Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shasta View Care Center during CMS and state inspections, most recent first.
Resident Council call-light concerns were not documented on the required Department Response Form or otherwise shown as addressed. Three residents with good cognition reported prolonged call-light waits, including waits of 30 minutes to 2 hours, and meeting notes confirmed the issue was raised multiple times. The AD acknowledged the form was not completed, and the Admin confirmed the form was meant to capture resident concerns, the facility response, and follow-up.
A resident at risk for PI developed a Stage 4 coccyx wound plus DTIs to the right heel and right big toe after staff failed to identify worsening skin changes, did not consistently document turning and repositioning, and delayed key wound care interventions. The resident’s skin assessments were inaccurate, the LAL mattress was delayed, the WD evaluation was delayed, and a wound culture result was not followed up, leaving the coccyx wound infection untreated until hospital admission for IV antibiotics and aggressive wound care.
The facility failed to ensure that two LNs and three CNAs had completed and maintained required competency and orientation documentation. Files reviewed showed that the LNs had only limited competencies such as hand hygiene and PPE, while one CNA had a blank, unsigned orientation section, one registry CNA had only a self-evaluation skills checklist, and another registry CNA had no file or skills checklist available.
Infection control practices were not maintained during resident care. A CNA provided care to two residents on EBP without the required gown and gloves, and an RN/TN repeatedly touched her mask and opened a resident’s door with dirty gloves while giving skin care. During wound care for a resident with a wound and urinary catheter, the treatment nurse did not clean the overbed table or use a barrier pad, placed a box of gloves on the resident’s bed, and wiped unused wound care supplies with incompatible wipes before returning them to the cart.
A resident with MI, SOB, and a hip replacement was assessed as needing substantial to maximal assistance to roll in bed and being at risk for PI. The care plan only said staff should encourage repositioning as tolerated and did not direct CNAs or LNs to assist with turning and repositioning, despite the resident being unable to reposition independently. A family member reported the resident was left in a wheelchair for hours without repositioning, and staff later observed the resident needing almost all of the help to turn and reposition.
Oil-Based Product Used on Resident Receiving Oxygen: A resident with COPD and respiratory failure was receiving oxygen via nasal cannula when an TN mixed zinc oxide with petroleum jelly and applied it to the resident's buttocks. The TN stated the product was safe because it was not applied at the nose, while the DON confirmed petroleum jelly could not be used with oxygen because it was a fire hazard.
Medication Given Without Physician Order: A resident with HTN and chronic pain had a rash under both breasts and in the apron area, with care planned to follow a physician's order. The TN reviewed the chart, confirmed no skin treatment orders were present, then applied miconazole cream and nystatin powder without an order. The TN later stated she decided the treatment herself and would call the WD afterward; the DON, IP, and WD all confirmed no physician order was in place before the antifungal treatment was given.
Unsafe and Unsanitary Rehab Room Condition: The rehab room had an open wall and ceiling area with a large piece of plastic hanging down and draining roof leakage into a 5-gallon bucket containing stagnant, foul-smelling water and trash. The MD and OT confirmed the condition, and the MD stated the setup had been placed after water damage from a rainstorm and that the OT said it had been present for about three weeks.
A resident with MS, chronic pain syndrome, and other serious diagnoses had PRN pain meds ordered and pain monitoring required every shift, but the EMAR showed multiple doses documented as ineffective or unknown without other interventions or MD notification. The record also showed the resident’s Percocet was not consistently administered as ordered, and both an LPN and the resident reported long waits for pain medication and ongoing uncontrolled pain; the MD confirmed staff had been late and had not updated him about the pain not being controlled.
Two residents with mental health disorders and COPD were issued 30‑day discharge notices that did not comply with facility policy or regulatory requirements. The notices lacked key elements such as the date given, planned discharge date, specific discharge location, complete reasons for discharge, and contact information for the local Ombudsman and the state agency protecting the rights of individuals with mental illness. One resident’s records showed no safe or reasonable discharge location and ongoing need for staff assistance with medical needs, while the other resident reported being told by the ADON they were being discharged because they were "high functioning" without any discharge plan in place. The DON confirmed both notices were incomplete, and the Administrator acknowledged there was no firm discharge plan for either resident when the notices were issued.
A resident with borderline personality disorder and anxiety was prescribed PRN hydroxyzine for anxiety-related worry that their needs were not being met, and the care plan directed staff to monitor and track anxiety-related behaviors. The facility’s policy required medications to be monitored for effectiveness, but from admission through the survey period there was no behavioral monitoring in place to track signs or symptoms of anxiety. During an interview and record review, the DON confirmed the absence of behavioral monitoring, despite acknowledging its purpose to count episodes and assess medication effectiveness, resulting in failure to ensure the resident’s drug regimen was free from unnecessary medications.
The facility did not follow its Influenza Exposure Control policy when several residents with significant comorbidities, including COPD, pneumonia, dementia, diabetes, heart disease, chronic kidney disease, and cirrhosis, tested positive for Influenza A. After learning from a hospital that a resident was influenza-positive and while lacking influenza test kits on site, the IP tested only roommates of positive residents and those with flu-like symptoms, without reviewing the facility’s policy. A new consultant RN advised the IP on testing without first reviewing the policy and later acknowledged more residents should have been tested. The DON confirmed the facility was not prepared for an influenza outbreak, that the policy was not followed, and that all residents should have been tested due to shared dining, activities, and sick employees, and the report states this failure put residents, staff, and families at risk for Influenza A and potential serious negative clinical outcomes.
A resident with multiple complex conditions, including stroke-related paralysis, diabetes, COPD, chronic kidney disease, pressure ulcers, and moderate cognitive impairment, had a new physician order for a wound vac to a left hip pressure ulcer with specific dressing change and pressure settings. Despite a facility policy requiring care plan review and revision upon status change, the comprehensive care plan was not updated to include the new wound vac interventions or resident-specific considerations, such as the resident allowing only one nurse to perform wound care and possible involvement of a family member if treatments were refused. The DON confirmed during interview that the wound care plan had not been revised and needed to be more specific for wound care, and the report notes this failure had the potential to result in discomfort, further wound deterioration, and possible infection and hospitalization.
Two residents, both cognitively intact and with complex medical histories, were financially exploited by an Activity Assistant who solicited money, manipulated them into providing access to their bank cards, and failed to provide receipts for transactions. The staff member also made unauthorized purchases and discussed personal financial issues with residents, causing distress and violating facility policies regarding resident funds.
A resident with multiple medical and mental health conditions reported that an Activity Assistant received money from her for services that were not provided. The facility did not complete a thorough investigation, failed to interview all relevant parties, submitted the required abuse investigation report to CDPH late, and did not communicate findings or reimburse the resident as indicated. The DON and Regional Nurse Consultant confirmed the investigation was incomplete and not in accordance with facility policy.
Staff failed to follow infection control protocols for COVID-19, including improper use of PPE and lack of hand hygiene when entering and exiting a room with a COVID-19 positive resident. Both a CNA and an activity assistant did not comply with facility policy or posted precautions, resulting in lapses such as not wearing required PPE, not performing hand hygiene, and not changing PPE between residents.
