another resident’s legs without performing hand hygiene before or after the care. The CNA acknowledged she was not doing hand hygiene before and after the resident’s care. The resident’s record showed a diagnosis of muscle wasting. The Infection Preventionist stated hand hygiene before, after, and in between caring for any resident was imperative and was the most important thing to prevent transmittal of disease. A LVN failed to follow hand hygiene and contamination control practices during care for residents on precautions for C. difficile and EBP. After providing care to a resident on transmission-based precautions for C. difficile, the LVN used alcohol-based hand rub instead of washing with soap and water, and later acknowledged she should have washed her hands with soap and water immediately after exiting the room. The LVN also carried a medication tray from the C. difficile room without disinfecting it, reused the tray in another resident’s room on EBP, and placed it on the bedside table. The DON and Infection Preventionist stated the tray could have cross-contaminated multiple surfaces and placed the second resident at risk for C. difficile infection.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of a resident’s transfer to the hospital. During a concurrent interview and record review, the MDS Coordinator reviewed the medical record for Resident 1 and stated the resident was transferred to the hospital due to respiratory complications. The record did not indicate that the Ombudsman was notified of the transfer. During interviews, Social Services stated she was responsible for notifying the Ombudsman of resident transfers and discharges and that her process was to notify the Ombudsman of all facility transfers and discharges on a monthly basis. She stated the notification of Resident 1’s hospital transfer should have been recorded in the resident’s medical record, and later stated the facility did not have a record of notifying the Ombudsman of the transfer in October 2025. The facility policy titled Transfer or Discharge Notice stated that a copy of the transfer notice is sent to the Office of the State Long-Term Care Ombudsman at the same time as the notice of transfer.
Failure to Care Plan for Anticoagulation Therapy
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident 123 that included anticoagulation therapy. Resident 123 was admitted with a primary diagnosis of cerebral infarction, and the Order Summary Report dated 3/6/26 showed an order for Rivaroxaban 20 mg by mouth once daily for atrial fibrillation, with a black box warning. During a concurrent interview and record review on 3/12/26 at 12:03 p.m., the DON reviewed the resident’s medication orders and care plan and confirmed that the black box warning symbol indicated Rivaroxaban was a high-risk medication that could cause bleeding. The DON stated Resident 123’s care plan did not address the resident’s use of the high-risk medication or anticoagulation therapy. The DON stated it should have been care planned to help establish interventions to monitor and prevent bleeding with the goal of safe anticoagulation therapy for Resident 123. The facility policy titled Care Plans, Comprehensive Person-Centered, dated 3/2022, stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and reflects recognized standards of practice for problem areas and conditions.
Unupdated Anticoagulant Care Plan
Penalty
Summary
The facility failed to ensure Resident 3’s anticoagulant care plan was reviewed and updated after the resident was no longer receiving apixaban. During a concurrent interview and record review, the DSD reviewed Resident 3’s physician orders and care plan and found that the care plan still indicated the resident was on anticoagulant therapy with apixaban, even though there was no current order for the medication and the resident did not take it anymore. The DSD stated the care plan should have been resolved once the resident was no longer on the medication. The DON also stated the apixaban care plan should have been closed because the resident was not taking it anymore, and that the care plan should have been current so staff could provide appropriate care. The facility policy stated resident assessments are ongoing and care plans are revised as resident information and conditions change.
Failure to Maintain Current Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident 106 received respiratory care with a current physician's order. During observation, Resident 106 was found in bed with the head elevated and wearing a nasal cannula connected to an oxygen concentrator delivering oxygen at 4 L/min. The resident stated she had been on oxygen therapy due to shortness of breath, and an RNA later confirmed the concentrator was set at 4 L/min and said the resident had been on oxygen for some time. Record review showed the resident's MDS dated 12/23/2025 indicated oxygen therapy while a resident, and the care plan dated 12/23/2025 identified the resident as at risk for changes in respiratory status and listed O2 at 3 L/min via nasal cannula continuously, initiated 08/20/2023. During review of the physician's orders, staff found there was no order for oxygen therapy. An LVN stated there should have been an order because the resident had been on oxygen for a long time and that the order was needed to show how much oxygen was safe to give. The DON also stated there should have been an order for oxygen therapy so staff could give the O2 rate as prescribed by the doctor.
Incomplete Nursing Hour Posting
Penalty
Summary
The facility failed to document on the daily Census and Nursing Hour Posting the facility name and the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift, including RNs, LPNs/LVNs, and CNAs. During a concurrent observation, interview, and record review on 3/11/2026 at 2:20 p.m. with the DSD, the Census and Nursing Hour Posting dated Wednesday, March 11, 2026 was reviewed and found to not include the facility name or the correct number of staff and staffing hours for the AM, PM, and NOC shifts. The DSD stated that the facility name was not on the posting and that the correct number of staff and hours for each shift were not correct.
