Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sequoia Transitional Care during CMS and state inspections, most recent first.
A resident who was dependent on staff for ADLs, including personal hygiene and grooming, was observed with fingernails approximately one inch long on both hands, including a contracted hand. The resident reported asking multiple staff members to trim his nails without the care being provided. A CNA confirmed the nails were excessively long and needed trimming. An LVN stated nail care was offered daily and on a designated weekly day but could not produce documentation that this resident had been offered nail care for about one and a half months. The DON acknowledged the nails were too long, and the resident's care plan and the facility's ADL policy both required staff to provide necessary grooming and hygiene services for residents unable to perform these tasks independently.
Failure to Monitor Opioid Pain Medication: A resident with COPD and fibromyalgia received PRN morphine for severe pain and later returned from an appointment over-sedated. An LPN did not monitor for sedation after the resident returned, and the MAR showed a morphine dose was given early. The resident later became hard to arouse and vomited repeatedly, was transferred to a GACH, and was treated for suspected opioid overdose with Narcan and intubation.
Improper Disposal of Controlled Medications: Two medication carts had pharmaceutical waste containers with removable lids that contained multiple intact pills, including narcotics. LPNs stated they discarded wasted or dropped narcotics into the same waste containers used for non-controlled medications after verification with another nurse, and the DON confirmed the containers were accessible and posed a diversion risk. The facility policy required controlled substances to be kept in a securely locked area until destroyed by the DON and consultant pharmacist.
Infection control failures were observed involving a resident on oxygen, clean supplies, and hand hygiene. A humidifier bottle for a resident receiving O2 was not changed weekly, clean linen and clean diapers were left on the floor in a resident room, and a CNA entered and exited a resident room without performing hand hygiene before or after bedside care.
An LVN failed to follow the facility's insulin pen administration policy for two residents with Type 2 DM and physician orders for insulin lispro sliding scale before meals. During med pass observation, the LVN administered 4 units SQ to each resident using an insulin pen but did not prime the pen before either injection; the DON confirmed the pen should be primed before each use.
Untrimmed Nails and Untreated Toe Laceration: A resident with Parkinsonism, muscle weakness, and wheelchair dependence was observed with untrimmed fingernails and toenails and scabs on the inner right great toe. The resident said a nail caused a cut during a transfer and that nurses did not treat it. An LVN confirmed the nail care issues and toe scabs, stated there was no treatment order, and the DON stated a change in condition and physician notification should have occurred for the injury of unknown source.
A soiled dish towel was observed on a table tray with clean cups in the kitchen during a concurrent observation and interview with the Dietitian. The Dietitian stated the towel should have been placed in the soiled linen container. Facility P&P for sanitation states kitchen staff are responsible for cleaning and that cleaning products or sanitizers are not to be used in food prep or storage areas in a way that could contaminate exposed food items.
A resident with a vascular/venous wound to the right lower leg had a revised wound care order documented by the wound physician, specifying cleansing with NS, patting dry, and applying Dakin’s flush with betadine to eschar QD and PRN. However, the active treatment orders in the record continued to reflect an older regimen using wound cleanser and betadine-soaked gauze with kerlex wrap. During interview and record review, the ADON could not show evidence that the new order was implemented and acknowledged the order was not updated, contrary to facility policy requiring a current and complete list of treatment orders. This failure resulted in the physician’s order being incorrect and created the potential for the wound to worsen.
A resident with dementia, muscle weakness, and a history of repeated falls, who was totally dependent on staff for toileting, was left waiting for about 30 minutes after requesting help. The resident attempted to use the bathroom without assistance, resulting in a fall that caused a head laceration and a T5 compression fracture. Staff and records confirmed the resident's high fall risk and need for total assistance, and the facility's failure to provide timely care led directly to the incident.
The facility failed to ensure an RN was on duty for eight hours a day, seven days a week, as required by policy. Interviews and record reviews with the DSD revealed multiple instances across several months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage.
The facility failed to notify the resident's representative and the state LTC ombudsman in writing when two residents were transferred to the hospital. One resident was transferred twice, once for gastrointestinal bleeding and once due to a fall, without notifying the family member listed as the Responsible Party. Another resident was transferred without notifying the ombudsman. The facility's policy requires such notifications, but they were not carried out.