A resident with bipolar and borderline personality disorder was prescribed Aripiprazole, but the informed consent form for this psychotropic medication was incomplete, lacking both the dosage and the diagnosis. Staff confirmed the consent was missing required information, resulting in the resident not being fully informed about her treatment.
A resident with PTSD, bipolar disorder, anxiety, borderline personality disorder, suicidal ideations, and other SMHIs was admitted with an inaccurate PASARR Level 1 that stated no serious mental health diagnoses were present. Staff confirmed the screening was wrong and could not identify who ensured accuracy before admission. A later PASARR showed serious mental illness and required a Level 2 review, but facility staff did not respond to the State agency’s attempts to complete the evaluation, and the case was closed.
A resident with severe cognitive impairment and multiple medical conditions was transferred to another facility without proper consent from the resident or his Responsible Party. The transfer was initiated without documentation of an IDT meeting or a 30-day discharge notice, and was only stopped after the Responsible Party intervened. The resident experienced distress due to the lack of communication and proper procedure.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that a resident received treatment and supports for daily living in a safe manner.
The facility did not have an RN on duty for at least 8 hours on multiple days, as confirmed by staffing records and the Interim DON, resulting in noncompliance with required RN coverage.
Surveyors found that kitchen staff failed to air dry a blender after cleaning, used two nonstick pans with excessively worn surfaces, and did not properly clean the stove exhaust hood, which had greasy, black debris. The CDM confirmed these issues, which affected food preparation for 52 residents with different diet requirements.
The facility did not maintain its walk-in freezer in safe operating condition, as evidenced by internal temperatures well above freezing, melted and thawed food items, and excessive ice build-up on the floor. Structural issues such as dry rot, exposed insulation, and missing exterior walls were also observed, with staff confirming the freezer was not functioning as required for safe food storage.
The facility did not provide the required minimum square footage per resident in 12 rooms, with multiple rooms set up to accommodate three residents each despite not meeting regulatory size standards. Residents in these rooms had reasonable privacy and adequate space for personal belongings, and no complaints about room size were reported.
Multiple residents did not receive care in accordance with physician orders and professional standards, including administration of oxygen without a physician's order, failure to administer prescribed medication due to pharmacy delays without a physician's hold order, improper wound care treatment, and failure to change and label oxygen tubing as required by care plans and facility policy.
A resident with chronic pain and syncope, who regularly used physician-ordered pain medication and oxygen, did not have care plans developed for pain management or oxygen use. Despite facility policy and staff confirmation of these needs, the care plans were missing, as verified by the DON.
A resident with significant physical and mental health needs did not receive timely PT services due to an unresolved insurance transfer after admission from another facility. The resident, who required substantial assistance and had a documented need for skilled PT, only received therapy once because staff did not help resolve the insurance issue, resulting in a violation of resident rights.
A resident who was cognitively intact and dependent on staff for daily living activities reported that an RN was rude during a disagreement about treatment timing, leading to feelings of disrespect. The incident was confirmed by the DON and administrator as a violation of the resident's dignity and rights, despite facility policies requiring respectful treatment of all residents.
A resident with quadriplegia and cognitive intactness was verbally abused by a CNA during a transfer with a Hoyer lift, causing the resident to feel scared and hurt. The CNA yelled at the resident and made derogatory remarks, which was witnessed and confirmed by other staff. The incident was documented in the resident's record and the CNA's employee file.
A resident with dementia, who was known to be resistive to care and preferred afternoon showers, became combative during a morning shower when a CNA did not follow the care plan intervention to leave and return later. The care plan also failed to include the resident's preference for afternoon showers, leading to an incident where the resident's wrist was injured during the shower. The DON confirmed that the care plan did not reflect the resident's needs and that staff did not follow established interventions.
A resident's care plan was not updated after a significant change in condition following hospitalization. Despite new orders for comfort care and medications, the care plan remained unchanged, leading to unrecognized care needs. The facility's administrator and DON confirmed the oversight.
A facility failed to conduct a required skin assessment for a re-admitted resident with complex medical needs, including pressure ulcers and new comfort care orders. The oversight was due to miscommunication and lack of follow-up among nursing staff, despite clear policy requirements for assessments upon re-admission.
The facility failed to thoroughly investigate an abuse allegation involving two residents and did not submit the required 5-day investigation results to CDPH. The incident involved one resident aggressively squeezing another's wrists and shouting threats. The facility's policy required interviews with all involved parties, but the 5-day follow-up report lacked statements from staff witnesses and was not submitted to CDPH, potentially leaving abuse allegations uninvestigated.
A facility failed to verify a staff member's nursing license before assigning her nursing duties. The staff member, previously a CNA, reported passing her LVN exam but had no online license verification due to a claimed spelling error. Despite this, she worked unsupervised on night shifts. The facility's policy required online verification, which was not followed, leading to the discovery that she had not passed her exam.
The facility failed to employ a full-time RD or qualified nutritional professional, resulting in unsafe food service practices for all residents. Observations revealed improper food safety protocols, such as inadequate freezer and dishwasher temperatures, and poor sanitation procedures. The RD, UDM, and CDM did not ensure dietary staff had required competencies, leading to unsafe food handling. Additionally, unresolved issues from kitchen audits further compromised food safety.
A resident experienced severe weight loss due to the facility's failure to maintain nutritional status. Despite recommendations for nutritional supplements, no orders were placed, and the care plan was not updated. The resident's weight was not consistently monitored, and significant changes were not communicated to the physician. The resident's ability to communicate deteriorated, and there was inadequate involvement of her Durable Power of Attorney in care planning.
The facility failed to maintain 24-hour licensed nursing coverage on multiple dates in the first and second quarters of 2024, as revealed by PBJ data. The administrator confirmed the reporting of these staffing deficiencies to CMS and did not contest the findings.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, during the first and second quarters of 2024. This was identified through a review of the Payroll-Based Journal (PBJ) data, which showed multiple dates without RN coverage. The facility administrator confirmed the issue during an interview.
The facility failed to ensure competent dietary staff, with eight out of ten lacking required training. Issues included improper dishwashing procedures and incorrect freezer temperatures, risking foodborne illness for 49 residents. The CDM and RD noted ongoing staffing and equipment challenges.
The facility failed to maintain proper food storage and sanitation practices, with freezer temperatures above required levels, improperly dated food items, and inadequate sanitation procedures. Kitchen staff were unable to demonstrate correct dishwashing techniques, and pests were observed in the kitchen. Management oversight was insufficient, with part-time CDM and infrequent RD visits, leading to unresolved issues.
The Administrator failed to ensure effective oversight and resources, leading to deficiencies in dietary services and resident care. The lack of a full-time RD or CDM resulted in unsanitary food practices, while dietary services did not follow national standards, risking infection and foodborne illness. Additionally, the Administrator did not ensure proper care for residents, leading to severe weight loss, unnecessary medical treatment, and inadequate fall care plans.
The facility's Governing Body failed to manage the dietary department, resulting in Immediate Jeopardy due to inadequate oversight and monitoring. The Registered Dietician identified numerous sanitation and operational issues, such as debris in kitchen drawers, mold in the ice machine, and malfunctioning equipment. Despite being informed, the Administrator did not implement a Performance Improvement Plan, and the issues persisted, with no structured plan to address the deficiencies.