Unlabeled Ointment Medications in Treatment Cart
Penalty
Summary
Two of 12 ointment medications in the treatment cart were found without pharmacy labels during a concurrent observation and interview with the TLN at the nurses' station hallway. The unlabeled medications were a collagenase ointment 250 u/gm and a silver sulfadiazine cream USP 1% 50 gm, both stored in the second drawer of the treatment cart in clear bags with resident labels on other medications nearby. The TLN stated the unlabeled medications were for residents, did not know whose they were, and stated resident ointments should have been labeled with a resident label. During an interview the next day, the DON stated that if the medication was resident specific it should have a pharmacy label and that an ointment medication without a resident label could be used on a different resident. The facility policy titled Medication Labeling and Storage, dated 2/2023, stated that labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and accepted pharmaceutical practices, and that the medication label includes the medication name and resident's name.
Inaccurate MAR Documentation for Lacosamide
Penalty
Summary
The facility failed to ensure that Resident 70’s MAR for Lacosamide was accurate. During observation and record review, a bubble pack of Lacosamide was found with nine tablets removed, and the pharmacy label indicated the medication was to be taken one tablet twice daily at 9 a.m. and 9 p.m. Review of the medication record showed nine signatures from 3/6/2026 at 9 p.m. through 3/11/2026 at 9 p.m., but LVN 4 stated that only one dose had been given on 3/8/2026 at 9 p.m., and the 9 a.m. dose was not administered. Resident 70’s MAR documented that both the 9 a.m. and 9 p.m. doses of Lacosamide were given on 3/8/2026, and the 9 a.m. dose was signed by LVN 5. During interview, LVN 5 stated the 9 a.m. dose was not given and acknowledged that the MAR was not accurate because only the evening dose was administered. LVN 5 stated the record should have accurately reflected what was given so the medication’s effectiveness could be monitored. The DON stated the MAR should not have been signed if the medication was not given and should accurately reflect whether the resident received or refused the medication for clinical record accuracy and resident safety.
Pavement Gap in Smoking Area Creates Wheelchair Hazard
Penalty
Summary
The deficiency involves the facility’s failure to maintain the designated smoking area free of accident hazards, specifically a gap in the pavement that interfered with wheelchair movement. During an observation and interview, two alert and oriented residents who used wheelchairs reported that their wheelchairs were caught by the pavement gap, with one resident describing it as a “speed bump” that could cause residents to fall from their wheelchairs. A third alert and oriented resident using a wheelchair also reported that his wheelchair had gotten stuck in the same pavement gap and described it as a fall hazard for wheelchair users. During a concurrent observation and interview in the smoking area, the Director of Maintenance measured the pavement gap and stated it was 0.75 inches wide. The Activities Director, who stated she was responsible for monitoring residents in the smoking area, acknowledged the need to ensure that residents using wheelchairs were not caught in the pavement gap. Review of the facility’s policy titled “Safety and Supervision of Residents,” dated July 2017, indicated that the facility strives to make the environment as free from accident hazards as possible, which was not achieved in this instance due to the unresolved pavement gap in the smoking area.
Failure to Schedule Post-Surgical Follow-Up Appointment
Penalty
Summary
The facility failed to follow its policy and procedure regarding social services referrals by not scheduling a follow-up appointment with a surgeon for a resident who had recently undergone neck surgery for a C5-6 fracture and vertebral artery stenosis. Upon admission, the resident's history and physical report clearly indicated the need for a follow-up with the surgeon within two weeks. However, review of the clinical records and interviews with staff, including the LVN, DON, and Social Services Director, revealed that no such appointment was scheduled or documented. The information necessary to arrange the appointment, including the surgeon's name and hospital, was present in the resident's medical record, but was overlooked during the admission and subsequent reviews by social services. The resident reported having inquired about the follow-up appointment with social services but confirmed that no appointment had been made since admission. The care plan also included an intervention to follow up with the surgeon as indicated, but this was not carried out. The facility's policy required social services to coordinate medical referrals and document them in the resident's record, but this process was not followed, resulting in a delay in arranging necessary post-surgical care for the resident.