The facility failed to develop and implement individualized care plans for three residents, potentially leading to unmet care needs. A resident with speech issues, another with gastrointestinal bleeding, and a third with incontinence did not have appropriate care plans in place, contrary to the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to use a communication tool for a resident with a speech impairment, leading to potential unmet needs. The resident was observed speaking in gibberish, and while a CNA familiar with the resident could understand her, the MDS assessment indicated unclear speech. The MDSC noted that without a communication tool, newer staff would struggle to meet the resident's needs, contrary to the facility's policy on effective communication.
The facility failed to follow its repositioning policy for two residents dependent on staff for mobility. Resident 71 was not repositioned consistently every two hours as required, and Resident 52, with hemiplegia, was not turned every hour while in a chair. Documentation showed irregular repositioning times, and discrepancies between care plans and actual needs were noted.
A facility failed to assess a resident for a Bowel and Bladder Training program, despite documentation indicating the resident was always incontinent. The Minimum Data Set Consultant and Coordinator found no care plan or documentation for such a program, and discrepancies in the resident's continence status were noted. Additionally, the facility could not provide a bowel and bladder training program policy.
The facility failed to monitor two residents on anticoagulation therapy as per their protocol. There was no documentation of monitoring for adverse effects of Eliquis and Xarelto for DVT prevention, as confirmed by the ADON and MDS Consultant. The facility's protocol requires monitoring for complications and consulting with a physician if signs of bleeding are observed.
The facility failed to remove expired medications from medication carts for two residents, risking administration of expired drugs. Additionally, a resident's medications were found unsecured in their room without a self-administration assessment. Licensed staff acknowledged responsibility for checking and removing expired medications, which was not done, and the facility's policies on medication storage and self-administration assessments were not followed.
A facility failed to follow a physician-prescribed therapeutic diet for a resident, potentially leading to adverse outcomes. The resident's diet required chopped meat due to multiple missing teeth, but the chicken fried steak served was not chopped, leaving it uneaten. An LVN confirmed the steak should have been chopped, as per the resident's dietary requirements.
The facility failed to ensure that arbitration agreements were clearly explained to residents in their primary language, resulting in several Spanish-speaking residents signing agreements in English without full understanding. The agreements were presented without certified interpreters, and staff members who were not certified to translate legal terms facilitated the process.
A resident received incorrect discharge appeal information, and the Ombudsman was notified late about the discharge. The NOPD contained wrong contact details for appeals, and the Ombudsman was informed three days after the notice, against the facility's policy.
A facility failed to notify a resident's responsible party before a room change, violating the resident's rights. The DON confirmed the room swap occurred without documented consent from the responsible party, contrary to facility protocol requiring notification and documentation in the clinical record.
A resident with Guillain-Barre syndrome was not referred to a neurologist as ordered, leading to a delay in care. The receptionist attempted to schedule the appointment but lacked documentation of these attempts. The DON confirmed the absence of documentation, contrary to the facility's policy requiring coordination and documentation of referrals.
The facility did not have a full-time licensed DON, as the previous DON left in March 2024. An interim DON, who completed the RN program but lacked an RN license, was assigned to the role. This situation did not comply with the facility's policy requiring a licensed RN as a full-time DON.
Failure to Provide Required Nail Care as Part of ADL Support
Penalty
Summary
The facility failed to provide necessary nail care as part of activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene, grooming, and other ADLs. During an observation in the resident's room, the resident was seen lying in bed with the head of the bed elevated, and both hands had fingernails approximately one inch long beyond the fingertips. The resident's left hand was contracted, with fingers permanently bent toward the palm, and the fingernails on that hand were also approximately one inch long. The resident reported having asked several staff members to trim his nails, but stated that no staff member returned to perform the nail trimming. A CNA, during a concurrent observation and interview, confirmed that the resident's fingernails were long and should be trimmed. An LVN stated that nail care was provided daily and that Sundays were designated for offering and trimming residents' nails, but was unable to provide documentation showing that this resident had been offered nail care for the previous one and a half months. The DON also stated that the resident's fingernails were too long and required trimming. Review of the resident's care plan dated 7/21/25 showed the resident was dependent on staff for bathing, personal hygiene, dressing, and grooming. Review of the facility's ADL policy dated 3/2018 indicated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, which was not carried out for this resident.