The facility's ineffective QAPI committee resulted in several deficiencies, including lack of oversight in dietary services, failure to address insidious weight loss in a resident, unmet social service needs, and inadequate fall care plans. The administrator was aware of these issues but failed to implement corrective actions, and the QAPI meetings lacked proper documentation.
The facility's QAA program was ineffective, lacking a full-time RD or CDM for dietary oversight, leading to Immediate Jeopardy. Dietary services failed to meet cleanliness and safety standards, and staff did not address weight loss in a resident. Social Services did not meet care needs for several residents, and fall care plans were not timely initiated or revised. The facility had not started any PIPs, as shown by a blank document during a QAPI review.
The facility experienced multiple equipment failures, including non-functioning call light systems in two rooms, a walk-in freezer not maintaining the required temperature, and a broken dishwasher. These issues led to potential risks for residents, such as delayed assistance and food safety concerns. The Plant Operations Supervisor confirmed the call light issues, while the Certified Kitchen staff and administrators were unaware of the freezer's temperature problem.
The facility failed to maintain an effective pest control program, leading to flies and other pests throughout the building. Residents reported flies landing on them during meals, and observations confirmed the presence of pests in the kitchen and dining areas. Despite the installation of flytraps and weather stripping, the pest issue persisted, compromising residents' right to a pest-free environment.
The facility did not accommodate the needs and preferences of three residents in an overcrowded room, leading to safety hazards and restricted independence for a resident with mobility impairments. The room contained multiple obstacles, including fans and a portable air conditioner, which hindered access to personal items and the bathroom. Staff confirmed the presence of trip hazards and unsecured cords, but no alternative solutions were provided to ensure resident safety.
The facility failed to update care plans for three residents after significant incidents. A resident with multiple falls, including one with injury, did not have a fall care plan revised. Another resident experienced two Hoyer lift incidents without care plan updates. A third resident with severe cognitive impairment and high fall risk had two falls with injuries, yet no care plan was revised. The lack of timely care plan revisions left staff without updated guidance on necessary interventions.
A resident with a suprapubic catheter experienced a delay in care due to the facility's failure to assess and reevaluate the catheter's necessity. Despite symptoms of a UTI and pain, the facility did not conduct timely evaluations or communicate effectively with the physician. This led to the resident's hospitalization for treatment. The facility's lack of documentation and follow-up on a urology referral contributed to the deficiency.
The facility failed to provide adequate social services and care planning for four residents. A resident received unnecessary psychiatric evaluations, another missed a quarterly care conference, a third lacked a discharge care plan, and a fourth did not receive a required urology consult. These deficiencies were due to miscommunication and oversight by the social services director and staff.
Resident Council Call-Light Concerns Were Not Documented or Addressed
Penalty
Summary
The facility failed to ensure that concerns raised by three Resident Council members about long call-light wait times were addressed, as no Department Response Form was completed to document any follow-up or actions taken. The facility’s policy for Resident Council Meetings stated that the Activity Director would serve as a liaison for resident concerns and that the facility would act on those concerns, make recommendations, and attempt to accommodate residents. Resident 1 was admitted with flaccid hemiplegia affecting the left dominant side and chronic pain, had a BIMS score of 15 out of 15, and reported waiting up to two hours for staff to respond to a bathroom call light and then 40 minutes after being assisted. Resident 2 was admitted with a broken right hip and difficulty walking, had a BIMS score of 14 out of 15, and reported call-light waits up to an hour during meal tray delivery. Resident 3 was admitted with difficulty walking and hypertension, had a BIMS score of 13 out of 15, and reported 30-minute call-light wait times, including when helping roommates who needed assistance. Resident Council meeting notes from multiple meetings documented that call lights were not being answered in a timely manner, and the Activity Director confirmed the concerns were discussed but no Department Response Form had been completed. The Activity Director stated this was due to a lack of knowledge about using the form. The Administrator reviewed a blank Department Response Form and confirmed it was intended to capture resident concerns, the facility’s response, and any follow-up regarding a solution, and stated that follow-up should be done.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
Resident 1 developed three facility-acquired pressure injuries: a Stage 4 pressure injury on the coccyx, a deep tissue pressure injury to the posterior right heel, and a deep tissue pressure injury to the tip of the right big toe. Resident 1 was admitted with myocardial infarction, shortness of breath, and a left artificial hip joint, had a BIMS score of 8, required substantial to maximal assistance with rolling and transfers, and was identified as being at risk for pressure injuries on admission. The admission MDS also indicated Resident 1 had moisture-associated skin damage and was not on a turning or repositioning program. Licensed nurses and CNAs did not identify the progression of skin changes over a 24-day period, and the facility’s documentation showed repeated skin assessments with no concerns until the coccyx wound was later identified. One nurse documented the wound as being on the sacrum and not in a pressure area, although the ADON confirmed it was actually on the coccyx and in a pressure area. The nurse later stated she relied heavily on CNA reports and prior EMR information and had not visually inspected Resident 1’s skin until the coccyx pressure injury was identified. CNA documentation did not show that Resident 1 was turned and repositioned every two hours, and staff interviews confirmed that turning and repositioning was not consistently documented or verified. The facility also delayed key wound-related interventions. A low air loss mattress was ordered after the coccyx pressure injury was identified, but it was not provided until 11 days after the injury was discovered and 3 days after the physician order. The wound doctor did not first assess the coccyx wound until 10 days after the physician recommended wound doctor follow-up. In addition, a wound culture ordered for the coccyx wound was not followed up to completion, the final culture report was not obtained, and no antibiotic treatment was ever ordered for the infection. The resident was later admitted to the hospital for an infected sacral wound requiring IV antibiotics and aggressive wound care.
Missing Competency and Orientation Documentation for Nursing Staff
Penalty
Summary
The facility failed to ensure that two Treatment Nurses and three Certified Nursing Assistants had the required competencies and orientation needed to provide safe and effective care. The facility’s policy on competent nurse staffing stated that licensed nurses were to demonstrate appropriate skills and competencies for resident care, including administering medication, obtaining physician orders, providing wound care, performing accurate assessments, documenting, and recognizing changes in condition. The orientation policy stated that new and contracted staff were to receive an effective orientation process, including a preceptor who would verify competency in a skill, and that the Director of Staff Development was responsible for maintaining orientation plans and submitting them to Human Resources once completed. Record review and interviews showed that TN C and TN D each had only hand hygiene and donning/doffing PPE competencies in their files, with TN C also having a wound care competency, but no other competencies for licensed nurse duties. CNA F’s orientation form had a blank, unsigned section for Day 2 training topics, including CNA job duties, resident rights, dementia, choking residents, and turning and repositioning. CNA K, who worked through a registry, had only a self-evaluation skills checklist and no facility competency checklist. CNA L, also registry, had no employee file or skills checklist available for review, and the facility had not maintained competency or orientation documentation for these staff members.
