Average — CMS composite of the measures below.
A standard survey is most likely before 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 Santa Rosa Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe smoking environment, provide adequate supervision, and properly care plan for residents who smoke. The outdoor smoking area and adjacent maintenance/housekeeping space were cluttered with cardboard, wood pallets, debris, overfilled trash bins, and accessible maintenance and housekeeping chemicals and aerosols, with a shed door left open and numerous cigarette butts scattered on the ground. Several residents with varying cognitive and physical impairments, including those with hemiplegia, schizophrenia, COPD, fractures, and histories of falls, were allowed to smoke unsupervised despite facility policies and contracts specifying designated smoking times and supervision requirements. One resident struck another in the face during an unsupervised altercation in the smoking area, another resident’s coat had burn holes from a cigarette while he was alone, a resident requiring supervised smoking and unable to self‑propel was left outside unattended and extinguished cigarettes with his fingers and stored butts in his pocket, and another resident used a plastic wheelchair cup holder as an ashtray. Smoking care plans were missing or not initiated timely for some smokers, and the DON and other staff acknowledged that smoking rules were not enforced, residents went out to smoke at any time, and staff were not adequately prepared to manage safety in the smoking area.
Two residents with cognitive and psychiatric impairments were involved in a physical altercation in the smoking area when one resident refused to share a cigarette and lighter and the other struck him in the face, as confirmed by witness statements and the facility’s own investigation. Required 72‑hour COC monitoring was not fully documented for either resident, with multiple shifts lacking nursing notes despite staff and the DON stating that every shift should monitor and document changes after such incidents. Additionally, one resident who had hit another was assessed as able to smoke independently and was observed smoking outside without staff supervision, even though his care plan called for monitoring of the smoking area and staff reported they had been instructed to supervise the residents while smoking.
A resident with intact cognition and multiple medical conditions, including diabetes and difficulty walking, was in bed when another cognitively impaired resident with vascular dementia entered the room, verbally threatened to kill and expressed hatred toward him, then punched and bit him on the hand. An LN had previously observed the aggressive resident in the hallway in disarray and called for a CNA to assist, but the CNA was occupied with another resident when the incident occurred. The LN responded after hearing the victim call out, removed the aggressive resident from the room, and later noted obvious bite marks with droplets of blood on the victim’s hand. Documentation reflected that the victim sustained a human bite to the right hand, and the facility’s abuse policy states that residents have the right to be free from abuse.
A resident with diabetes and end-stage renal disease experienced a significant medication error when staff failed to follow person-centered care planning for hypoglycemia, administered insulin doses incorrectly and without proper documentation, and did not use a Spanish interpreter to communicate with the resident. The resident became unresponsive due to hypoglycemia, and staff did not administer glucagon per protocol, resulting in the need for emergency hospital treatment.
Failure to Use Interpreter During Insulin Communication: An LPN failed to use an interpreter when communicating with a resident whose primary language was Spanish about insulin administration. The resident stated he was vomiting, did not feel well, and refused the insulin, but the LPN administered it anyway. The LPN did not speak Spanish and relied on a CNA to translate, though the CNA said the translation did not involve insulin. The resident had Type 2 DM and moderate cognitive impairment on MDS.
Medication administration and blood glucose monitoring were not accurately managed for a resident with Type 2 DM. An LPN gave insulin at the wrong time, documentation was incomplete, a high blood glucose reading was not documented or reported to the MD, and glucagon was not available by order when the resident had repeated hypoglycemic episodes and later became unresponsive with a BG of 50. The facility’s only glucometer was also not tracking correct dates or times, and the DON acknowledged the readings were not reliably linked to residents.
The facility failed to complete annual performance reviews for three of three randomly selected CNAs. During record review and interview, the DSD confirmed the aides’ most recent competency evaluations were more than 12 months old, and stated these reviews should be done annually so staff remain competent and able to provide proper care for residents.
Insufficient staff training and competency for dementia and PTSD care: The facility failed to ensure CNAs had the required competencies and training to meet residents’ behavioral health needs. Twelve CNA files lacked documentation of dementia training, an an CNA competency checklist was incomplete even though the CNA was working with residents, and only 29 of 61 CNAs attended a dementia/PTSD inservice. The facility assessment identified residents with memory problems, dementia, PTSD, and trauma, including 37 residents with Alzheimer’s/dementia and 7 with a history of PTSD/trauma.
Food service practices were not sanitary when expired spices were found on the kitchen shelf, a dietary aide used the same dirty gloves to move from dirty dishes to clean dishes without hand hygiene, and the dish machine sanitizer tested below detectable levels. The DS confirmed the glove and sanitizer issues, and the RD confirmed that spices should not be kept past the use-by date and that dishwashing sanitizer must be at the proper concentration.
Ineffective pest control allowed flies inside the facility. Residents reported flies hovering around them and landing on food, blankets, and equipment, and one resident said the flies were unsanitary and irritating. The IP, an LPN, and the Maint Dir all acknowledged flies were present, and the Maint Dir stated the facility had not implemented the exterminator’s recommendation to place a blowing fan on the doors. The facility policy stated it should maintain an effective pest control program.
Baseline care plan summaries were not documented as provided to two residents or their RP. One resident had Alzheimer's disease and muscle weakness, and the other had MS and muscle weakness. The SSD and MDSC both verified the BCP summary was not provided, and the facility policy required a written summary to be given and documented in the medical record.
Failure to Provide Ordered RNA-P: A resident with lung disease and a R BKA was not receiving the ordered restorative nursing program for AROM and resistive UE exercises as outlined in the care plan and active orders. The resident said the program had stopped even though he wanted to continue, and the DSD, DON, and RNA acknowledged there were no current restorative meetings, no recent evaluation, and no order to discontinue the program.
Inadequate Pain Control for a Resident with Hip Fracture A resident with a left hip fracture and pain related to orthopedic devices had frequent moderate to severe hip pain that affected sleep, mobility, and daily activities. Although he had PRN orders for acetaminophen for mild pain and hydromorphone for moderate to severe pain, he received hydromorphone daily, sometimes 4 to 5 times a day, and was also given acetaminophen when reporting severe pain. The resident stated the pain regimen was ineffective, he often had to wait for medication, and the unrelieved pain negatively affected his mood, socialization, and quality of life.
Commode Covered With Blanket: A resident with muscle weakness and difficulty walking had a commode in the room covered with a blanket instead of an appropriate lid. The resident stated staff had used the blanket for about two months, and an LN verified the practice had always been done that way. The IP stated this was an infection control issue because cloth can trap and harbor bacteria and become a contaminated surface.
Call Light Not Within Reach for Resident With Hemiplegia: A resident with hemiplegia had a pressure pad call button that was not working, and the working call light was coiled around the lower bed post and out of reach. The resident said staff did not respond when she tried to use the pressure pad, and an LPN verified the call system issue and that the reachable call light was not positioned within the resident’s reach.
Kitchen Sewage Drainpipe Disconnected and Leaking: A black plastic sewer pipe outside the kitchen was observed disconnected at a joint and leaking near the food prep sink area. The Maint Dir confirmed the pipe was not supposed to be disconnected, and the DS acknowledged that a leaky drainpipe could attract pests and should have been fixed. Facility policy required maintenance of buildings, grounds, and equipment in a safe and operable manner at all times.