Failure to Monitor Opioid Pain Medication
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with COPD and fibromyalgia who was receiving morphine sulfate for severe left shoulder blade pain. On 12/11/25, the resident left the facility for an ophthalmology appointment after receiving PRN morphine, and when she returned at 10:40 a.m. she was over-sedated. The resident’s physician changed the morphine order to 7.5 mg by mouth every 12 hours as needed for moderate to severe pain, but the resident refused scheduled medications after returning to the facility. The resident’s MAR showed morphine 15 mg was administered at 4:00 a.m. and again at 7:19 a.m., which was 41 minutes early for a medication ordered every four hours as needed. The assigned LVN stated she did not monitor the resident for sedation after the resident returned from the appointment and acknowledged the resident remained sedated for the rest of the shift. The ADON confirmed there was no documented evidence that licensed nurses monitored the resident for over-sedation after her return to the facility. By early the next morning, the resident began repeatedly vomiting green liquid and was hard to arouse. The physician was notified and the resident was transferred to a GACH for evaluation. Hospital records documented pinpoint pupils, administration of Narcan for suspected opioid overdose, opioid-induced respiratory depression, acute encephalopathy, aspiration of sputum, and intubation for respiratory support, with a seven-day hospitalization beginning 12/12/25.
Improper Disposal of Controlled Medications
Penalty
Summary
The facility did not comply with its policy for securely disposing of controlled medications on two medication carts. During a concurrent observation and interview on 1/13/26 at 2:48 p.m. with LVN 3, the bottom drawer of the South 1 Medication Cart contained a pharmaceutical waste container with a removable lid, and the container held multiple intact pills. LVN 3 stated that the container held wasted medications, including narcotics, and explained that if a narcotic was not given because a resident refused or if the medication was dropped on the floor, she would discard it in the waste container after verifying with another nurse. During a concurrent observation and interview on 1/13/26 at 2:58 p.m. with LVN 4, the bottom of the North 2 Medication Cart also contained a pharmaceutical waste container with a removable lid, and it contained multiple intact pills. LVN 4 stated that the container held wasted medications, including narcotics, and said she would discard a narcotic in the waste container after verification with another nurse if it was not given or was dropped. LVN 4 also stated she would take the full pharmaceutical waste container to the biohazard room. The Pharmacy Consultant stated that when a narcotic medication was wasted, licensed nurses would dispose of it with other non-controlled medications in the pharmaceutical waste container with a removable lid, and that staff could remove medication from the container. During a concurrent observation and interview on 1/14/26 at 9:26 a.m. with the DON, both South 1 and North 2 Medication Carts were observed, the DON opened the removable lid of the pharmaceutical waste container, and stated there was a risk for diversion. The DON validated that both containers contained multiple intact medications. The facility policy stated that controlled substances are to be retained in a securely locked area with restricted access until destroyed by the DON and Consultant Pharmacist, and that controlled medications given to the DON for destruction are to be recorded in a perpetual inventory log.
Infection Control Failures With Oxygen Equipment, Linen Storage, and Hand Hygiene
Penalty
Summary
The facility failed to implement infection prevention and control measures related to respiratory equipment for a resident receiving oxygen. Resident 57 was admitted with diagnoses including shortness of breath and was observed receiving 2 liters of oxygen via nasal cannula in the room. The oxygen humidifier bottle was dated 12/28/25, and an LVN stated it should have been changed weekly. The Infection Preventionist reviewed the facility policy on respiratory therapy infection prevention, which stated that the bottle should be marked with the date upon opening and discarded according to MD orders; the IP also stated the humidifier should be changed weekly to prevent infection and ensure sufficient water was in the bottle. The facility also failed to maintain clean linen and clean diapers appropriately and failed to ensure hand hygiene was performed during resident care. During observation, a bag of clean linen and clean diapers was found on the floor in a resident's room, and both an LVN and a CNA stated they should not have been stored there. In a separate observation, CNA 2 entered and exited a resident's room to respond to a call light without washing hands before entering or after exiting the room. CNA 2 confirmed she was in the room to perform bedside care and stated she should have performed handwashing before entering and exiting the resident's room. The facility policy on handwashing indicated personnel are expected to adhere to hand hygiene practices before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to meet professional standards of quality for two residents with Type 2 diabetes when LVN 2 did not follow the facility policy and procedure titled, Insulin Pen Administration. Resident 51 had a physician order dated 12/5/25 for insulin lispro to be injected per sliding scale before meals. During medication pass observation on 1/14/26 at 11:13 a.m., LVN 2 administered 4 units of lispro subcutaneously using an insulin pen but did not prime the pen before giving the injection. Resident 98 also had Type 2 diabetes and a physician order dated 12/5/25 for insulin lispro to be injected per sliding scale before meals. During medication pass observation and interview on 1/14/26 at 11:24 a.m., LVN 2 administered 4 units of lispro subcutaneously using an insulin pen and again did not prime the pen before administration. During a concurrent interview and record review on 1/15/26, the DON reviewed the facility policy, which required a safety test before each injection by selecting 2 units, tapping the cartridge, pressing the push-button, and returning the dose selector to 0. The DON stated the insulin pen should be primed before each use to ensure the resident does not receive too much or too little insulin.