Infection Control and Wound Care Practices Not Maintained
Penalty
Summary
Infection control practices were not maintained during resident care for two residents who were on enhanced barrier precautions (EBP). One resident had diagnoses of myocardial infarction and shortness of breath and had a wound and urinary catheter; another resident had diagnoses of hypertension and chronic pain. During observation, a CNA repositioned the first resident without wearing a gown even though EBP signage was posted and the resident had a wound and urinary catheter. During another observation, a CNA assisted the second resident with applying deodorant and had just assisted with a shower without wearing a gown or gloves, despite EBP signage being posted outside the room. Standard precautions were also not followed by a treatment nurse while providing skin care to the second resident. The nurse performed a skin assessment and applied zinc oxide cream and antifungal cream, but repeatedly pulled her face mask down to her chin and back up over her mouth while wearing dirty gloves. The nurse also opened the resident’s door while still wearing the dirty gloves and then cleaned the door handle. The nurse confirmed the observation and acknowledged that touching the mask and opening the door with dirty gloves was an infection control concern. In addition, wound care for the first resident was not performed using the facility’s clean dressing change process. The treatment nurse removed items from the resident’s overbed table, but the table was not cleansed and no disposable barrier pad was placed before clean wound care supplies were set on it. The nurse placed a box of gloves directly on the resident’s bed, then returned it to the wall rack after care. Unused wound care supplies were placed on the wound cart outside the room and wiped with Micro-Kill Two wipes before being returned to the cart. The nurse confirmed the observation, and the infection preventionist confirmed the table should have been cleaned with a barrier pad, the gloves box should not have been placed on the bed, and the unused supplies should not have been cleaned with those wipes.
Care plan lacked turning and repositioning instructions for a resident at risk for pressure injuries
Penalty
Summary
The facility failed to ensure staff developed and implemented a resident-specific care plan for one resident who was at risk for pressure injuries. The resident was admitted with diagnoses including myocardial infarction, shortness of breath, and a left artificial hip joint, and the admission MDS indicated the resident had a BIMS score of 8, required substantial to maximal assistance to roll in bed, and was at risk for developing pressure injuries. The resident’s family member reported visiting almost daily and stated that between 2/25/26 and 4/7/26 the resident was observed sitting in a wheelchair for three hours or longer without repositioning, and that the resident could not turn or reposition without staff assistance. During observation, the resident was seen lying on their back, and a CNA later entered and provided almost all of the help needed to turn and reposition the resident. Review of the resident’s care plan titled Potential for Pressure Ulcer Development showed that staff were to encourage the resident to reposition as often as tolerated, but it did not include specific instructions directing CNAs and LNs to assist with turning and repositioning. The MDS Nurse and MDS Resource Nurse confirmed the resident was at risk for pressure injuries and stated the care plan should have reflected that staff would assist with turning and repositioning as tolerated because the resident could not reposition independently.
Oil-Based Product Used on Resident Receiving Oxygen
Penalty
Summary
The facility did not ensure one of two sampled residents was free from accident hazards when Treatment Nurse C used an oil-based product on Resident 2, who was receiving oxygen. Resident 2 was admitted with COPD and acute and chronic respiratory failure with hypoxia and hypercapnia, and their annual MDS indicated they received oxygen therapy. During an observation, Resident 2 was in bed with an oxygen concentrator running at 3 liters per minute and was wearing a nasal cannula. While observing Resident 2's buttocks, TN C asked about allergies to zinc oxide or petroleum jelly, then mixed zinc oxide and petroleum jelly together and applied the mixture to Resident 2's buttocks. When asked later whether petroleum jelly was contraindicated for residents receiving oxygen, TN C stated it could be applied to the skin because it was placed on the resident's bottom, not at the nose. The DON later confirmed petroleum jelly could not be used on residents who received oxygen because it was a fire hazard and stated, "It's not safe."
Medication Given Without Physician Order
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when Treatment Nurse C administered antifungal medication without a physician's order for one resident. The resident was admitted with diagnoses of hypertension and chronic pain, was their own responsible party, and had a care plan noting a rash underneath both breasts with treatment to be given per physician's order. During a concurrent observation, interview, and record review, Treatment Nurse C reviewed the resident's physician orders before entering the room and confirmed there were no skin treatment orders present, yet assessed the resident's skin and applied miconazole cream underneath both breasts and nystatin powder to the apron area. During interview, Treatment Nurse C confirmed the antifungal cream and powder were applied without a physician's order and stated she decided what treatment was needed after assessing the skin, then called the Wound Doctor afterward for recommendations and would obtain an order later. The DON confirmed a physician's order was required before any treatment or medication was administered, and the DON and Infection Preventionist confirmed no order was present in the resident's record for the antifungal cream or powder. The Wound Doctor also confirmed the nurse should have called for treatment recommendations and obtained an order before providing treatment, and stated Treatment Nurse C did not call for recommendations regarding the resident's skin assessment.
Unsafe and Unsanitary Rehab Room Condition
Penalty
Summary
The facility failed to maintain the rehabilitation room in a safe and sanitary condition when a large piece of plastic bag was hanging from an open area in the wall and ceiling and was draining roof leakage water into a five-gallon bucket. During observation, the bucket contained stagnant, foul-smelling water and trash. The area around the bucket included weighted exercise bags on the wall, a physical therapy table, a wooden set of stairs, a scale, a wheelchair leg rest, and a piece of exercise equipment placed close to the bucket. During the observation, the Maintenance Director and Occupational Therapist confirmed the condition of the room and the water collection setup. The Maintenance Director stated the plastic and bucket had been placed there on 1/6/26 after the rehabilitation room ceiling sustained water damage during a rainstorm and a section of the wall had been removed because it was leaking. The Occupational Therapist stated the condition had been present for three weeks. The Maintenance Director also indicated the water inside the plastic was caused by rainstorms the week prior to the observation, and the inside of the plastic was wet because zip ties trapped the water inside.
Delayed and Incomplete Pain Management
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident who required pain services. The resident was admitted with multiple diagnoses including primary progressive multiple sclerosis, chronic pain syndrome, epilepsy, anxiety, depression, post-traumatic stress disorder, insomnia, migraine, cramp and spasm, bed confinement, and hypertension. The resident’s most recent MDS indicated no cognitive problems, with a BIMS score of 14 out of 15. The resident had active orders for pain monitoring every shift, non-pharmacological pain interventions every shift, and multiple PRN pain medications including acetaminophen, ibuprofen, and Percocet. The EMAR for April 2026 showed several PRN pain medication administrations documented as ineffective or unknown for effectiveness, with no other interventions documented and the MD not updated. Specifically, doses on 4/3, 4/24, 4/25, and 4/27 were documented as ineffective, and doses on 4/1, 4/3, 4/6, 4/7, 4/18, 4/22, and 4/23 were documented as unknown for effectiveness. The record also showed that the resident’s Percocet 5-325 mg order was not consistently given every six hours as ordered; it was administered every six hours for only two days, and on the remaining days in April it was given two to three times per day only. During interview, an LPN confirmed the resident had a lot of problems getting pain medication on time as ordered and stated the resident had to wait for hours on some shifts. The resident stated he was tired of begging for pain medication and that almost all nurses made him wait for hours, describing significant ongoing pain. The MD confirmed some nurses had been late with the resident’s pain medication and stated no one had updated him about the resident not having pain controlled, despite his expectation that staff call if the medication was not effective.