Three residents did not receive multiple prescribed medications, including heart failure, antidepressant, anti-fungal, pain, psoriasis, and thyroid treatments. The MARs showed missed doses, and interviews confirmed that available emergency stock was not used and that staff did not document contacting the pharmacy or physician as required. The DON and Administrator confirmed these were medication errors and that facility policy was not followed.
A resident with dementia and cardiomegaly reported sexual abuse by a CNA, but the CNA was allowed to work a shift after the allegation was known, before a full investigation was completed. The DON identified the alleged perpetrator but did not immediately remove him from the facility, contrary to policy, allowing continued access to residents.
A resident with moderate cognitive impairment alleged that a male CNA exposed himself and forced her to touch him, but the facility failed to conduct a thorough investigation as required by policy. Documentation was inconsistent due to improper record-keeping, and key staff and resident interviews were omitted. Another resident also reported inappropriate touching by the same CNA, but this was not properly addressed or reported.
Two residents were involved in an incident of resident-to-resident abuse, but staff did not notify family representatives or physicians, failed to complete required incident reports, and did not document interdisciplinary team notes or initiate care plans as required by facility policy.
An allegation of abuse involving two residents with dementia was not reported to the appropriate authorities within the required timeframe. The facility delayed notification by five days due to a misunderstanding of reporting requirements, despite policy mandating immediate reporting of suspected abuse.
A resident made an abuse allegation that was not reported to the State, Ombudsman, and law enforcement within the required two-hour timeframe, as the facility delayed reporting until the following day. Interviews with staff, including LNs, the Social Services Assistant, DSD, administrator, and DON, revealed a lack of knowledge about the correct reporting timeframe, with most believing that only abuse with injury required reporting within two hours. The facility's policy required immediate reporting, defined as within two hours, for all abuse allegations.
A resident with dementia and a history of wandering repeatedly entered other residents' rooms, causing distress by taking personal items. Despite complaints and awareness of the issue, the facility failed to implement effective measures to manage the behavior, leading to emotional distress among affected residents.
A facility failed to provide timely access to medical records for several residents, including one with Central Cord Syndrome, due to delays caused by the legal department's review process. Despite the facility's policy allowing verbal requests, residents faced repeated delays and were informed that formal legal requests were necessary. The facility's policy required access within 24 hours and copies within two business days, but these standards were not met, affecting six out of 15 sampled residents.
A resident with a DNR order was resuscitated by nurses at an LTC facility, despite her documented wishes. The resident, who had intact cognition and was her own responsible party, was found unresponsive and CPR was initiated before her DNR status was realized. This resulted in physical, psychosocial, and financial harm to the resident, who now faces a financial burden due to the need for assisted living care.
The facility failed to respond appropriately to a scabies outbreak, affecting 41 residents. The infection preventionist did not implement surveillance or report the outbreak to the local health department, delaying additional resources and assistance. Despite one resident testing positive for scabies, the Director of Nursing took a conservative approach, treating residents prophylactically without confirming the diagnosis. The facility's policy required reporting outbreaks according to CDC guidelines, which was not followed.
A resident's family experienced frustration due to the facility's failure to provide a reliable communication channel. Phone calls to the facility were often unanswered, particularly in the evenings, leading to difficulties in contacting the resident. The facility's phone system was unreliable, and staff were not always available to answer calls. The DON acknowledged the issue but stated there was no policy on handling calls.
A resident did not receive prescribed doses of Lyrica, leading to unrelieved pain and an emergency room transfer. The facility failed to ensure medication availability, contrary to physician orders and facility policy. The DON confirmed the oversight, noting the nurse should have notified the physician about the depleted supply.
The facility failed to provide consistent access to communication for residents with their families after 5 p.m. and on weekends. Two residents and their families reported frustration due to unanswered calls, which was corroborated by staff interviews and observations. The issue was attributed to insufficient staffing during these times, impacting residents' ability to communicate with loved ones.
A resident with multiple health issues, including Dysphagia and cognitive deficits, lost 7.8 pounds in one week due to inadequate nutrition and weight monitoring. Despite needing 1:1 feeding assistance, the resident was often left to eat independently, resulting in less than 50% meal intake. The facility failed to follow weight monitoring protocols, leading to the resident's discharge and subsequent emergency treatment for dehydration.
The facility failed to complete Baseline Care Plans (BCPs) within the required 48-hour timeframe for several residents, including those with significant medical conditions. Staff interviews revealed a lack of awareness regarding the BCP process and its importance, leading to potential risks in resident safety and care quality.
The facility failed to maintain adequate staffing levels, resulting in delayed responses to call lights and unmet resident needs. Several residents reported long wait times for assistance, with some waiting over two hours. Staff interviews confirmed frequent short-staffing, impacting their ability to provide timely care and posing safety risks.
The facility failed to serve food at an appetizing temperature, affecting several residents. Observations showed food items were below acceptable temperature ranges, and staff admitted to not checking temperatures before serving. Residents reported receiving cold, bland, and sometimes undercooked meals, leading to dissatisfaction and reliance on outside food. Staff acknowledged the importance of proper food temperature to prevent safety risks like weight loss and inadequate nutrition.
A resident with specific dietary needs was not provided with a vegan menu, despite his preference and his wife's communication to the facility. The facility lacked a plant-based menu, and staff were unaware of the need to provide vegan meals, resulting in the resident receiving vegetarian meals instead. This oversight potentially compromised the resident's nutritional intake, as the facility did not ensure the meals met his dietary requirements.
The facility failed to employ a certified Dietary Manager (DM) to oversee food and nutrition services in the absence of a full-time Registered Dietician (RD). The DM, who was not certified, was responsible for managing the dietary department despite lacking the necessary qualifications. The Director of Nursing (DON) and the Administrator were aware of the DM's uncertified status, and the facility lacked a policy for hiring a certified DM.