Untrimmed Nails and Untreated Toe Laceration
Penalty
Summary
Resident 57, who was admitted with diagnoses of Parkinsonism, muscle weakness, and wheelchair dependence, was observed lying in bed with exposed feet, untrimmed fingernails and toenails, and three scabs on the inner area of the right great toe. During interview, the resident stated that about a week earlier, while being transferred from the bed, the left foot nail dug into the right great toe and caused a cut, and that licensed nurses did not treat the cut. The resident also stated the nails were too long and wanted them cut. On a later observation, an LVN confirmed the resident’s fingernails and toenails were untrimmed and the inner right great toe had scabs. The LVN stated he was unaware of the injury before the observation and that there was no treatment ordered. The LVN also stated the resident’s untrimmed toenails and movement disorder could have caused the injury. The DON stated staff should have completed a change in condition and notified the physician about the right great toe laceration. Facility policy required regular nail care, podiatry referral for foot care needs, and notification of the physician for injuries of unknown source.
Sanitary Food Service Environment Not Maintained
Penalty
Summary
The facility failed to maintain a sanitary environment when, during a concurrent observation and interview on 1/12/26 at 2:25 p.m. with the Dietician in the kitchen, one soiled dish towel was observed placed on the surface of a table tray that contained clean cups. The Dietitian stated the soiled dish towel should have been disposed of in the soiled linen container. A review of the facility's policy and procedure titled, Sanitation Section 8, dated 2023, indicated that kitchen staff are responsible for cleaning and that cleaning products or sanitizers are not to be used in food preparation or food storage areas in any way that could result in contamination of exposed food items.
Failure to Update and Implement Revised Wound Care Orders
Penalty
Summary
The facility failed to ensure that a physician’s updated wound care order was implemented and reflected in the resident’s active treatment orders. A progress note completed by the wound physician on 12/4/25 documented that the resident’s right shin vascular wound (Wound #2) was not healed and included a specific treatment order: cleanse the wound with normal saline, pat dry, and apply Dakin’s flush with betadine to the eschar every day and as needed. However, the resident’s Order Summary Report continued to show an earlier treatment order for a venous wound to the right lower leg, directing staff to cleanse with wound cleanser, pat dry, apply betadine-soaked gauze to the wound bed, cover with a dry dressing, and wrap with kerlex every day or as needed. During an interview and concurrent record review with the ADON, the facility was unable to provide evidence that the 12/4/25 wound care order had been implemented or that the treatment order had been updated in the clinical record. The ADON acknowledged that the treatment order for the venous wound to the right lower leg was not updated with the new order and stated that it should have been. The facility’s own Medication Orders policy required that a current list of orders be maintained in each resident’s clinical record and that treatment orders specify the treatment, frequency, and duration, but this was not followed for this resident’s wound care. The report stated that this failure resulted in the physician’s order being incorrect and created the potential for the resident’s wound to worsen.