Failure to Maintain Resident Nail Hygiene as Required by Care Plan
Penalty
Summary
The facility failed to ensure that a resident's fingernails were kept clean and trimmed, as required by the resident's care plan and facility policy. The resident, who had a diagnosis indicating a need for assistance with personal care and demonstrated moderately impaired cognition, required substantial to maximal assistance with personal hygiene. Observations revealed that the resident's fingernails were long and had dark debris underneath, and the resident had multiple scratches and open skin areas on both arms and abdomen. The resident reported frequent itching and a desire to have his fingernails trimmed. Staff interviews confirmed that the resident's fingernails were supposed to be kept short and clean to prevent infection and injury, especially given the resident's history of picking and scratching at his skin. The care plan specifically included interventions to keep the resident's nails short to reduce the risk of skin injury and infection. However, the care plan was not followed, as acknowledged by the Infection Control Preventionist, and the facility's policy on nail care, which requires daily cleaning and regular trimming, was not implemented for this resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Follow Contact Precautions and Hand Hygiene Protocols
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to wear the required personal protective equipment (PPE) when entering the room of a resident who was on contact precautions due to diagnoses of Extended Spectrum Beta Lactamase (ESBL) resistance and Vancomycin-Resistant Enterococci (VRE) in the urine. The resident's room had a clearly posted Contact Precautions sign instructing staff to wear a gown and gloves upon entry. During observation, the CNA was seen transferring the resident from bed to wheelchair without wearing a gown and stated she was unaware of the resident's contact precautions status. Additionally, a housekeeping staff member was observed cleaning the same resident's bed without wearing a gown, contrary to facility policy and procedure for contact isolation. In a separate incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after removing used gloves during suprapubic catheter care for another resident. The LVN cleaned the catheter insertion site, removed gloves, and donned new gloves without washing hands in between, despite facility policy requiring hand hygiene after glove removal. The LVN acknowledged the lapse during interview, and the Infection Control Preventionist confirmed that the facility's policy was not followed.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Improper Installation of Medical Equipment and Unsanitary Wheelchair
Penalty
Summary
A deficiency occurred when a low air loss mattress, intended to prevent and treat pressure injuries, was improperly installed for a resident with moderately impaired cognition. The air hose connectors were positioned at the head of the bed and left on the floor, contrary to manufacturer instructions that specify placement at the foot of the bed. The resident reported being struck in the head by the machine multiple times over a two-week period and stated that a CNA was informed but did not correct the setup. Observations by the Maintenance Director and a Licensed Vocational Nurse confirmed the improper installation and location of the air hose connectors. Additionally, the same resident was provided with a wheelchair that had a cracked and peeling right arm rest and a left arm rest covered in duct tape. The resident stated the wheelchair was received in this condition. The Maintenance Director confirmed the damage and was unable to verify if the arm rests could be sanitized. A Licensed Vocational Nurse stated that cracked and peeling arm rests should be replaced, as they cannot be properly sanitized. The facility's infection prevention and control policy requires maintaining a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases.
Failure to Complete Wound Treatments and Weekly Assessments
Penalty
Summary
The facility failed to ensure that wound treatments were completed as ordered by the physician for three residents. For one resident, wound treatments to the right upper arm, forearm, and hand were not performed on two specific dates, as indicated by blank entries on the Treatment Administration Record (TAR). For another resident, wound treatments for pressure injuries on the left iliac crest, right gluteus, and right iliac crest were not completed on five separate dates, with the TAR left blank for all wounds on those days. A third resident did not receive wound treatments for multiple wounds, including the left lateral heel, left ischium, and right medial thigh, on several dates, as evidenced by missing documentation on the TAR. Staff interviews confirmed that if the TAR was not signed, the treatment was not performed, and when the wound nurse was not present, floor nurses were responsible for completing treatments, which did not occur as required. Additionally, the facility did not complete weekly wound assessments for two residents. For one resident, several Skin & Wound Evaluations (SWE) were missing wound measurements or were left incomplete for multiple wounds, including the left iliac crest and right gluteus. Another resident's admission assessment and subsequent weekly assessments were missing wound measurements and other required documentation for multiple wounds, such as venous stasis ulcers and pressure injuries. Staff interviews confirmed that these assessments were incomplete or missing, and that weekly wound assessments should have been performed but were not. A review of the facility's policies and procedures indicated that documentation of wound care should include the date and time care was given, the name and title of the person performing the care, and all assessment data such as wound bed color, size, and drainage. The policy also required weekly risk assessments and wound assessments for residents. The observed deficiencies were due to the failure to follow these documentation and assessment protocols, as evidenced by incomplete or missing records and staff confirmations during interviews.
Failure to Complete Timely Background Check Prior to Employment
Penalty
Summary
The facility failed to follow its own policy and procedure regarding background screening investigations for new hires. Specifically, the employee file for one Licensed Vocational Nurse (LVN) showed that the background check was completed more than a month after the hire date, rather than prior to employment as required by the facility's policy. The policy states that background and criminal checks must be initiated within two days of an offer of employment and completed before the employee starts work. During an interview, the Director of Staff Development confirmed that the background check was not completed before the LVN began employment.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control practices as outlined by the CDC, specifically in the use of Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident with an infected wound on the right big toe, who was under EBP, without wearing the required personal protective equipment (PPE) such as gloves and a gown. The CNA assisted the resident in transferring from a wheelchair to a bed, making direct contact with the resident's right foot and leg. Afterward, the CNA handled another resident's food item without performing hand hygiene, despite the CDC guidelines posted outside the room that mandated cleaning hands before entering and upon leaving the room, and wearing gloves and a gown during high-contact activities like transferring and wound care. Additionally, the facility did not ensure hand hygiene was performed for two residents before their meals were served. In separate observations, two different CNAs delivered lunch trays to residents without assisting them with hand hygiene, despite the facility's policy requiring staff to provide hand wipes, sanitizer, or assist with handwashing for residents unable to do so themselves. Both CNAs acknowledged the oversight when questioned, and one resident confirmed that hand hygiene was not typically performed before meals.