Unsafe Smoking Environment, Inadequate Supervision, and Poor Smoking Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, hazard‑free smoking environment and to provide adequate supervision and care planning for residents who smoke. Surveyors observed the designated outdoor smoking area at the back of the facility to be a 10 ft by 10 ft covered space open to the parking lot, with a table, a wooden chair, a standing cigarette butt receptacle, and a carpet mat. Numerous cigarette butts were scattered on the ground under the shade structure, and residents and staff confirmed that not everyone used the ashtray and that the area was often dirty and only occasionally swept. Approximately 10–12 ft beyond the smoking area, the maintenance/housekeeping shed and surrounding grounds contained multiple empty to full cardboard boxes, tarped boxes and furniture, wood pallets and slabs, a plastic crate with spray bottles and a plastic bottle of cleaning solution, random debris, and two overfilled garbage bins. One shed door adjacent to the smoking area was left open and unattended, allowing access to maintenance supplies, tools, chemical solutions, aerosols, documentation, broken equipment, and boxes of glass fluorescent tube lights stored in a cluttered, disorganized space. The Life Safety/Housekeeping Director acknowledged that the shed and the overflowing garbage bins were hazardous and that flammable aerosol items and boxes of ethyl alcohol‑based hand sanitizer were stored there. The facility also failed to provide adequate supervision in the smoking area, which contributed to resident‑to‑resident abuse and unsafe smoking practices. Resident 1, with hemiplegia/hemiparesis and moderately impaired cognition (BIMS 12), was assessed as able to smoke without supervision and had signed the smoking policy and contract. Resident 2, with paranoid schizophrenia and severely impaired cognition (BIMS 5), was also assessed as independent and allowed to smoke without supervision, with his conservator signing the smoking policy and contract. Resident 3, cognitively intact (BIMS 15) with COPD, was likewise allowed to smoke unsupervised. Resident 4, with COPD, adult failure to thrive, and moderately impaired cognition (BIMS 11), was assessed as requiring supervision to smoke, and Resident 5, with a right femur fracture and history of falls and moderately impaired cognition (BIMS 11), was also assessed as requiring supervision. Resident 6, cognitively intact (BIMS 15) with a Colles fracture and repeated falls, was assessed as independent to smoke without supervision. Despite facility smoking policies and resident contracts specifying set smoking times and supervision requirements, surveyors observed residents smoking unsupervised outside of scheduled times. Resident 2 and Resident 3 were seen smoking alone, with Resident 3 positioned in the parking lot past the first row of cars. Resident 2 was observed with two small burn holes in the front of his coat, which he attributed to a burning cigarette that went out on its own while he was alone. An incident of resident‑to‑resident abuse occurred in the smoking area when Resident 2 hit Resident 1 on the right side of the face during an altercation while both were outside smoking unsupervised. Progress notes and care plans for both residents documented the incident and indicated that staff were to continue to monitor the smoking area, but staff interviews revealed that increased supervision after the altercation lasted only briefly and that there were not enough staff to consistently supervise smoking times or prevent residents from going out to smoke independently. Resident 4, who required supervision and was non‑ambulatory, was observed smoking outside unsupervised in his wheelchair, with both legs wrapped in kerlix gauze from ankles to knees. He reported that a CNA had brought him outside and left him in the sun, and he stated he could not help himself since his legs were wrapped. He was seen extinguishing his lit cigarette with his fingers and placing the butt in his coat pocket, and he needed assistance to turn his wheelchair and open the door to re‑enter the building. Resident 1 was observed flicking his cigarette into a plastic cup holder attached to his wheelchair, which contained ash and later two cigarette butts; the Activities Director and DON acknowledged that using a plastic cup holder as an ashtray was not allowed and posed a fire hazard. The facility also failed to adequately incorporate residents’ smoking status and supervision needs into their care plans. Resident 4’s care plan report contained no evidence of a smoking care plan, despite his documented need for supervised smoking. Resident 6’s smoking care plan was not initiated until the time of the survey, even though she had been admitted months earlier and had signed the smoking policy and contract. Facility policies required that any smoking‑related privileges, restrictions, and concerns, including the need for close monitoring, be noted on the care plan, and the DON stated that smoking status should be care planned within seven days of admission so staff would know a resident is a smoker and whether supervision is required. Staff interviews confirmed that care plans are used to guide monitoring and actions, including assessing whether residents are safe to use and keep lighters, and that without appropriate care planning, staff may not be aware of residents’ smoking needs. The DON acknowledged that residents who required supervision should not be outside unsupervised, that residents sometimes went out to smoke at any hour despite rules, that the smoking rules were not enforced, and that staff were not prepared for the interaction that occurred between Resident 1 and Resident 2 in the smoking area. Facility policies and job descriptions emphasized maintaining a safe environment, identifying safety risks and environmental hazards, and ensuring safe smoking practices. The Safety and Supervision of Residents policy stated that the facility strives to make the environment as free from accident hazards as possible and that resident supervision is a core component of safety. The Maintenance Service policy and the Maintenance Director and Housekeeper job descriptions required maintaining buildings and grounds in good repair and free from hazards, inspecting storage and work areas, and maintaining a safe, orderly, and clean environment free of obstacles. The Smoking Policy‑Residents documents, including the version signed by residents and responsible parties, specified designated smoking times, required that smoking‑related privileges and monitoring needs be noted on care plans, and stated that residents with smoking privileges may not keep smoking articles outside of designated times and that violations could result in loss of smoking privileges or discharge. Despite these written expectations, observations, interviews, and record reviews showed that the smoking area and adjacent maintenance/housekeeping area were cluttered and hazardous, that residents smoked unsupervised and outside of designated times, that unsafe methods of extinguishing cigarettes were used, and that smoking care plans were missing or delayed for some residents, resulting in unmet care needs and inadequate care planning.
Failure to Protect Residents From Abuse and Incomplete Post‑Incident Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during and after a resident-to-resident altercation. One resident with hemiplegia, hemiparesis following cerebrovascular disease, and anxiety disorder, and with moderately impaired cognition (BIMS score 12), was involved in a physical altercation with another resident diagnosed with paranoid schizophrenia and systemic lupus erythematosus, whose cognition was severely impaired (BIMS score 5). According to the SBAR and interviews, the incident occurred in the smoking area when the cognitively impaired resident asked the other resident for a cigarette and lighter, was refused, and then struck the resident on the right side of the face. Witness accounts varied slightly regarding whether the first resident swung his arm or elbowed the second resident, but all accounts and the facility’s own investigation confirmed that physical contact and a resident-to-resident altercation occurred. The facility did not complete required 72-hour monitoring following this change of condition for either resident. Documentation showed that for the first resident, monitoring was recorded on the day of the incident during evening and night shifts, and on the next two days for all shifts, but there was no evidence of any 72-hour monitoring on the third day for any shift. For the second resident, monitoring was documented on the day of the incident during evening and night shifts, and on the following day for morning and evening shifts, but not for the night shift. On the third day, monitoring was documented only for the morning shift, with no evidence of monitoring for the evening and night shifts, and no monitoring at all on the fourth day. Nursing staff and the DON stated that any change in condition required 72-hour monitoring every shift, documented in progress notes, and emphasized that this was especially important for residents involved in an abuse allegation. The facility also failed to implement and maintain protective supervision measures in the smoking area after the altercation. The second resident’s care plan noted involvement in the incident and that he had hit the other resident on the right side of the face, with staff expected to continue to monitor the smoking area. However, a smoking observation/assessment completed later that same day indicated that this resident could smoke independently without supervision and that the IDT had decided he may smoke without supervision. Observations on subsequent days showed this resident smoking outside without staff present and sitting unattended in the smoking area. Staff interviews indicated that, although there was a brief period when more staff were outside to supervise, this increased supervision only lasted about a day, and the Activities Director reported that staff were told to supervise the two residents when smoking but stated they did not have the manpower to always be outside and could not prevent residents from going out to smoke outside of scheduled smoking times. The DON acknowledged that the smoking assessment allowing unsupervised smoking conflicted with the recent abuse allegation and the facility’s stated expectation of supervised smoking times.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Human Bite
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident entered his room and bit him on the hand. Resident 1 had been admitted in November 2025 with diagnoses including diabetes mellitus, difficulty walking, and morbid obesity, and had a BIMS score of 15, indicating no memory impairment. Resident 2 was admitted in December 2025 with vascular dementia and anxiety disorder and had a BIMS score of 1, indicating severe memory impairment. On 1/13/26, Resident 1’s SBAR form documented that Resident 2 wandered into Resident 1’s room, was confused and angry, and bit Resident 1 on the right hand, resulting in impaired skin integrity and risk for pain, discomfort, and infection. On the day of the incident, a licensed nurse observed Resident 2 in the hallway in disarray and called for a CNA to assist Resident 2 back to his room. The CNA was occupied assisting another resident when the nurse heard Resident 1 call out, “He bit me.” The nurse then went to Resident 1’s room, removed Resident 2 from the room, and later assessed Resident 1, observing obvious bite marks with droplets of blood on his hand. In a subsequent interview, Resident 1 reported that he had been in bed when Resident 2 charged toward him, stated “I’m going to kill you and I hate you,” then punched and bit him. The facility’s abuse prevention policy states that residents have the right to be free from abuse, but this incident occurred despite that policy.