Failure to Provide Timely Toileting Assistance to High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, muscle weakness, and dementia, who was assessed as being at high risk for falls and totally dependent on staff for toileting, was left waiting for assistance for approximately 30 minutes after requesting help to use the bathroom. The resident's care plan and assessments clearly indicated the need for total assistance with toileting due to severe cognitive impairment and physical limitations. Despite these documented needs, the resident was not assisted in a timely manner after making the request to a CNA. During this period of waiting, the resident attempted to transfer herself to the bathroom without assistance. This resulted in an unwitnessed fall in the bathroom, where the resident was found on the floor with a laceration to the head and later diagnosed with a T5 compression fracture. Multiple staff interviews confirmed that the resident was known to be a high fall risk and required total assistance for toileting, and that the fall could have been prevented if the resident had been assisted promptly. Facility records, including the care plan, post-fall reviews, and staff interviews, consistently documented the resident's dependence and high risk for falls. The facility's own policy required appropriate support and assistance with activities of daily living, including toileting, for residents unable to perform these tasks independently. The failure to provide timely assistance directly led to the resident's fall and subsequent injuries.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews conducted with the Director of Staff Development (DSD) on January 8, 2025. The Nursing Staff Assignment and Sign-in Sheets (NSASS) for several months in 2024 and early 2025 revealed multiple instances where no RN was on duty for the required duration. Specifically, the absence of an RN for eight hours a day was noted on several days in July, August, September, October, November, and December 2024, as well as in January 2025. The facility's policy, titled 'Staffing, Sufficient and Competent Nursing,' dated August 2022, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the DSD confirmed during interviews that there were numerous days across the reviewed months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage. This failure had the potential to negatively impact resident care, although specific consequences or resident conditions were not detailed in the report.
Failure to Notify Representatives and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's representative and the state long-term care ombudsman in writing when two residents were transferred to the hospital. Resident 52, who had a history of diabetes and high blood pressure, was transferred to the hospital on two occasions: once for gastrointestinal bleeding and another time due to a fall. In both instances, the resident's family member, listed as the Responsible Party, was not notified. The first failure to notify was due to the nurse incorrectly listing the resident as his own representative, and the second was due to a full voicemail box. Resident 82 was transferred to the hospital, but the ombudsman was not notified. The facility's policy requires that when a resident is transferred or discharged, appropriate notice must be provided to the resident and/or legal representative, and a copy of the notice must be sent to the state long-term care ombudsman. However, the Social Services Designee admitted to not sending notifications to the ombudsman or the resident's representatives in these cases.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for three residents, which could potentially lead to unmet care needs. Resident 46 was observed in her wheelchair speaking in gibberish, and despite a CNA's ability to understand her needs, there was no care plan addressing her speech deficit. Resident 52 was transferred to the hospital for gastrointestinal bleeding and upon readmission, there was no care plan addressing this condition. Resident 79's records indicated incontinence, but there was no care plan to address this issue. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. These care plans should be updated when there is a significant change in condition, when outcomes are not met, or when a resident is readmitted from a hospital stay. However, the facility did not adhere to this policy, as evidenced by the lack of care plans for the identified issues in Residents 46, 52, and 79.
Failure to Use Communication Tool for Resident with Speech Impairment
Penalty
Summary
The facility failed to ensure the use of a communication tool for a resident with a speech impairment, identified as Resident 46. During an observation, the resident was noted to speak in short clips of gibberish with no discernable words. A Certified Nursing Assistant (CNA) who had cared for the resident for the past year stated she could understand the resident's needs. However, the Minimum Data Set (MDS) assessment indicated that the resident had unclear speech and was rarely or never understood. The Minimum Data Set Coordinator (MDSC) acknowledged that not using a communication tool would make it difficult for newer staff to understand and meet the resident's needs. The facility's policy on effective communication, dated February 2018, required staff to assist residents with language barriers to maintain effective communication, which was not adhered to in this case.
Failure to Follow Repositioning Policy for Dependent Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for repositioning residents, which was identified during interviews and record reviews. The policy required that residents in bed be repositioned at least every two hours, and those in a chair every hour, to prevent skin breakdown and promote circulation. However, the documentation for two residents, who were dependent on staff for mobility, showed inconsistent repositioning times that did not meet the policy's requirements. Resident 71, who was dependent on staff for all mobility tasks, was not repositioned consistently according to the facility's policy. The records indicated that the resident was turned at irregular intervals, often exceeding the two-hour requirement. This inconsistency was confirmed during an interview with the Assistant Director of Nursing, who reviewed the resident's medical records and noted the lack of adherence to the repositioning schedule. Similarly, Resident 52, who had a diagnosis of hemiplegia and was dependent on staff for mobility, was also not repositioned according to the policy. The documentation showed that the resident was turned at irregular intervals, failing to meet the one-hour requirement for residents in a chair. The Minimum Data Set Consultant acknowledged the discrepancy between the care plan and the actual needs of the resident, highlighting the potential for resident injury due to inaccurate care planning and documentation.