Failure to Follow Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to adhere to physician orders for several residents, leading to potential health risks. Resident 10, diagnosed with epilepsy, did not have their blood work drawn monthly as ordered, which could have left the physician unaware of medication levels, increasing the risk of seizures. The nursing consultant confirmed that the necessary labs were not conducted from September 2024 to January 2025, highlighting a significant oversight in monitoring the resident's condition. Resident 26, with medical diagnoses including muscle wasting and reduced mobility, was not provided with compression stockings as ordered for DVT prophylaxis. Observations revealed that the resident was not wearing the stockings, and staff members were unaware of the requirement. The medication administration record inaccurately indicated that the stockings had been applied, suggesting a documentation error and a lack of awareness among staff about the resident's needs. For residents on IV medications, the facility failed to administer the medications at the prescribed rates. Residents 352, 351, 96, and 2 were all receiving IV antibiotics at incorrect flow rates, which could potentially affect the efficacy of the treatment and the residents' health. The facility's policy on medication administration was not followed, as the flow rates were set incorrectly, and staff were not regulating the flow as prescribed. This oversight in medication administration could lead to adverse effects on the residents' health, as noted by the RN during observations.
Failure to Maintain RN Competency in IV Flow Rate Calculation
Penalty
Summary
The facility failed to maintain competency for a registered nurse (RN 1) in calculating intravenous (IV) medication flow rates, which had the potential to result in incorrect medication dosages for residents. During observations and interviews, it was found that RN 1 was administering IV antibiotics to several residents using a flow rate controller set to open or incorrect settings, leading to faster-than-prescribed infusion rates. RN 1 admitted to using the internet to calculate flow rates and stated that she had not received any competency training on this task since nursing school two years ago. The Director of Nursing (DON) confirmed that competency training was provided for PICC line and central line procedures but not specifically for IV flow rate calculations. The facility's job description for registered nurses required mathematical skills to apply concepts such as fractions and ratios, but RN 1's competency skills checklist did not document current competency for IV medication administration. The facility's policy on infusion therapy medication administration emphasized the need for safe and accurate regulation of medication flow, which was not adhered to in this case.
Medication Handling and Security Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure for discarding and destroying medications, as observed in several instances involving Licensed Vocational Nurses (LVNs). LVN 5 was observed discarding a white pill found on the floor in a resident's room into a trash can instead of the designated pharmacy discard bin. Additionally, LVN 5 was seen tossing a blue pill into an open container on top of a medication cart, stating she would dispose of it later. Similarly, LVN 1 was observed discarding a Vitamin C tablet into a trash can instead of the pharmacy receptacle. These actions were contrary to the facility's policy, which requires medications to be destroyed in a specific manner to prevent potential drug diversion. The facility also failed to maintain proper security and documentation for controlled drugs. An unattended medication cart was found unlocked in a resident's doorway, and LVN 5 admitted to leaving it unsecured while attending to a resident. Furthermore, the Controlled Drug Records (CDR) lacked signatures from two nurses for several medications, including dronabinol and hydrocodone/acetaminophen, indicating a failure to follow the required procedure for documenting and handling controlled substances. The Director of Nursing (DON) acknowledged that the CDRs were not reviewed, and the necessary signatures were missing, which could lead to medications being unaccounted for.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 96, was clinically assessed and determined capable of self-administering medication. Resident 96 had been using eye drops, specifically an ophthalmic solution, at his bedside without a physician's order or an interdisciplinary team (IDT) assessment to confirm his ability to self-administer the medication safely. The resident reported using the eye drops for five years following eye surgery, and some nurses were aware of this practice. However, there was no documentation in the medical records or care plan to support that the resident had been evaluated for self-medication administration. The facility's policy on self-medication administration requires an IDT assessment to determine if a resident can safely self-administer medication, with documentation in the medical record and care plan if deemed appropriate. In this case, there was no IDT documentation or nursing progress notes regarding the resident's capacity to self-administer medication. Additionally, the eye drops were not stored securely, as required by the facility's policy, which mandates that self-administered medications be kept in a safe and secure place inaccessible to other residents.