Failure to Ensure Safe Insulin Administration and Hypoglycemia Management
Penalty
Summary
A resident with end-stage renal disease and insulin-dependent type 2 diabetes mellitus experienced a significant medication error due to multiple failures in care planning, medication administration, and communication. The resident's care plan did not include specific interventions for the administration of glucagon during hypoglycemic episodes, nor did it address the resident's risk for refractory hypoglycemia, despite a prior hypoglycemic event. The facility also failed to ensure that the glucometer used for blood glucose monitoring was accurately tracking dates and times, and it did not associate blood sugar values with specific residents, leading to confusion in documentation and care. On the day of the incident, a nurse administered insulin at a time that did not correspond with the scheduled order, and subsequently gave two doses of insulin within a short period (1 hour and 18 minutes). The nurse did not document a critically high blood glucose value of 434 mg/dL, nor was the physician notified of this abnormal result. Additionally, the nurse did not use a Spanish language interpreter to communicate with the resident, who primarily spoke Spanish, when administering insulin. The resident reported that he attempted to refuse the insulin due to feeling unwell and having vomited, but the nurse proceeded with the administration regardless. Later, when the resident became unresponsive with a blood glucose level of 50 mg/dL, another nurse failed to administer glucagon as per facility protocol, citing inability to locate the medication and not considering the emergency kit as a resource. Instead, oral interventions were attempted, but the resident was unable to swallow. Emergency services were called, and the resident required life-saving treatment at a hospital. The sequence of events was compounded by incomplete and inaccurate documentation, lack of timely physician notification, and inadequate communication among staff.
Failure to Use Interpreter During Insulin Communication
Penalty
Summary
Licensed Nurse 2 failed to ensure Resident 1’s right to communication by not using a language interpreter when communicating with him about insulin administration. Resident 1 was admitted with Type 2 DM, his primary language was Spanish, and he was his own responsible party. His MDS dated 8/5/25 showed a BIMS score of 12, indicating moderate impairment in processing knowledge and understanding. During an interview with an interpreter, Resident 1 stated that on 11/2/25 he was vomiting, did not feel well, and told LN 2 that he did not want the insulin injection. Resident 1 stated LN 2 administered the insulin anyway and that LN 2 did not use an interpreter to communicate with him. LN 2 stated he did not speak Spanish and had CNA 1 translate for him that day, but CNA 1 stated the translation he provided did not involve insulin. The Administrator stated staff had options for translation, including other staff, their phone, or a website. The facility’s policy stated that LEP residents must have meaningful access to information and services and that oral interpretation includes communicating the resident’s needs and questions back to English.
Medication Administration and Blood Glucose Documentation Failures
Penalty
Summary
Licensed nurses did not provide accurate and safe pharmaceutical services for a resident with Type 2 DM who was admitted to the facility on 4/23/25. The resident’s care plan identified a goal of being free from signs or symptoms of hypoglycemia or hyperglycemia and noted a prior hypoglycemic event in which glucagon had been given. The resident also had a physician order for sliding-scale insulin lispro with instructions to initiate the hypoglycemic protocol and notify the MD if blood glucose was under 70 mg/dl or above 401 mg/dl. On 11/2/25, LN 2 administered insulin to the resident at 11:07 a.m. even though it was scheduled for 6:30 a.m., and the DON later stated the charting made it appear as though insulin had been given twice because the overnight nurse had not administered it at the scheduled time. The resident’s chart also lacked documented evidence of a blood glucose reading of 434 mg/dl, and there was no progress note or change-of-condition note showing that the physician was notified of that result even though it was outside the resident’s ordered parameters. LN 2 later stated he obtained a blood sugar value of 434 mg/dl and did not document the medications given when he administered the resident’s morning medications. The resident experienced hypoglycemic episodes on multiple occasions between 7/4/25 and 11/1/25, including readings of 62 mg/dl, 60 mg/dl, 45 mg/dl, and 65 mg/dl. Despite these episodes, the resident did not have a physician’s order for glucagon until 11/7/25. On 11/2/25, LN 1 found the resident not making sense, with a blood glucose of 50 mg/dl, and attempted to give orange juice and glucose gel, but the resident could not swallow and spit them out. LN 1 stated he looked for glucagon in the medication room but did not think to open the emergency kit to obtain it. The resident was later sent to the ER after becoming unresponsive and sweaty, and the Medical Director confirmed glucagon would have been appropriate when the resident was unresponsive and unable to take anything orally. The facility’s only glucometer was also not properly working because it was not tracking accurate dates or times, and the DON acknowledged that historical blood sugar values were off by a considerable number of days and hours. The DON also stated the device did not associate blood sugar values with resident names or ID numbers, and the glucose reading of 434 mg/dl was identified by process of elimination as belonging to the resident.
Missed Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three of three randomly selected CNAs. During a concurrent interview and record review of competency evaluations for five randomly selected staff on 9/12/2025 at 11:18 AM, the DSD confirmed that the most recent performance evaluations for CNA Q, CNA R, and CNA S were all more than 12 months old, with the last competency evaluations dated 4/2/23 for CNA Q and 4/1/23 for CNA R and CNA S. The DSD stated that staff competency reviews should be conducted annually so staff remain competent and able to provide proper care for residents. The report also cited the State Operations Manual Appendix PP and CFR Tag F730, which states the facility must complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews.
Insufficient Staff Training and Competency for Dementia and PTSD Care
Penalty
Summary
The facility failed to ensure sufficient staff members had the competencies and skills needed to meet the behavioral health needs of residents with mental disorders and residents with a history of trauma and/or PTSD, as reflected in the facility assessment. During interviews, the Director of Staff Development stated she had been in her role since November 2024 but did not know how many staff had completed mandatory dementia training and could not provide documentation showing the training had been provided to and completed by staff. Record review showed that 12 CNA personnel folders, including CNA D through CNA O, did not contain a signed acknowledgement of dementia training being provided or completed. CNA D’s competency checklist, dated 9/2/25, was reviewed and the Director of Staff Development confirmed it was not marked or filled out to identify the specific competencies CNA D had satisfactorily passed or completed, while also confirming CNA D was working with residents. A facility inservice on dementia and PTSD managing difficult and challenging behaviors for CNAs showed only 29 of 61 CNAs signed and attended the training, and no other in-service training on PTSD was provided for other staff. The facility assessment, updated and reviewed in January 2025, indicated the resident profile included residents with memory problems, PTSD, and dementia, and the resident matrix showed 96 residents total, including 37 with Alzheimer’s/dementia and 7 with a history of PTSD/trauma.