Failure to Assess Resident for Bowel and Bladder Training Program
Penalty
Summary
The facility failed to assess a resident, identified as Resident 79, for a Bowel and Bladder Training program, which is designed to help residents regain control over their bowel and bladder functions. During a review of Resident 79's medical records, it was found that the Bowel and Bladder Observation/Assessment indicated incontinence, with the resident always being incontinent of both bowel and bladder. However, there was no care plan for incontinence or documentation of the resident being placed on a bowel and bladder training program. The Minimum Data Set Consultant and Coordinator noted discrepancies in the documentation and acknowledged the absence of a bowel and bladder training program policy, which should have been in place given the resident's recent onset of incontinence.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to adhere to its policy and procedure for monitoring residents on anticoagulation therapy, specifically for two residents, Resident 10 and Resident 57. During a review of Resident 10's Medication Administration Record (MAR) for December and early January, it was found that there was no documentation of monitoring for adverse effects of the blood-thinning medication Eliquis, which was prescribed for deep vein thrombosis (DVT) prevention. The Assistant Director of Nursing confirmed the absence of such documentation, which was required by the facility's protocol. Similarly, for Resident 57, a review of the Order Summary Report revealed that there was no documentation of monitoring for adverse effects of the anticoagulant Xarelto, also prescribed for DVT. The Minimum Data Set Consultant acknowledged the lack of documentation. The facility's anticoagulation clinical protocol, dated November 2018, mandates that staff and physicians monitor for complications in individuals on anticoagulation therapy and manage related problems, including consulting with a physician if signs of bleeding are observed before administering the next dose.
Expired Medications and Insecure Storage Found in Facility
Penalty
Summary
The facility failed to implement its policy and procedure regarding expired medications for two residents, as expired medications were found in the medication administration carts. During an observation, three expired medications were found in the medication cart for one resident, including Hyosyne oral drops, Acetaminophen suppositories, and Bisacodyl suppositories, all with expiration dates of 9/19/24. Another resident had expired artificial tears lubricant eye drops with an expiration date of 8/2022 in the medication storage room. Licensed staff acknowledged that it was their responsibility to check and remove expired medications, which was not done, leading to the potential for expired medications to be administered. Additionally, the facility failed to ensure that a resident's medications were securely stored, as observed in the resident's room where five vials of Refresh Digital PF and a medication cup of unlabeled cream were found on the bedside table. The LVN confirmed that the cream was Voltaren gel, and there was no order for the resident to keep medication at the bedside. The resident had not been assessed for self-administration of medication, which should have been completed before allowing the resident to self-administer. The facility's policy required medications to be stored in locked compartments and for self-administration assessments to be conducted, which were not adhered to in this case.
Failure to Follow Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to adhere to the physician-prescribed therapeutic diet for a resident, identified as Resident 64, which could potentially lead to adverse outcomes. The Order Summary Report for Resident 64, dated March 12, 2024, specified a regular diet with chopped meat texture and thin liquids consistency. However, during an observation and interview on January 9, 2025, it was noted that the chicken fried steak on Resident 64's food tray was not chopped, rendering it uneaten. Resident 64, who had multiple missing teeth, expressed an inability to eat the unchopped steak. Licensed Vocational Nurse 1 confirmed that the steak should have been chopped according to the resident's dietary requirements. The facility's policy and procedure, dated October 2017, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care, taking into account the resident's informed choices, preferences, treatment goals, and wishes.