Incomplete Discharge Notices and Lack of Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own transfer and discharge policy and federal requirements when issuing 30‑day discharge notices to two residents. The facility’s policy required that discharge notices be understandable to the resident and include the specific reason for discharge, the discharge date, the exact location (with address) to which the resident would be discharged, the name and address of the local Ombudsman, and information for the state agency responsible for protecting the rights of individuals with mental health illnesses. The policy also required that the notice be provided 30 days prior to discharge and that the Ombudsman’s office be notified when a 30‑day discharge notice was issued. Resident 1, who had borderline personality disorder, bipolar disorder, suicidal ideation, COPD, bowel and bladder incontinence, and functional limitations requiring assistance with ADLs, received a Notice of Involuntary Transfer or Discharge dated 2/20/26. The notice stated that the resident would be discharged to a home or apartment of their choice in another city but did not include a specific address. It listed reasons for discharge as improved health, no longer requiring skilled care, and the facility’s inability to meet the resident’s needs, but omitted information on how to contact the state agency responsible for protecting the rights of people with mental health illnesses. The DON confirmed that the IDT‑Notice of Transfer/Discharge for this resident was incomplete, missing the date the notice was provided, the planned discharge date, specific discharge location, the reason for discharge, Ombudsman and mental health rights contact information, and signatures from the resident and ADON. The record also showed that the resident’s discharge care plan and care conference summary documented that the resident did not have a safe or reasonable discharge location and required staff assistance for medical needs. Resident 2, who had bipolar disorder, schizoaffective disorder, COPD, and intact memory, was also issued an IDT‑Notice of Transfer/Discharge dated 2/20/26. The DON confirmed this notice was incomplete in the same ways: it lacked the date it was provided to the resident, the planned discharge date, specific discharge destination information, the reason for discharge, and contact information for the local Ombudsman and the state agency responsible for protecting the rights of people with mental health illnesses. Resident 2 reported being told by the ADON that they were being discharged in 30 days because they were “high functioning” and confirmed there was no discharge plan in place when the notice was given. The Administrator stated that there was no firm discharge plan in place for either resident at the time the 30‑day notices were issued and that the Administrator was not aware the notices had been provided, despite the expectation that a solid discharge plan should exist before issuing such notices.
Failure to Monitor PRN Anti-Anxiety Medication Use
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary medications when they did not implement behavioral monitoring for an as-needed anti-anxiety medication. The facility’s undated “Unnecessary Drugs” policy stated that medications would be monitored to ensure effectiveness. The resident was admitted with diagnoses of borderline personality disorder and anxiety and was her own responsible party. The resident’s anxiety care plan, dated 11/23/25, directed staff to monitor and track the resident’s behaviors. A physician’s order dated 11/22/25 prescribed hydroxyzine 50 mg every six hours as needed for anxiety, targeting symptoms of worry that needs were not being met due to anxiety. During an interview and concurrent record review on 2/26/26, the DON confirmed that from admission through 2/26/26 there was no behavioral monitoring in place to track signs or symptoms of anxiety, and stated that the purpose of such monitoring is to count the number of episodes and monitor the effectiveness of the medication. This lack of behavioral monitoring for the resident receiving PRN hydroxyzine for anxiety resulted in the facility not ensuring the resident’s medication regimen was monitored for effectiveness as required by facility policy and the resident’s care plan, and had the potential for the resident to not maintain their highest practicable mental, physical, and psychosocial well-being.
Failure to Follow Influenza Testing Policy During Outbreak
Penalty
Summary
The facility failed to implement its Influenza Exposure Control policy when multiple residents tested positive for Influenza A and timely, comprehensive testing of exposed residents was not conducted. The policy, revised in January 2026, required a multifaceted approach to preventing influenza transmission, including testing ill persons in both affected and previously unaffected units. Four residents with significant comorbidities, including respiratory failure, COPD, pneumonia, dementia with agitation, diabetes, heart disease, chronic kidney disease, and cirrhosis, were confirmed positive for Influenza A. The Infection Prevention Nurse (IP) reported that the facility first became aware of influenza in the building when notified by a local hospital that one resident was positive, and also stated that the facility initially had no influenza test kits on hand. The IP acknowledged that she only tested residents who shared rooms with influenza-positive residents and those with flu-like symptoms, and confirmed she did not review the facility’s influenza exposure policy before determining who to test. A consulting RN, who had been at the facility for about a week, confirmed she advised the IP without reviewing the facility’s policy and later acknowledged that more residents should have been tested. The DON confirmed that the facility was not prepared for an influenza outbreak, that the influenza policy was not followed for resident testing, and that all residents should have been tested because they dined and participated in activities together and there were sick employees. The report states that this failure to follow the infection control policy for testing put residents, staff, and families at risk for contracting Influenza A and had the potential to result in serious negative clinical outcomes.
Failure to Revise Wound Care Plan After New Wound Vac Order
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s wound care plan after a new physician order was issued for a wound vacuum-assisted closure (wound vac) to the left hip pressure ulcer. The facility’s policy titled “Care Plan Revisions Upon Status Change,” revised in 2025, requires that the comprehensive care plan be reviewed and revised as necessary when a resident experiences a status change, and that the care plan be updated with new or modified interventions. Record review showed that the resident had an order dated 1/20/26 for a wound vac to the left hip, with instructions to change the dressing every Monday, Wednesday, and Friday on the AM shift and as needed, and to ensure the wound vac dressing was sealed and intact with a setting of 125 mm/Hg every shift every day. However, the corresponding care plan was not updated to include these new wound vac interventions. The resident involved had multiple significant diagnoses, including paralytic syndrome following cerebral infarction affecting the right side, diabetes, COPD, dysphagia, pressure ulcers, chronic kidney disease, hypertension, a rare skin carcinoma, pulmonary embolism, and chronic pain. The most recent MDS indicated a moderate cognitive deficit with a BIMS score of 9/15 and total dependence on staff for all ADLs. During concurrent review of the care plans and interview on 2/5/26, the DON confirmed that the wound care plan needed revision to include specific interventions related to the new wound vac order and acknowledged that the care plan was not revised and needed to be more specific for wound care, including resident-specific considerations such as the resident allowing only one nurse to complete wound care and the potential involvement of a family member if the resident refused treatments. The report states that this failure had the potential for the resident’s wound care not to be managed appropriately, which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization.