Expired spices, improper glove use, and inadequate dish machine sanitizer concentration
Penalty
Summary
Food was not stored and handled in a safe and sanitary manner in the kitchen for a census of 98 residents receiving food from the facility. During observation, four containers of spices were found on the kitchen shelf past their use-by dates, including ground nutmeg, rubbed sage, ground [NAME], and poultry seasoning. The kitchen cook confirmed the spices were expired, and the RD later confirmed that spices should not be stored past their use-by date and should be discarded. The facility policy on food receiving and storage stated that foods shall be received and stored in a manner that complies with safe food handling practices. In the dishwashing area, a dietary aide was observed washing dishes and then using the same dirty gloves to push clean dishes to the clean side of the dish machine without performing hand hygiene. The dietary supervisor confirmed the observation and stated hand hygiene was needed before moving to the clean side or touching clean dishes. In a separate observation, the dish machine sanitizing solution was tested and the chlorine test strip did not change color, indicating the sanitizer was not present at detectable levels, even though a posted sign indicated the solution must be at 100 ppm. The RD confirmed staff should test the dish machine sanitizing solution and expected it to be at appropriate concentrations to sanitize dishes. The facility policy for dishwashing machine use stated staff must wash hands before handling clean dishes and that chlorine sanitizer concentrations should be 50-100 ppm.
Ineffective pest control allowed flies inside the facility
Penalty
Summary
The facility failed to maintain an effective pest control program when flies were observed inside the building around residents and their belongings. During an interview, Resident 82 reported a fly hovering around her food and landing on her blanket, and stated there had been a lot of flies in the facility that upset her because she believed they were unsanitary, especially when they landed on food. During an observation, two flies were seen flying around Resident 73 and both landed on his blanket, and later three flies were noted hovering over him, with two landing on his blanket and one landing on his LAL control unit. Resident 73 stated there were lots of flies in the facility and that they irritated him, especially when they landed on his food. Resident 45 also reported seeing a fly buzzing around him and stated he had noticed more flies over the past few days, describing it as gross and very unsanitary when flies touched food. The Infection Preventionist stated she had heard reports of flies in the facility and said it was not acceptable because flies can contaminate food and could get residents sick. A Licensed Nurse stated she had witnessed flies in the facility and that it was the facility's responsibility to ensure there were no flies because they put residents at risk of getting sick. The Maintenance Director stated he had received reports of flies, acknowledged the exterminator had recommended placing a blowing fan on the doors to push out flies, and stated the facility had not implemented that recommendation. The facility policy stated it should maintain an effective pest control program.
Baseline care plan summaries were not documented as provided to residents or responsible parties
Penalty
Summary
The facility failed to ensure a written summary of the baseline care plan was provided to the resident and/or responsible party for two sampled residents. Resident 31 had an admission date in 7/2025 and diagnoses of Alzheimer's disease and muscle weakness. Resident 82 had an admission date in 3/2024 and diagnoses of Multiple Sclerosis and muscle weakness. For both residents, the Baseline Care Plan Person-Centered Care Planning form-V3 did not indicate that the printed baseline care plan summary was provided to the resident or the responsible party. During a concurrent interview and record review on 09/11/2025, the Social Services Director reviewed the baseline care plan forms for Residents 31 and 82 and verified there was no indication the summary was provided to the resident and/or responsible party. The Minimum Data Set Coordinator also reviewed the forms and verified the baseline care plan summary was not provided to either resident or their responsible parties. The facility policy titled Care Plans-Baseline, revised 3/2022, stated that the resident and/or representative are provided a written summary of the baseline care plan and that provision of the summary is documented in the medical record.
Failure to Provide Ordered Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that one sampled resident was provided the Restorative Nursing Assistant Program (RNA-P) in accordance with physician orders, the resident’s person-centered care plan, and the resident’s choice to participate. Resident 28 was admitted with diagnoses including lung disease and absence of the right leg below the knee. His MDS indicated he was able to express ideas and wants. His care plan and active order summary directed RNA-P for active range of motion to both upper extremities with resistive exercise three times for 15 repetitions, encouragement to perform bicep/triceps curls, chest press, and overhead press as tolerated, and use of the omnicycle for both upper extremities at level 1-2 for about 15 minutes on Mondays, Wednesdays, and Fridays. Record review showed the RNA weekly summary documented that the resident was seen only twice during the week of 7/20/25 and used the bicycle without complaint of pain. During interview, the resident stated he was no longer getting RNA-P, did not know why it stopped, had previously been going three days a week, and wanted to continue because he liked going to activity outings and wanted to remain strong enough to participate. The DSD stated she was responsible for the RNA-P, but meetings had not been scheduled in a while and the spreadsheet she presented was an old January 2025 list; she acknowledged there were no current spreadsheets or meeting notes and no physician order to discontinue the program. The DON and RNA also acknowledged the resident had not been evaluated since 7/20/25, meetings had not been scheduled, and there were no orders to end the program.
Inadequate Pain Control for Resident with Hip Fracture
Penalty
Summary
The facility failed to provide adequate pain management for one resident who had a left hip fracture and pain related to internal orthopedic prosthetic devices, implants, and grafts. The resident had intact cognition and was assessed as experiencing frequent aching and stabbing hip pain that affected sleep, rest, social activities, physical activities, and mobility. His care plan addressed discomfort after left hip arthroplasty and directed staff to notify the physician if pain became unmanageable or intolerable. The resident’s physician orders included acetaminophen 325 mg, 2 tablets every 6 hours as needed for mild pain, and hydromorphone HCL 2 mg every 4 hours as needed for moderate to severe pain. Review of the EMAR showed the resident received hydromorphone daily, sometimes up to 5 times per day, and continued to report severe pain on multiple days in August and September 2025. On several occasions, staff administered acetaminophen even when the resident reported severe pain, despite the order limiting acetaminophen to mild pain. On one date, the resident reported an 8 out of 10 pain level and stated hydromorphone was ineffective, but there was no indication that an alternative medication was provided. During observation and interviews, the resident stated he was in pain daily, often had to wait about 1 1/2 hours for hydromorphone because it was not yet time, and said he had requested that the physician be contacted because the regimen was ineffective. He stated the unrelieved pain was frustrating and negatively affected his mood, desire to socialize, and quality of life. The MDS coordinator, pharmacist, licensed nurse, and physician all acknowledged that the pattern of daily moderate to severe pain and frequent PRN hydromorphone use suggested the current pain regimen was ineffective and that the resident’s pain was not adequately controlled.
Commode Covered With Blanket
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for one resident out of 20 sampled residents when the resident’s commode was covered with a blanket. Resident 87 was admitted in July 2025 with diagnoses of muscle weakness and difficulty walking. During a concurrent observation and interview on 09/09/2025 at 12:34 PM, a commode in Resident 87’s room was observed covered with a blanket, and the resident stated staff had used a blanket to cover the commode for about two months. During a concurrent observation and interview later that day, LN C verified that Resident 87’s commode bucket was covered with a blanket and stated it had always been covered that way. LN C stated this was not acceptable and that it was the facility’s responsibility to ensure the commode was covered with the appropriate lid. LN C also stated that covering the commode bucket with a blanket was unhygienic and unsanitary. The IP later stated that covering the commode with a blanket was not acceptable because it was an infection control issue, explaining that cloth traps and harbors bacteria and becomes a contaminated surface.
Call Light Not Within Reach for Resident With Hemiplegia
Penalty
Summary
The facility failed to ensure a working call system was available within reach for one of five sampled residents, Resident 102. Resident 102’s face sheet showed an admission in April 2020 with a diagnosis of hemiplegia. During a concurrent observation and interview on 09/09/2025 at 11:47 AM, Resident 102 stated she had been using the pressure pad to call for help and no staff responded because she believed it was not working. She stated her normal call light had been changed earlier that morning to the pressure pad call button and that it was very frustrating to have a call light that was not working because it was the way to call staff when help was needed. During the same observation, Licensed Nurse C verified that Resident 102’s pressure pad call button was not working, but stated there was a working call button that was coiled around the lower bed post and too far for Resident 102 to reach. Licensed Nurse C stated a call light must always be in working condition and within a resident’s reach. During an interview on 09/12/2025, the Director of Staff Development stated call lights were meant to be used by residents to call staff when help was needed and that a call light wrapped on the lower bed post was unacceptable and not within a resident’s reach. The facility policy titled Answering Call lights stated that when a resident is in bed or confined in a chair, the call light should be within easy reach.