Failure to Ensure Completion of Advance Directive
Penalty
Summary
The facility failed to ensure that an advance directive (AD) was offered and completed for one of the sampled residents, identified as Resident 16. During an interview and record review, the Minimum Data Set Coordinator (MDSC) was unable to locate Resident 16's completed AD in the medical record. The MDSC acknowledged that the AD should have been present in the medical record. The facility's policy and procedure on advance directives, dated 2013, requires that prior to or upon admission, residents are provided with written information about their rights to make medical care decisions, including the formulation of advance directives. Additionally, the policy states that each resident's plan of care should align with their documented treatment preferences and/or advance directive. The absence of Resident 16's AD in the medical record indicates a failure to adhere to this policy, potentially impacting the resident's healthcare wishes.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of transfers or discharges, specifically in notifying the ombudsman. This deficiency was identified during interviews and record reviews involving two residents. Resident 16 was transferred to the hospital on two occasions, and Resident 38 was transferred once. In both cases, the Social Services Director (SSD) could not find documentation that the ombudsman had been notified of these transfers, as required by the facility's policy. The facility's policy, titled 'Transfer or Discharge, Facility-Initiated,' mandates that notice of transfer should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, the SSD confirmed that there was no documentation of ombudsman notification for the transfers of Resident 16 and Resident 38. This oversight could potentially result in the residents not having an advocate to inform them of their rights and options regarding admission, transfer, and discharge.
Failure to Accurately Document Urine Output for Resident with Urostomy
Penalty
Summary
The facility failed to accurately assess and document urine output for a resident with a urostomy, leading to the physician being unaware of the resident's accurate urine output measurements. During an observation and interview, it was noted that the resident self-catheterizes as needed, but there was no bag attached to the urostomy. The resident's care plan indicated that licensed nurses should monitor urine output every shift, and the order summary report required daily total output documentation for intermittent straight catheterization. However, the medication administration record showed inconsistent documentation of the number of self-catheterizations and milliliters of urine output. Further review of the resident's voiding diary for February 2025 revealed zero totals for urine output each day from February 1st through February 12th. The facility's policy on documentation accuracy emphasized the importance of accurate clinical records for continuity of care and coordination of services. Despite this, the facility did not provide a policy for urine intake and output, indicating a lack of proper documentation procedures. This deficiency highlights the facility's failure to ensure accurate and consistent documentation of the resident's urine output, which is crucial for meeting the resident's individualized needs.
Incomplete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure the discharge summaries for two residents were completed accurately, which could potentially impact their follow-up care and safety. Resident 60, who was admitted with multiple diagnoses including Parkinsonism, muscle wasting, COPD, hepatic encephalopathy, and liver cirrhosis, requested to be discharged home to continue therapy services. However, the discharge summary for Resident 60 lacked essential information such as the contact details for the primary care physician and pharmacy, a recapitulation of the resident's stay, the discharge status, and an assessment of the resident's ability to perform required care at home. Similarly, Resident 84, admitted with a fracture of the left femur, muscle wasting, foot drop, and abnormal gait, also had an incomplete discharge summary. The summary did not include the physician's contact information, pharmacy details, a recapitulation of the resident's stay, discharge status, an assessment of the resident's ability to perform required care at home, and was not signed by the resident. These omissions were identified during interviews and record reviews with the facility's Nursing Consultant and Social Services Director, highlighting a failure to adhere to the facility's discharge summary policy.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident not being referred to podiatry for treatment of foot and toenail disorders. During an observation, the resident's toenails were found to be thick, long, and yellowish, with small scabs and redness on some toes. The resident confirmed not having seen a podiatrist. A registered nurse also observed the condition and acknowledged the need for a podiatry referral, but there was no documentation of this observation or referral in the resident's records. Further review revealed that the facility's policies required residents with foot disorders to be referred to qualified professionals, but there was no documentation of the physician being notified or a podiatry referral being made. The facility's social services policy also indicated that social services staff are responsible for making referrals and obtaining needed services, which was not done in this case. This lack of action and documentation led to the deficiency in providing necessary foot care for the resident.