Failure to Explain Arbitration Agreements in Resident's Language
Penalty
Summary
The facility failed to ensure that the terms and conditions of its arbitration agreement were clearly explained to five residents, resulting in them signing the agreement without fully understanding that they were waiving their rights to a court proceeding in the event of a dispute. The residents involved primarily spoke Spanish, and the arbitration agreements were only available in English. The facility did not use certified interpreters to explain the agreements, relying instead on a staff member who was not certified to translate legal or medical terminology. Resident 26, with moderate cognitive impairment, and Resident 135, also with moderate impairment, both signed the English arbitration agreements without a certified interpreter present. Resident 57, Resident 70, and Resident 80, who were cognitively intact, also signed the agreements in English. Resident 80, who was very sick at the time of signing, stated he did not remember what he signed and was unsure if the documents were in English or Spanish. The Director of Marketing and a Certified Nursing Assistant (CNA) were involved in presenting and translating the arbitration agreements. The Director of Marketing admitted to encouraging residents to sign the agreements and acknowledged that the facility did not have agreements in Spanish. The CNA, who assisted with translations, was not certified to translate legal documents. The facility's policy required that arbitration agreements be explained in a manner that residents understand, considering their language and literacy, but this was not adhered to in these cases.
Failure to Provide Correct Discharge Information and Timely Ombudsman Notification
Penalty
Summary
The facility failed to provide proper discharge information to a resident, identified as Resident 1, as part of a 30-day notice. The Notice of Proposed Discharge (NOPD) given to the resident contained incorrect appeal information, directing the resident to contact the California Department of Public Health for complaints rather than the appropriate state agency for discharge appeals. This error was acknowledged by the Director of Nursing (DON) during an interview, who confirmed that the information provided was incorrect according to the facility's policy and procedure, which mandates that residents receive the correct contact details for appealing discharge notices. Additionally, the facility did not notify the Ombudsman in a timely manner regarding the facility-initiated discharge of Resident 1. The Ombudsman was informed three days after the notice was given to the resident, contrary to the facility's policy that requires notification within one day. The Social Service Director (SSD) admitted to the delay during an interview, and the DON confirmed that it was the SSD's responsibility to notify the Ombudsman. The facility's policy clearly outlines the responsibilities of the Social Services in preparing a resident for discharge, including informing relevant parties about the discharge.
Failure to Notify Responsible Party of Room Change
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a room change, resulting in a violation of the resident's rights. On August 15, 2024, a room change was conducted for two residents, where Resident 1 was moved to a different room to accommodate a request from Resident 2. The Director of Nurses (DON) confirmed that the room swap occurred on this date, but there was no documented evidence that Resident 1's responsible party was informed or consented to the change. During interviews and record reviews, it was revealed that the facility's protocol requires notification and consent from the resident and/or their responsible party before any room changes, with documentation in the clinical record. However, both the Licensed Vocational Nurse (LVN) and Social Service Designee (SSD) were unable to find any documentation indicating that Resident 1's responsible party was notified. The facility's policy and procedure also stipulate that all parties involved in a room change should be given advance notice, and the change should be documented in the resident's medical record, which was not adhered to in this case.
Failure to Schedule Neurology Appointment
Penalty
Summary
The facility failed to ensure that a resident was referred to a neurologist as ordered by the physician, resulting in a delay of care. The resident had a diagnosis of Guillain-Barre syndrome, a condition where the immune system attacks the nerves, and the physician had ordered a neurology consult. The receptionist, responsible for scheduling appointments, stated she attempted to schedule the neurology appointment but could not provide evidence of these attempts. The Director of Nursing confirmed the absence of documentation regarding the scheduling attempts in the resident's medical record. The facility's policy required social services or a designee to coordinate referrals and document them in the medical record, which was not adhered to in this case.
Lack of Full-Time Licensed DON
Penalty
Summary
The facility failed to ensure there was a full-time licensed Director of Nursing (DON), which had the potential to affect the needs of all 94 residents. Interviews and record reviews revealed that the previous DON had not worked at the facility since March 2024. An interim DON, who had completed the Registered Nursing (RN) program but was awaiting a testing date, was currently assigned to the position. However, this interim DON did not possess an RN license. The facility's policy and procedure indicated that the DON should be a licensed RN employed full-time, which was not the case at the time of the survey.
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 193 citations issued within 25 miles in the last 12 months — 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 Porterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Medical Center | 0.2 mi | ★★★★★ | 1 | 0 |
| River Walk Care Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Sierra Valley Rehab Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Gateway Post Acute | 1.5 mi | ★★★★★ | 0 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 10.5 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.