Kitchen Sewage Drainpipe Disconnected and Leaking
Penalty
Summary
The facility failed to maintain the kitchen drain in working order when the sewage drainpipe outside the kitchen was observed disconnected and leaking near the wall corresponding to the kitchen's food preparation sink. During a concurrent observation and interview, the Maintenance Director confirmed that the black plastic sewer pipe was not supposed to be disconnected. The pipe was seen coming off the wall down to the ground, with light-colored solid particles scattered in the direction of the slope of the ground from the pipe's opening. In a later interview, the Dietary Supervisor acknowledged that a leaky drainpipe could attract pests and stated that it should have been fixed. The facility policy on Maintenance Service stated that maintenance service shall be provided to all areas of the building, grounds, and equipment, and that the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Failure to Administer Medications as Ordered and Lack of Required Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents. One resident, admitted with congestive heart failure and adjustment disorder with depressed mood, did not receive multiple doses of her heart failure medication, antidepressant, and topical ointment for skin redness as documented in the Medication Administration Record (MAR). Another resident with Alzheimer's disease missed a scheduled dose of anti-fungal powder for moisture-associated skin damage. A third resident, diagnosed with recurring shoulder dislocation and psoriasis, did not receive her prescribed pain-relieving patch, topical cream for psoriasis, or her thyroid medication as ordered. Interviews and record reviews confirmed that the missed doses were not due to medication unavailability alone. The Infection Preventionist (IP) verified that the facility's emergency medication stock contained at least one of the missed medications, but it was not administered. Additionally, there was no documentation that the pharmacy or the physician was contacted regarding the missed doses, nor was there evidence of any instructions or alternative orders being recorded in the residents' charts. The acting Director of Nursing (DON) and the Administrator acknowledged that missing a medication dose constitutes a medication error and could negatively affect residents' health. The facility's policy requires medications to be administered according to prescriber orders and within required time frames, but this was not followed in these cases, as confirmed by the MARs and the lack of appropriate documentation or follow-up.
Failure to Protect Residents from Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to protect all residents from sexual abuse by allowing a certified nursing assistant (CNA) who was the subject of an abuse allegation to continue working in the facility before a complete investigation was conducted, as required by facility policy. After a resident with cardiomegaly and dementia reported to a CNA that she experienced sexual abuse by a male staff member, the Director of Nursing (DON) identified the alleged perpetrator based on the resident's description. Despite this, the CNA was permitted to clock in and work a shift on the same day the allegation was reported, providing him access to the resident and others. The DON became aware of the allegation around midday and interviewed the CNA only after he had already started his shift. The CNA admitted to providing showers to the resident and documenting them under another CNA's name. Facility policy requires that residents be protected from abuse and from contact with alleged perpetrators during investigations, but this was not followed. The failure to immediately remove the CNA from the facility during the investigation placed the resident and others at risk.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse made by a resident with moderate cognitive impairment, who reported that a male CNA exposed himself and forced her to touch his genitals. The resident described the alleged perpetrator in detail, and documentation showed that the CNA had provided her with showers, although records were inconsistent due to the CNA documenting under another staff member's name. The initial investigation by facility staff was limited, with only a single interview of the resident and a review of documentation that did not accurately reflect who had provided care, due to improper documentation practices. The Director of Staff Development (DSD) and Director of Nursing (DON) did not follow the facility's abuse investigation protocol, as required by policy. The DSD did not interview all relevant staff or residents, failed to document staff interviews, and did not include the resident's roommate or other potentially involved individuals in the investigation. The DSD also admitted to not being trained in abuse investigations and concluded the investigation quickly due to perceived inconsistencies in the resident's account. The DON did not assist in the investigation or ensure that it was thorough, and the Administrator did not provide formal training on proper investigative procedures. Additional interviews revealed that another resident reported inappropriate touching by the same CNA, which was disclosed to the Administrator but not acted upon or reported according to policy. The facility's failure to conduct a comprehensive investigation, including interviewing all relevant parties and properly documenting findings, decreased the potential to protect the affected resident and others from harm. The facility's own policy required a thorough investigation, including interviews with all involved staff and residents, but this was not followed.
Failure to Implement Abuse and Change of Condition Policies After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse and change of condition policies for two residents following an allegation of resident-to-resident abuse. Specifically, after one resident reported being physically assaulted by her roommate, staff did not notify the residents' family representatives or physicians, did not complete Special Incident Reports (SIR), and did not document Interdisciplinary Team (IDT) notes in the residents' charts. The investigation summary and interviews confirmed that these required notifications and documentation were not completed, and there was no evidence of care plans being initiated for either resident involved in the incident. Staff interviews revealed that licensed staff were expected to notify family representatives and physicians, complete SIRs, and initiate care plans after abuse allegations, but these actions were not taken. The facility's policies required immediate reporting and documentation of such incidents, as well as interdisciplinary review and care plan updates following significant changes in a resident's condition. Despite these requirements, the records showed no documentation of the necessary notifications, incident reports, or care plan revisions related to the abuse allegation.
Delayed Reporting of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe for two residents. An incident involving suspected dependent adult or elder abuse occurred between two residents, both of whom had dementia, but the facility did not notify the California Department of Public Health until five days after the event. The Administrator stated that the delay was due to a mistaken belief that reporting was not required when residents had dementia and there was no serious bodily injury. Facility policy required immediate reporting of suspected abuse, defined as within two hours, but this was not followed in this case.
Failure to Timely Report Abuse Allegation and Staff Unawareness of Reporting Requirements
Penalty
Summary
The facility failed to implement its abuse policy for one resident when an abuse allegation was made. The incident occurred when a resident reported an allegation of abuse, but the facility did not report the allegation to the State, Ombudsman, and law enforcement within the required two-hour timeframe. Instead, the report was made the following day, exceeding the policy's definition of 'immediately,' which is within two hours for abuse allegations. Interviews with six facility staff members, including licensed nurses, the Social Services Assistant, the Director of Staff Development, the administrator, and the Director of Nursing, revealed a consistent misunderstanding of the required reporting timeframe. Most staff believed that abuse allegations without injury should be reported within 24 hours, and only those with injury within two hours. The Social Services Assistant specifically stated she did not know the required timeframe for reporting abuse allegations. A review of the facility's policy and procedure confirmed that any suspicion of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within two hours for abuse allegations. The failure to report the abuse allegation within this timeframe, as well as the lack of staff knowledge regarding the correct reporting protocol, led to the deficiency.