Failure to Complete Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PE) for two Certified Nursing Assistants (CNAs), specifically CNA 1 and CNA 5, as required by their policy. During an interview and record review with Human Resources (HR), it was revealed that CNA 1, hired on February 6, 2023, did not have a PE completed for the last two years. Similarly, CNA 5, hired on March 15, 2023, also lacked a completed PE. The facility's policy, dated February 2023, mandates that each employee's job performance be reviewed and evaluated at least annually, with the completed evaluation sent to HR to be placed in the employee's personnel record. The absence of these evaluations indicates a failure to adhere to the facility's policy, potentially leaving staff unaware of areas needing improvement in patient care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass observation, resulting in a medication error rate of 9.26%. This was due to five medication errors observed in a sample size of 54 opportunities for error. The errors involved incorrect flow rates for intravenous (IV) antibiotic medications being administered to residents. Specifically, the flow rates for antibiotics such as Piperacillin-Tazobactam and Ceftriaxone were set higher than prescribed, leading to faster infusion rates than intended. For instance, Resident 352's IV antibiotic was set to an unmetered flow, while the label indicated it should be infused over one hour at a specific rate. Similarly, Resident 351's and Resident 96's antibiotics were also infused at rates higher than prescribed. During interviews, RN 1 acknowledged the discrepancies in the flow rates, stating that the current rates were higher than the prescribed 25 drops per minute. The Director of Nursing (DON) also confirmed that an intravenous flow rate of 40 drops per minute is too fast for residents. The facility's policy and procedure documents, dated 2019, emphasize the importance of administering medications in accordance with prescriber orders and regulating the flow of medication infusion as prescribed. However, these guidelines were not adhered to, resulting in the observed medication errors.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to evaluate and accommodate the food preferences of a resident, identified as Resident 90, which led to the resident receiving peanut butter and jelly sandwiches for every meal over a period of seven days. This situation resulted in the resident expressing discontent and anger due to the lack of variety and the quality of the meals, which were described as bland and cold. Despite the resident's requests for alternatives, no changes were made to the meal offerings, and the resident did not recall any communication with kitchen staff regarding his preferences. Interviews and record reviews revealed that the Certified Dietary Assistant, who was covering for the dietary manager, had not assessed the resident's food preferences. Although the Registered Dietitian met with the resident and updated his food preferences, the facility failed to provide an updated meal ticket reflecting these preferences. The facility's policy on menu alternatives, which requires providing equivalent nutritional substitutions for disliked foods, was not followed, as evidenced by the lack of alternative meal options for the resident.
Failure to Document Resident's Edema in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of edema in the resident's lower extremities. During an observation, the resident was noted to have swollen legs and feet, but this condition was not documented in the Weekly Nursing Summary (WNS) for several weeks. The Minimum Data Set Coordinator (MDSC) confirmed the absence of documentation regarding the edema in the WNS and stated that there was no indication that the condition was brought to anyone's attention. Interviews with staff revealed that the weekly nursing summary is supposed to include changes in the resident's condition, such as edema, in a narrative section. However, this was not done for the resident in question. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, and the Registered Nurse Job Description emphasizes the need for informative and descriptive nursing notes. The lack of documentation could potentially lead to the resident's physician being unaware of the condition and not ordering appropriate tests or medication.
Failure to Document Verbal Acknowledgment of Binding Arbitration Agreement
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the Binding Arbitration Agreement (BAA) for two residents. Specifically, the Admission staff did not document a verbal acknowledgment of the BAA from the family representatives of two residents. This oversight was identified during interviews and record reviews, where it was noted that the facility's policy required a verbal acknowledgment of understanding from the resident or their representative, which was not documented in the medical records. Interviews with the family representatives of the two residents revealed that they had signed the BAA and claimed to understand the agreement without any questions or concerns. However, the Marketing Director/Admissions confirmed that the facility did not document whether the residents or their representatives verbally acknowledged or understood the BAA. The facility's policy explicitly stated that a signature alone was insufficient and required a verbal acknowledgment to be documented, which was not done in these cases.
Ineffective QAPI Program and Lack of Staff Awareness
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program for all 96 residents. During interviews, Licensed Vocational Nurses (LVNs) 3 and 4 were unaware of the QAPI plan and the facility's process improvement projects. The Administrator stated that the QAPI Committee meets monthly or quarterly, focusing on falls, rehospitalization, call lights, surveyor visits, and complaints. However, the Administrator could not identify other process improvement projects using clinical indicators apart from the CMS-required quality measures. The Director of Nursing (DON) presented the rehospitalization process improvement project, citing disease processes like diabetes, hypertension, and heart disease. However, the DON could not provide evidence of aggregate data on the number of residents monitored for these diseases, the signs and symptoms triggering the project, or other clinical indicators to monitor and determine interventions to decrease rehospitalization. The facility's policy and procedure on QAPI indicated the need for a comprehensive plan to monitor and evaluate resident care quality, but the facility lacked documentation and specific quality indicators for individual departments.