Failure to Protect Residents from Financial Abuse and Exploitation by Staff
Penalty
Summary
The facility failed to protect two residents from financial abuse, manipulation, and exploitation by an Activity Assistant (AA J). The first resident, who was cognitively intact and had multiple medical conditions including osteomyelitis, diabetes, and bipolar disorder, was manipulated by AA J into giving her debit card and PIN. AA J withdrew money from the resident's account on multiple occasions, keeping a portion for herself and failing to provide receipts as required by facility policy. Additionally, AA J solicited money from the resident under the pretense of providing post-discharge services and for a going-away party, which she never delivered, causing the resident anxiety and embarrassment. The second resident, also cognitively intact and with diagnoses including lupus, chronic kidney disease, and schizoaffective disorder, gave her bank debit card to AA J to purchase coffee creamer. Despite the facility being able to provide the item, AA J uploaded the resident's card information to her personal online shopping account and had the item delivered to her own home. The resident was unsure if she received a receipt and later had to cancel her debit card after it went missing. Staff interviews confirmed that AA J violated the facility's policy by handling resident funds and making unauthorized purchases. Multiple staff members and witness statements indicated that AA J frequently discussed her personal financial problems with residents, complained about the activity budget, and implied that residents needed to contribute money for activities. These actions made residents uncomfortable and led to some giving money directly to AA J. The facility's policies clearly prohibit staff from handling resident funds or soliciting money, and require receipts for all transactions involving resident funds, but these policies were not followed in these instances.
Failure to Thoroughly Investigate and Report Financial Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of financial abuse involving a resident who was cognitively intact and responsible for her own healthcare decisions. The resident, who had multiple complex medical conditions including osteomyelitis, pressure ulcers, diabetes, and mental health diagnoses, reported that an Activity Assistant (AA) had received money from her under the pretense of providing services. The facility's policy required immediate and thorough investigation of abuse allegations, including identifying all involved parties, interviewing witnesses, and documenting findings. However, the investigation was not completed in a timely manner, and the required five-day report to the California Department of Public Health (CDPH) was submitted two days late. Interviews and record reviews revealed that the investigation was incomplete and did not follow facility policy. Key individuals, such as the resident's family member and other potential witnesses, were not interviewed. The Director of Nursing (DON) and the Regional Registered Nurse Consultant both confirmed that the investigation lacked thoroughness and proper documentation. Additionally, the facility failed to communicate the results of the investigation to the resident and did not reimburse the resident as indicated in their report to CDPH. Further, the staff member accused of financial abuse was not properly restricted from returning to work pending the outcome of the investigation, and there was no evidence that the required one-on-one abuse training was provided as reported. The facility's failure to follow its own abuse investigation procedures and to report findings within the required timeframe constituted a deficiency in responding to and documenting alleged violations.
Failure to Adhere to COVID-19 Infection Control Protocols
Penalty
Summary
The facility failed to properly implement its infection control program to prevent the spread of COVID-19, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and hand hygiene. Certified Nursing Assistant (CNA) A and Activity Assistant (AA) both entered a room with a resident confirmed positive for COVID-19 without following the required procedures. AA entered the room without wearing a gown, gloves, or eye protection, did not perform hand hygiene upon exit, and took a snack cart into the room, which was not permitted. AA also failed to remove his N95 mask after leaving the room and admitted to forgetting about the COVID-19 status of the resident, acknowledging non-compliance with posted signage and facility policy. CNA A entered the same room and put on a gown and gloves only after entering, did not tie the gown properly, and did not wear eye protection. She did not dispose of her N95 mask or perform hand hygiene upon exit and failed to change her gown and gloves between providing care to multiple residents in the room. CNA A stated she was unaware of the need to don PPE before entering and to change PPE between residents, despite having attended a recent in-service on these procedures. The Infection Preventionist and Administrator confirmed that both staff members did not follow facility policy regarding PPE and hand hygiene for contact and droplet precautions.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the treatment being provided, specifically regarding the use of a psychotropic medication. The facility's policy required that residents be fully informed prior to initiating or increasing a psychotropic medication. However, a review of the consent form for the use of Aripiprazole (Abilify), an antipsychotic medication prescribed for bipolar disorder, revealed that the form was incomplete. The consent form did not include the dosage or the diagnosis for which the medication was prescribed. The resident involved had diagnoses of bipolar disorder and borderline personality disorder and was responsible for making her own medical decisions. Interviews with facility staff, including a licensed nurse and the administrator, confirmed that the consent form was missing required information and was not properly completed. This omission meant the resident was not fully informed about her treatment as required by facility policy.
PASARR Screening Not Accurate and Level 2 Follow-Up Not Completed
Penalty
Summary
The facility failed to ensure appropriate PASARR screening for one resident with multiple serious mental health diagnoses. The resident was admitted with PTSD, nightmare disorder, bipolar disorder, prolonged grief disorder, unspecified mood disorder, anxiety, borderline personality disorder, and suicidal ideations, and the hospital history and physical also documented bipolar disorder, depression with suicidal ideation, nightmares, and PTSD. The admission note further described bipolar episodes with catatonia and severe anxiety. A PASARR Level 1 screening completed before admission stated the resident did not have any serious mental health diagnoses, and staff confirmed that this screening was inaccurate. During interview, the BOM/SS stated the initial PASARR was done by the hospital and could not identify who was responsible for ensuring it was accurate before admission; the IP also confirmed the PASARR was inaccurate and stated the DON should have reviewed it for accuracy. The facility also failed to follow up on a later PASARR that identified the resident as positive for serious mental illness and requiring a Level 2 screening. The facility policy stated Level II resident review must be completed within 40 calendar days of admission, but the resident’s PASARR was not redone until later and the resulting notice indicated a Level 2 screening was required. A Notice of Attempted Evaluation showed facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 screening, and the case was closed. During interview, the BOM/SS confirmed the notice and the IP stated someone should have contacted social services to get the Level 2 screening completed.
Resident Transferred Without Proper Consent or Notice
Penalty
Summary
The facility failed to protect a resident's rights by attempting to transfer him to another facility out of the area without obtaining his or his Responsible Party's (RP) permission. The resident, who had a severe cognitive deficit as indicated by a BIMS score of 6 out of 15, was admitted with multiple diagnoses including a right femur fracture, metabolic encephalopathy, dysphagia, cardiomegaly, pleural effusion, hypotension, anxiety, urinary tract infections, and Guillain-Barre Syndrome. The facility's own policy required support of resident self-determination and choice, but there was no documentation of an Interdisciplinary Team (IDT) meeting or a progress note for a planned and safe discharge. The admission coordinator admitted to not knowing about the requirement for a 30-day discharge notice. The social worker stated that both the resident and the RP had agreed to the transfer during a meeting, but the RP later intervened and stopped the transfer, stating she had never approved it and did not want the resident moved to a distant facility. The resident expressed distress about the attempted transfer, stating he was upset and unaware of where he was being taken. There was no documentation supporting that the required processes for transfer or discharge were followed, and the administrator confirmed that the attempted transfer was a violation of the resident's rights.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 hours per day, 7 days a week, as required. Review of the Payroll Based Journal (PBJ) for the specified quarter revealed that there was no RN coverage on several specific dates, including multiple Saturdays and Sundays. This was confirmed during an interview with the Interim Director of Nursing (IDON), who acknowledged the absence of RN coverage during these periods. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Unsanitary Kitchen Conditions and Improper Equipment Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility kitchen related to food safety and sanitation. A blender was found stored wet with the lid on, and the Certified Dietary Manager (CDM) confirmed it had not been air dried after cleaning. This practice does not comply with the USDA Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing. Additionally, two nonstick frying pans were observed to have excessively worn cooking surfaces, and the CDM acknowledged that these pans were no longer cleanable and would be discarded. The USDA Food Code specifies that multiuse food-contact surfaces must be smooth and free of imperfections such as cracks or pits. Further, the exhaust hood over the stove was found to have greasy, black debris on its interior surface, despite documentation indicating it had been cleaned the previous day. The CDM confirmed the hood was not clean at the time of inspection. The facility's own policy requires the kitchen hood exhaust system to be properly cleaned and maintained to support a safe and healthful environment. These deficiencies were identified during observations, interviews, and record reviews, and affected the kitchen that prepared food for 52 residents with various dietary needs.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the walk-in freezer used for food storage. Observations revealed that the internal temperature of the freezer was significantly above the required level for safe food storage, with thermometer readings ranging from 20 to 40 degrees Fahrenheit. Food items such as a five-gallon container of strawberry ice cream, cinnamon bread dough, and raspberry sorbet were found either melted or thawed, indicating the freezer was not keeping food frozen as required. Excessive ice build-up was also observed on the freezer floor, including a large ball of frozen ice and a black floor mat covered in ice. The Certified Dietary Manager (CDM) and Director of Maintenance (DM) confirmed these findings and acknowledged ongoing issues with the freezer's temperature and structure. Further inspection showed that the freezer's defrost cycle contributed to water accumulation and subsequent ice formation on the floor. Structural deficiencies were also noted, including dry rot in the wall and roof, exposed insulation, wood framing, and missing exterior wall sections, leaving hardware exposed to the outside. The Director of Nursing (DON) confirmed that the freezer should maintain temperatures at or below 0 degrees Fahrenheit and that all foods should be frozen solid, which was not the case during the observations.