Failure to Prevent Wandering Resident from Disturbing Others
Penalty
Summary
The facility failed to provide a homelike environment for three residents when another resident, who had a history of wandering and aggressive behavior, repeatedly entered their rooms, rummaged through their belongings, and took items. This resident, diagnosed with polyneuropathy, vascular dementia, and Alzheimer's Disease, was known to wander and had previously been in a locked-down memory care unit. Despite the known risks, the facility did not take adequate measures to prevent the resident from entering other residents' rooms, leading to emotional distress and anger among the affected residents. Interviews with residents and staff revealed that the wandering resident's behavior was a persistent issue, causing significant distress. Residents expressed frustration and fear over the loss of personal items and the inability to relax in their own rooms. Staff members acknowledged the resident's behavior, noting that she often took items and became aggressive if confronted. The facility's administration was aware of the complaints but failed to implement effective interventions to manage the resident's behavior, instead suggesting that other residents should tolerate the situation. The facility's Director of Nursing admitted to being unaware of the severity of the issue until recently and expressed uncertainty about how to address the residents' concerns. Despite holding meetings with family members and offering reimbursement for missing items, the facility did not provide a concrete plan to prevent further incidents. The lack of action and effective management of the wandering resident's behavior resulted in a failure to uphold the residents' rights to a safe and homelike environment, as outlined in the facility's policy on resident rights.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide residents with copies of their medical records upon request, affecting six out of 15 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility's legal department delayed the release of records. Resident 1, who was admitted with Central Cord Syndrome, spinal fusion, and Spinal Stenosis, requested her medical records multiple times, both verbally and in writing, but faced repeated delays and was informed that her records needed legal review before release. Resident 1's Minimum Data Set indicated no cognitive impairment, and she had authorized the release of her records to her attorney. Despite this, the facility's Medical Records Director (MRD) informed her that a formal legal request was necessary, contradicting the facility's policy that allowed for verbal requests. The MRD confirmed that four out of seven residents who requested records between December 2024 and February 2025 had not received them due to pending legal department approval. The facility's policy stated that residents should have access to their records within 24 hours and copies within two business days of a request. However, the MRD and Administrator acknowledged that the facility's legal department's involvement caused delays, and the MRD admitted that the letter sent to Resident 1 contradicted the facility's policy, potentially causing confusion. The Record Release Log showed multiple instances of delayed record releases due to legal review, highlighting a systemic issue in the facility's process for handling medical record requests.
Failure to Honor DNR Order Results in Resident Harm
Penalty
Summary
The facility failed to provide resident-centered care by administering CPR to a resident who had a Do Not Resuscitate (DNR) order in place. The resident, who was her own responsible party and had intact cognition, had a Physician Orders for Life Sustaining Treatment (POLST) form indicating her decision not to be resuscitated. Despite this, Licensed Nurses performed CPR on the resident when she was found unresponsive, which was against her documented wishes. The incident occurred when a CNA found the resident slumped over and unresponsive in her wheelchair. Licensed Nurse A initiated CPR after transferring the resident to a bed, and Licensed Nurse B assisted with the chest compressions. It was only after CPR had been initiated that the nurses became aware of the resident's DNR status, at which point the resuscitation efforts were stopped. The resident was then transferred to the emergency department by paramedics. As a result of the CPR, the resident experienced physical, psychosocial, and financial harm. She survived the medical emergency but now faces a financial burden due to the need for assisted living care, which costs $6,000 per month. The resident expressed feelings of anxiety and depression due to her current situation, which she did not wish to be in. The facility's policies on resident rights and DNR orders were not followed, leading to this deficiency.
Failure to Respond to Scabies Outbreak
Penalty
Summary
The facility failed to appropriately respond to a scabies outbreak, resulting in 41 out of 95 residents developing an itchy rash. The infection preventionist did not implement surveillance for potential cases of scabies when rashes began appearing, did not identify the scabies outbreak, and did not report the outbreak to the local health department (LHD) as per CDC guidance. This failure potentially delayed additional resources and assistance from the LHD to prevent scabies from spreading to all residents and delayed the LHD from investigating potential exposures and further spread in the community. The Director of Nursing (DON) and Infection Preventionist (IP) were aware of the rash outbreak but took a conservative approach, treating residents prophylactically for scabies without confirming the diagnosis. Despite one resident testing positive for scabies in the hospital, the DON did not consider it an outbreak as there was only one confirmed case. The IP did not conduct any tracking of the rashes, did not start a map of the residents with rashes, and did not start a line list to track the rashes until instructed by the LHD. The IP admitted that she should have reported the outbreak to the LHD and should have started tracking when the first resident tested positive. Multiple residents and family members reported rashes and itching, with some residents being diagnosed with scabies by their doctors. The facility's medical director was aware of one confirmed and one suspected case but did not discuss reporting to the LHD. The facility's policy required reporting outbreaks according to CDC guidelines, which define an outbreak as two confirmed cases or one confirmed case and two suspected cases. The IP and DON failed to adhere to these guidelines, resulting in a delayed response to the outbreak.
Failure to Provide Reliable Communication for Resident
Penalty
Summary
The facility failed to provide a reliable communication channel for a resident, leading to difficulties in communication between the resident and her family. The family member reported that phone calls to the facility were often unanswered, particularly in the evenings, which was the only time she could contact her mother. This lack of communication caused frustration and distrust. An internet search confirmed the facility's publicly listed phone number, but calls made to the facility at different times were not picked up. Interviews with staff revealed that the facility's phone system was unreliable due to dependence on internet signal strength, which was inconsistent in the area. The facility had a receptionist to answer calls during business hours, but after hours, the responsibility fell to the staff, who were not always available to answer calls. Observations showed that the phone used for resident calls was not always in its designated place, and there were instances where a resident with dementia answered the phone. The Director of Nursing acknowledged the issue but stated there was no current policy on answering calls or assisting residents with calls.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of a resident, resulting in the resident not receiving prescribed doses of Lyrica, a medication used to treat painful nerve diseases. This occurred twice over a seven-day period, contrary to the physician's orders. The resident, who had been on Lyrica for a long time to control pain, experienced unrelieved pain due to the missed doses, which led to a transfer to the emergency room. The family member of the resident reported the missed doses and expressed concern about the risk of withdrawal symptoms. The Medication Administration Records (MARs) indicated that the doses were marked with a code that referred to the nurse's notes, but there was no documentation of any interventions to ensure the medication was available. The Director of Nursing confirmed the missed doses and acknowledged that the morning shift nurse should have realized the medication supply was depleted and notified the physician. The facility's policy on administering medications emphasized that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Communication Access Deficiency in Facility
Penalty
Summary
The facility failed to ensure that residents had consistent access to communication with their responsible parties and loved ones via the facility phone after 5 p.m. and on weekends. This deficiency was observed in two sampled residents, Resident 4 and Anonymous Resident 5, who expressed frustration and concern over the inability to communicate with their families. Interviews with staff and family members corroborated these issues, highlighting that calls to the facility often went unanswered during these times, leading to feelings of frustration and isolation among residents. Resident 4, who has diagnoses including muscle weakness and multiple sclerosis, reported that the facility phone was not answered after 5 p.m. or on weekends, despite the facility's claim of being open 24 hours. This lack of communication access was also experienced by Resident 4's sister, who frequently visited but was unable to reach the facility by phone during these times. Similarly, Anonymous Resident 5 recounted an instance where they attempted to call the nursing station for assistance but received no answer, raising concerns about the potential impact during emergencies. Interviews with licensed nurses and certified nursing assistants revealed that the issue of unanswered phones was well-known within the facility. Staff members acknowledged the difficulty in answering calls due to being occupied with other duties, particularly during nights and weekends when staffing levels were lower. This situation was further confirmed by observations of unanswered calls made to the facility at various times, demonstrating a systemic issue with phone communication access for residents and their families.