Failure to Develop Care Plan for Pressure Injury
Penalty
Summary
The facility failed to develop a care plan for a resident's pressure injury (PI) upon their readmission. The resident was readmitted with a PI on the right buttock, as noted in the Readmission Skin Assessment. Despite the presence of a physician's order for Medihoney wound gel to be applied daily for 21 days, there was no documented evidence of a care plan addressing the PI. Interviews with the Director of Nurses (DON) and the Treatment Nurse (TN) confirmed the absence of a care plan for the resident's PI. The facility's policy requires the development of a baseline care plan upon admission, which includes initial goals and physician orders. However, this was not adhered to, as the care plan was neither updated nor developed for the resident's wound, contrary to the facility's practice.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted with diagnoses including pain due to an internal orthopedic prosthetic device and unilateral osteoarthritis. Upon admission, the resident complained of a pain level of 5 out of 10. The Medication Administration Record (MAR) indicated that a Lidocaine patch, prescribed for pain, was not administered because it was not available. Although Acetaminophen was administered later for the resident's pain, the resident's pain level increased to 6 out of 10 shortly after. The Licensed Vocational Nurse (LVN) involved stated that the protocol was to assess the resident's pain and administer medication according to the physician's orders. However, the LVN did not call the physician for additional pain management orders when the resident's pain level increased. The Director of Nursing (DON) confirmed that the nurse should have contacted the physician to obtain an order for further pain management. The facility's policy on pain assessment and management emphasized the need for ongoing communication with the prescriber and immediate contact if the resident's pain was not adequately controlled.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents. For Resident 1, the Social Services and Rehabilitative Services sections of the Baseline Care Plan Person-Centered Care Planning (BCPPCCP) were completed six days after admission, and the Activities section was completed 21 days after admission. Resident 2's BCPPCCP had the Social Services section completed three days after admission and the Rehabilitative Services section four days after admission. For Resident 3, the Social Services section was completed six days after admission, and the Rehabilitative Services section was completed four days after admission. The Director of Nursing confirmed that the BCPPCCP should have been completed within 48 hours of admission, as per the facility's policy and procedure dated December 2023, which mandates a baseline care plan be developed within 48 hours and a written summary provided to the resident or their representative.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident, identified as Resident 1, which could potentially result in unmet psychosocial needs. Interviews and record reviews revealed that Resident 1 exhibited behaviors such as refusal of care, yelling, pushing, and grabbing, documented on multiple occasions. Despite these documented behaviors, the Social Services Director was unaware of Resident 1's behaviors, and there was no documentation of behavioral health services being provided to address these issues. Further investigation showed that the Minimum Data Set Coordinator acknowledged that Resident 1 should have been referred to a psychiatrist for behavioral health services. The facility's policy and procedure on Behavioral Assessment, Intervention, and Monitoring, dated 2001, mandates that residents receive behavioral health services as needed, based on a comprehensive assessment and plan of care. However, the clinical record for Resident 1 lacked documentation of such services, indicating a failure to adhere to the facility's policy.
Violation of Resident's Communication Rights
Penalty
Summary
The facility failed to honor a resident's right to receive a telephone call, resulting in a violation of the resident's communication rights. The incident involved a complainant who attempted to contact the resident with a confidential call. However, the receptionist refused to transfer the call to the resident, citing the impossibility of transferring phones. Additionally, a registered nurse (RN) confirmed that the complainant did not provide her name or phone number, and due to HIPAA regulations, the RN did not give the telephone to the resident. Observations revealed that the resident, who requires partial assistance for activities involving the lower extremities and uses a wheelchair, did not have a telephone in her room. The Director of Nursing (DON) stated that there was no specific protocol regarding who residents could speak to, and it was not the facility's business to inquire. The facility's policy indicated that telephones should be located in areas offering privacy and accommodating residents with hearing impairments or those who are wheelchair-bound, and assistance should be provided to residents needing help with telephone use.
Failure to Address Resident Non-Compliance in Care Plan
Penalty
Summary
The facility failed to ensure that a resident received the necessary services for pressure injuries to promote healing. The resident was identified as non-compliant with turning every two hours to offload pressure from the coccyx area and elevating legs to promote circulation, as documented in the interdisciplinary team skin management notes. Despite the resident's verbal acknowledgment of understanding the risks and benefits of these actions, the treatment nurse noted the non-compliance in the skin management notes but was unsure if this information was included in the active care plans accessible to certified nurse assistants. During a review of the resident's care plans, the Director of Nursing confirmed that no care plan addressing the resident's non-compliance was created. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and interventions derived from comprehensive assessments. However, the lack of a non-compliance care plan for the resident indicates a failure to adhere to this policy, potentially leading to unmet care needs.
Failure to Develop Individualized Care Plan for G-Tube Management
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who frequently pulled out his Gastrostomy Tube (G-Tube). The resident, who had a diagnosis of Gastrostomy Status, was observed to have pulled out his G-Tube on multiple occasions, as documented in the SBAR Communication and Progress Notes. These incidents occurred on several dates, including 4/30/2024, 5/3/2024, 5/8/2024, 6/6/2024, and 6/26/2024, each time resulting in the resident being sent to the emergency room for re-insertion of the G-Tube. During an interview and record review with the Director of Nursing (DON) on 8/2/2024, it was confirmed that there was no care plan in place to prevent the resident from frequently pulling out the G-Tube. Additionally, there was no interdisciplinary team meeting held to address this issue. The facility's policy and procedure on care plans, dated March 2022, requires a comprehensive, person-centered care plan to be developed by the interdisciplinary team within seven days of the completion of the required MDS assessment, which was not adhered to in this case.