Non-Compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms in 12 out of 22 resident rooms, as determined by observation, interview, and document review. During the survey, it was confirmed that rooms 1, 2, 3, 4, 5, 17, 18, 19, 20, 21, and 23 were set up to accommodate three residents each, despite not meeting the square footage requirements. A previous waiver for reduced bedroom sizes granted by CMS was reviewed, and there had been no physical expansion of the rooms since the last survey. Residents in these rooms were observed to have reasonable privacy, sufficient space for personal belongings, and no complaints regarding room size were reported.
Failure to Follow Physician Orders and Professional Standards in Medication and Oxygen Administration
Penalty
Summary
The facility failed to provide treatment and care to several residents in accordance with professional standards of practice and physician orders. One resident with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD) was observed receiving continuous oxygen therapy at 4 liters per minute without a physician's order. The resident's medication administration record (MAR) and order summary did not reflect an order for oxygen, although the care plan referenced oxygen therapy. The Director of Nursing (DON) confirmed that the resident was using oxygen without a physician's order, contrary to facility policy and professional standards. Another resident with osteomyelitis, a stage 4 pressure ulcer, polyneuropathy, and bipolar disorder did not receive their prescribed Lyrica medication for five consecutive days due to a pharmacy delivery issue. The MAR indicated the medication was held, but there was no physician order to hold it, and the care plan required administration per physician orders. The DON and a registered nurse confirmed that the pharmacy was notified but no follow-up occurred to obtain the medication, and the physician had not ordered the medication to be held. Additional deficiencies included failure to change and label oxygen tubing weekly as required by both care plans and facility policy for two residents, and failure to follow a physician's order for wound care for another resident. In one case, a nurse used table salt instead of Epsom salt for a prescribed soak, which was confirmed by the DON. In another case, oxygen tubing was not labeled or dated as required, and staff interviews confirmed inconsistent practices regarding tubing changes and labeling.
Failure to Develop Care Plans for Pain Management and Oxygen Use
Penalty
Summary
The facility failed to develop and implement care plans for pain management and oxygen use for one resident. Despite the facility's policy requiring a comprehensive, person-centered care plan for each resident, and revisions after each comprehensive and quarterly Minimum Data Set (MDS) assessment, no such care plans were created for this resident. The resident was admitted with diagnoses including chronic pain and syncope, and had a BIMS score indicating some memory and decision-making problems. Observations and interviews confirmed that the resident regularly used pain medication and oxygen, both of which were ordered by a physician. However, a review of the resident's care plans showed that neither pain management nor oxygen use was addressed. The Director of Nursing confirmed that these care plans were missing and acknowledged that they should have been developed.
Failure to Provide Timely Physical Therapy Due to Insurance Transfer Delays
Penalty
Summary
The facility failed to provide timely Physical Therapy (PT) services to a resident who required skilled PT following admission with multiple diagnoses, including hemiplegia and hemiparesis after a stroke, COVID-19, diabetes, hypertension, major depressive disorder, anxiety, muscle weakness, and chronic pain. The resident was cognitively intact and required substantial to maximum assistance with transfers, showers, and dressing, as documented in the Minimum Data Set. Despite a PT evaluation indicating the need for skilled therapy to assess functional abilities, enhance rehabilitation potential, and improve mobility and safety, the resident only received PT once since admission. The delay in therapy services was due to unresolved insurance transfer issues following the resident's move from another facility over 18 months prior. Staff interviews confirmed that the resident was not receiving therapy because her insurance had not been transferred to the local county, and no one had assisted her in resolving the issue. The Business Office Manager and facility leadership acknowledged that the insurance should have been changed months earlier, and the lack of assistance resulted in the resident not receiving needed PT services, which was confirmed as a violation of resident rights.
Resident Dignity Violated by RN's Rude Behavior During Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) was reported to have been rude to a resident during direct care, specifically during a disagreement about the timing of a treatment to the resident's left toe. The resident, who was cognitively intact with a BIMS score of 15 and required substantial assistance with activities of daily living due to multiple medical and mental health diagnoses, reported the incident to a licensed nurse and subsequently to the Director of Nursing (DON). The DON confirmed that the incident was discussed in a meeting with the resident and the Ombudsman present, and acknowledged that the RN's behavior constituted a violation of the resident's rights and dignity. The facility's policies on promoting and maintaining resident dignity, as well as resident rights, require all staff to treat residents with respect and dignity, regardless of their background or condition. Despite these policies, the RN's conduct during the care interaction failed to uphold these standards, resulting in the resident feeling disrespected and prompting her to report the incident. The administrator later confirmed that the RN's actions violated the resident's dignity and rights during the provision of care.
Verbal Abuse of Resident During Transfer
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) verbally abused a resident during a transfer using a Hoyer lift. The resident, who was cognitively intact and had significant physical disabilities including quadriplegia and contractures, reported feeling scared and hurt when the CNA stopped her mid-air during the transfer and began yelling at her. The CNA told the resident that no one liked to work with her or provide her care, which was confirmed by another CNA present in the room. A third CNA heard yelling from the hallway and entered the room to assist after being asked by the second CNA. The facility's policy defines abuse to include verbal abuse and intimidation that results in mental anguish. Documentation in the resident's clinical record and staff interviews corroborated the incident, with the resident expressing emotional distress and the CNA admitting to raising her voice and acting out of line. The incident was also documented in a Report of Suspected Dependent Adult/Elder Abuse and in the CNA's employee file, which noted misconduct and failure to maintain acceptable standards of respect for residents.