Failure to Provide Adequate Nutrition and Monitoring
Penalty
Summary
The facility failed to provide adequate nutrition and weight monitoring for a resident who lost 7.8 pounds, equivalent to 5.3% of their body weight, within the first week of admission. The resident, who has multiple diagnoses including Spastic Quadriplegic Cerebral Palsy, Epilepsy, Dysphagia, and a cognitive communication deficit, was dependent on 1:1 feeding assistance. Despite this requirement, the resident was documented as eating independently 15 times, and their meal intake was less than 50% during their stay. Additionally, the resident's meal trays were left unattended, leading to missed meals without proper staff intervention. The resident's care plan indicated a need for 1:1 feeding assistance and regular weight monitoring, but the facility only recorded two weights within a week, failing to follow the physician's order for weekly weights. The Director of Nursing admitted that only monthly weights were conducted, which did not comply with the prescribed monitoring protocol. The resident's weight loss was not adequately addressed, and there was a lack of documentation for dietary interventions to maintain nutritional and fluid intake. The resident was eventually discharged back to their group home and had to be sent to the emergency department for dehydration. Lab work from the receiving facility indicated elevated Blood Urea Nitrogen levels, confirming dehydration. The facility's policy required evaluation and intervention for significant weight changes, but these were not effectively implemented, leading to the resident's compromised health status.
Failure to Timely Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that staff were aware of the Baseline Care Plan (BCP) and its completion timeframe, resulting in untimely completion of BCPs for five sampled residents. This deficiency was identified through interviews and record reviews, revealing that staff members, including Licensed Staff A and B, were not knowledgeable about the BCP completion timeframe. The Social Services Director and the Director of Nursing confirmed that the BCP should be completed within 48 hours of admission, as per regulation and facility policy. However, the Dietary Manager incorrectly stated that the BCP should be completed within 72 hours, indicating a lack of consistent understanding among staff. The untimely completion of BCPs was evident in the cases of five residents, including those with significant medical conditions such as heart failure, Parkinson's disease, atrial fibrillation, and multiple sclerosis. For instance, Resident 1's BCP was completed a day after the required timeframe, and Resident 2's BCP was completed several days late. Additionally, Resident 4 and Resident 7's BCPs were completed long after their admission dates. Anonymous 5, another resident, reported not recalling a baseline care planning meeting, highlighting a gap in involving residents in their care planning. These failures had the potential to compromise resident safety and care quality, as timely BCPs are crucial for identifying and meeting residents' immediate needs upon admission.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to ensure adequate staffing levels, as evidenced by complaints from seven residents who expressed concerns about the lack of staff to meet their needs. Residents reported feeling upset, frustrated, and worried about the potential for emergencies due to the insufficient number of staff. Observations and interviews revealed that call lights were not answered promptly, with wait times ranging from 20 minutes to over two hours, leading to delays in care and unmet needs. Resident 1, with diagnoses including heart failure and Parkinson's disease, had a BIMS score indicating moderately impaired cognition. Resident 2, diagnosed with migraines and atrial fibrillation, reported waiting up to an hour for staff to respond to her call light and receiving meals late. Resident 4, who required assistance with daily activities, stated that staff were often rushed and unable to provide timely care due to being assigned too many residents. Other residents, including Anonymous 3 and 5, shared similar experiences of long wait times and concerns about safety during emergencies. Interviews with staff members, including unlicensed staff and licensed nurses, confirmed that the facility was frequently short-staffed, impacting their ability to respond to call lights promptly. The staffing coordinator acknowledged that the facility required a specific number of CNAs per shift to be considered fully staffed, but this was not consistently achieved. The Director of Nursing and other staff members recognized that delayed responses to call lights posed safety risks, such as falls and inadequate care, yet the issue persisted.
Failure to Serve Palatable and Safe Temperature Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, affecting seven sampled residents. Observations and interviews revealed that food items such as egg omelets, pureed bread, and hot cereal were served at temperatures below the acceptable range, with the hot cereal being particularly cold. Staff members admitted to not taking the temperature of the food before serving, which is against the facility's policy. This oversight was acknowledged by the Dietary Manager, who confirmed that the policy requires food temperatures to be checked to prevent gastrointestinal illnesses. Residents expressed dissatisfaction with the quality and temperature of the food. Several residents reported receiving cold meals regularly, with complaints about the food being bland, lacking flavor, and sometimes not thoroughly cooked. One resident mentioned receiving a raw hotdog and undercooked chicken, which affected their willingness to eat chicken again. The dissatisfaction with the food led some residents to rely on family members to bring food from outside the facility. Interviews with staff, including licensed and unlicensed personnel, highlighted the importance of serving food at the correct temperature to prevent safety risks such as weight loss and inadequate nutrition. The Dietary Manager and Registered Dietician emphasized the necessity of adhering to food safety protocols to ensure the well-being of residents. Despite discussions about implementing a plan to address these issues, the plan had not been put into action at the time of the report.
Failure to Provide Vegan Diet for Resident
Penalty
Summary
The facility failed to ensure that dietary staff were aware of and provided a vegan menu for a resident who required it. Despite the resident's preference for a vegan diet, the facility did not have a plant-based menu or recipes, and the dietary staff were not informed of the need to provide vegan meals. This oversight resulted in the resident receiving meals that did not align with his dietary preferences, potentially compromising his nutritional intake. The resident, who had a history of heart failure, vitamin B12 deficiency anemia, and Parkinson's disease, was dependent on staff for assistance with eating and other daily activities. His wife, acting as his responsible party, had communicated his vegan dietary preference to the facility. However, the facility continued to serve him vegetarian meals due to a lack of updated physician orders and communication between departments. Interviews with staff revealed a lack of awareness and understanding of the resident's dietary needs, with some staff admitting they were unsure if the meals provided met the resident's nutritional requirements. The facility's dietary manager acknowledged the absence of a plant-based menu and the need for one to ensure residents receive adequate nutrition. Despite multiple communications to nursing staff about the resident's vegan preference, the physician's order remained unchanged, and the resident continued to receive inappropriate meals. The facility's policy on menu planning did not specifically address plant-based diets, contributing to the oversight and failure to meet the resident's dietary needs.
Uncertified Dietary Manager Overseeing Services
Penalty
Summary
The facility failed to ensure that there was a qualified staff member with the appropriate competencies and skill sets to carry out food and nutrition services. A Dietary Manager (DM) who was not certified was overseeing dietary services in the absence of a full-time Registered Dietician (RD). The DM confirmed during an interview that she was not a certified Dietary Manager and was still in the process of obtaining her certification. She also stated that she was not a certified food service manager and had no certification at the facility. The DM was responsible for overseeing the kitchen and dietary needs of the residents when the RD was not present, despite lacking the necessary certification. The Director of Nursing (DON) and the Administrator both acknowledged that the current DM was not certified. The RD, who worked part-time and visited the facility two to three times a week, also confirmed that the DM was not certified and was responsible for overseeing the dietary department in her absence. The facility did not have a policy and procedure regarding the hiring of a certified DM, which contributed to the deficiency in ensuring qualified staff for food and nutrition services.
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Illustrative
What surveyors actually found near you
We read the 364 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Rosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summerfield Health Care Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Park View Post Acute | 0.8 mi | ★★★★★ | 13 | 0 |
| Spring Lake Village | 2 mi | ★★★★★ | 10 | 0 |
| Blue Oak Post-acute | 2.2 mi | ★★★★★ | 33 | 0 |
| Northvine Postacute Care | 3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.