Failure to Report and Investigate Allegation of Neglect
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of suspected abuse, neglect, or misappropriation for a resident who made an allegation of neglect. The resident, who was cognitively intact with a BIMS score of 13, reported that the facility was taking an excessively long time to attend to her needs, including a significant delay in receiving medication. The resident expressed concern for her safety and eventually called the police due to the lack of response from the facility staff. Despite the resident's serious allegations and the involvement of law enforcement, the facility did not conduct an investigation or report the incident to the California Department of Public Health (CDPH) as required by their policy. The Director of Nursing (DON) stated that there was no need for a care plan or investigation since the police found nothing. However, the facility's policy clearly mandates that all allegations of neglect must be reported and investigated, which was not done in this case.
Failure to Provide Psychosocial Monitoring After Allegation of Neglect
Penalty
Summary
The facility failed to provide medically related social services for a resident following an allegation of neglect. The Social Services Designee (SSD) did not follow up or provide psychosocial monitoring for the resident after the resident called the police, accusing the facility of neglecting her care and medication needs. The SSD was unaware of the incident and did not conduct a psychosocial assessment, as required by the facility's job description for the Social Services Director. This oversight had the potential to cause psychosocial distress to the resident.
Failure to Notify Resident of Room Change During Hospital Transfer
Penalty
Summary
The facility failed to provide advance notice of a room change to a resident during a three-day hospital transfer. The resident had signed a Bed-Hold and Return Agreement requesting the facility to hold his bed space during his absence. However, during the resident's hospital stay, the facility converted his room into a female room and moved his belongings to a new room without informing him. Upon his return from the hospital, the resident was unaware of the room change and expressed dissatisfaction with the new arrangement. The Director of Nursing confirmed that the resident was on a paid bed hold during his hospital stay and was not informed of the room change prior to his return. The facility's policy and procedure on room changes state that residents should be provided with advance notice unless the change is medically necessary or for the safety and well-being of the residents. The policy also states that residents have the right to refuse a room change if it is solely for the convenience of the staff. In this case, the facility did not adhere to its policy, resulting in the resident being unaware of the room change until his return.
Resident's Right to Return to Previous Room Not Honored
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not allowing him to return to his previous room after a hospital stay. The resident, who had a moderate cognitive impairment with a BIMS score of 12, was transferred to the hospital following a seizure. Upon his return to the facility after three days, he found that his belongings had been packed and he was moved to a different room without his consent. The resident expressed his dissatisfaction and stated that he had not been asked for permission to move and wanted his original room back. The Director of Nurses (DON) confirmed that the resident's previous bed was no longer available as it had been assigned to two new female residents during his absence. The resident's clinical records, including the Bed-Hold and Return Agreement signed by the resident, indicated that he had requested the facility to hold his bed space during his absence. Despite this, the facility did not honor the agreement, leading to the resident's distress and feeling of being disrespected.
Failure to Provide Proper Oxygen Administration
Penalty
Summary
The facility failed to provide oxygen as ordered by the Medical Doctor (MD) for one of three sampled residents. Resident 1, who was diagnosed with chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD), was observed with an oxygen setting of 2.5 liters instead of the ordered 2 liters. Licensed Vocational Nurse (LVN) 1 confirmed the discrepancy during an interview and record review. The facility's policy and procedure for oxygen administration required verification of the physician's order and proper adjustment of the oxygen delivery device, which was not followed in this case. Additionally, the facility failed to provide humidified oxygen for two of three sampled residents on continuous oxygen. Resident 1 and Resident 2, both diagnosed with COPD and chronic respiratory failure, were observed without humidifiers for their oxygen. Resident 2, who was on oxygen 24 hours a day, confirmed the absence of humidification. The Director of Nursing (DON) acknowledged that all residents on oxygen should have humidifiers to prevent nasal dryness and potential nosebleeds. The facility's policy and procedure for oxygen administration also required the use of a humidifier bottle with water at an appropriate level, which was not adhered to in these instances.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 223 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards Post-acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Valley Healthcare Center | 2 mi | ★★★★★ | 26 | 0 |
| Height Street Skilled Care | 2.3 mi | ★★★★★ | 25 | 0 |
| The Rehabilitation Center Of Bakersfield | 2.3 mi | ★★★★★ | 23 | 0 |
| Kern River Transitional Care | 2.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Joaquin Nursing Center And Rehabilitation Cent.
100% money-back within 48 hours.
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.