Failure to Develop and Implement Individualized Care Plan for Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to develop and implement an individualized, person-centered care plan for a resident with dementia and Alzheimer's disease. The resident had a documented history of being resistive to care, particularly with activities of daily living such as bathing. The care plan included an intervention for staff to reassure the resident, leave, and return 5-10 minutes later if the resident resisted care. However, during a morning shower, a CNA did not follow this intervention and instead proceeded with the shower despite the resident becoming combative. The CNA admitted to grabbing the resident's hands and continuing with the shower, resulting in the resident sustaining redness, swelling, and tenderness to her wrist, which required medical evaluation and treatment. Additionally, the care plan failed to address the resident's preference for afternoon showers, a preference known to regular staff and the resident's family. The resident was not a morning person and was more cooperative with showers in the afternoon. This information was not included in the care plan, and the CNA who provided care that day was unaware of this preference, leading to increased resistance and the subsequent incident. Observations and interviews confirmed that the care plan did not reflect the resident's specific needs and preferences regarding the timing of showers. The DON acknowledged that the care plan lacked this critical information and that the staff did not follow the existing intervention to leave and return later when the resident resisted care. These failures contributed to the resident's combative behavior and the injury sustained during the shower.
Failure to Update Care Plan After Resident's Hospitalization
Penalty
Summary
The facility failed to revise and update the care plan for a resident following a significant change in condition after hospitalization. The resident, who was admitted with multiple diagnoses including heart failure, COPD, pressure ulcers, and malnutrition, was readmitted to the facility with new orders for comfort care and new medications. Despite these changes, the care plan was not updated to reflect the resident's current needs, including the new comfort care measures and medications. Interviews with the facility's administrator and Director of Nursing confirmed that the care plan had not been revised since before the resident's hospitalization. The last update to the care plan was on 12/10/24, and it did not include the new comfort medications or address the resident's new problems. This oversight resulted in the resident's individualized care needs going unrecognized, with the potential for further decline in their physical, mental, and psychological status.
Failure to Complete Re-Admission Skin Assessment
Penalty
Summary
The facility failed to complete a skin assessment upon the re-admission of a resident, identified as Resident 2, which was a requirement according to the facility's policy. Resident 2 had been re-admitted to the facility with a history of heart failure, COPD, pressure ulcers, and other medical conditions, including new orders for comfort care. Despite these needs, the necessary skin assessment was not conducted, which was confirmed by the administrator, a licensed nurse, and the Director of Nursing. This oversight was attributed to a lack of communication and follow-up among the nursing staff, as one nurse assumed another had completed the re-admission process. The facility's policy required that admission orders provide essential care information and that new admissions undergo assessments every shift for three days. However, during interviews, it was revealed that the responsible nurse did not complete the skin assessment or verify the completion of the re-admission process. The Director of Nursing had instructed the staff to treat the re-admission as a new admission, but the assessment was still missed. This failure to adhere to the facility's policy had the potential for negative clinical outcomes for Resident 2, who had specific skin treatment needs.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents and did not provide the California Department of Public Health (CDPH) with the required 5-day investigation results. The facility's policy and procedure on abuse, neglect, and exploitation required the identification and interview of all individuals involved in the allegations, including victims, perpetrators, witnesses, and anyone with relevant information. However, the facility did not adhere to this policy. The report of suspected abuse, dated 10/10/24, indicated that facility staff witnessed resident-to-resident abuse, where one resident aggressively squeezed another resident's wrists and hands while shouting threats. Despite this, the facility did not include statements from the staff who witnessed the incident in the 5-day follow-up report. The facility's administrator confirmed that the 5-day follow-up report was incomplete and acknowledged that it was not submitted to CDPH as required. The residents involved had specific medical conditions; one was diagnosed with depression and chronic pain syndrome and was his own responsible party, while the other had age-related cognitive decline and chronic pain syndrome and was not his own responsible party. The failure to conduct a thorough investigation and report the findings to CDPH had the potential to leave abuse allegations uninvestigated, placing residents at risk for harm.
Unverified Nursing License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that only staff with a verified nursing license were assigned to care for patients. A staff member, who had been a Certified Nurse Assistant (CNA) for eight years, was assigned nursing duties after reporting that she had passed her licensing exam to become a Licensed Vocational Nurse (LVN). However, her employee file did not include online verification of her nursing license. The Director of Nurses (DON) and the Director of Staff Development (DSD) were informed by the staff member that there was a spelling error in her name, which delayed the online posting of her license. Despite this, the facility allowed her to work as a nurse without verifying her license through the Board of Vocational Nursing's website. The DSD confirmed that the staff member provided documents that appeared genuine, including photos of her successful exam results, but these were not verified online. The facility's policy required online verification of licenses, which was not followed in this case. The staff member worked unsupervised on the night shift, responsible for the care of all residents, without a verified nursing license. It was only during a recent internal review that the facility discovered the staff member had not passed her exam and did not have an LVN license, highlighting a significant oversight in the facility's verification process.
Lack of Qualified Dietary Oversight Leads to Unsafe Food Practices
Penalty
Summary
The facility failed to employ a full-time Registered Dietician (RD) or a clinically qualified nutritional professional to oversee the dietary staff, resulting in unsafe and unsanitary food service practices for all 49 residents. Observations revealed that dietary staff did not follow proper food safety protocols, such as maintaining appropriate temperatures in the freezer and dishwasher, and ensuring proper sanitation procedures. The lack of qualified oversight led to potential foodborne illness risks, as evidenced by the presence of flies in the kitchen, improper dishwashing techniques, and undated food items. The RD, Unqualified Dietary Manager (UDM), and Certified Dietary Manager (CDM) did not ensure that all dietary staff had the required state and federal competencies upon hire. Several staff members lacked necessary food handler certifications and competency verifications for kitchen duties and equipment. This lack of training and oversight contributed to the unsafe food handling practices observed during the survey. Additionally, the RD and dietary management team failed to address identified issues from kitchen and sanitation audits. Problems such as mold in the ice machine, debris in kitchen drawers, and malfunctioning equipment were not resolved, further compromising food safety. The RD's infrequent presence and the absence of a consistent CDM exacerbated these issues, leaving the facility's dietary department without adequate leadership and oversight.
Removal Plan
- Hiring a full-time qualified Certified Dietary Manager (CDM) to provide supervision to Food and Nutrition services staff
- Plans to repair the freezer/dishwasher
- Remove all food that had potential to cause foodborne illness
- Buy 2 freezers
- Train all dietary staff in dietary policies and procedures
Failure to Address Nutritional Needs Leads to Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident 22, who experienced severe weight loss over time. Initially admitted with a stable weight and a regular diet, Resident 22's intake decreased significantly, and her weight dropped from 153.4 pounds to 119.0 pounds over several months. Despite recommendations from the Registered Dietician to add nutritional supplements, no orders were placed, and the resident's care plan was not updated to address her declining nutritional status. Resident 22 had a history of medical conditions, including cerebral infarction, mild cognitive impairment, and difficulty swallowing, which contributed to her nutritional challenges. The facility's weight monitoring policy required weekly weight checks for residents with weight loss, but Resident 22 was not weighed consistently, and significant weight changes were not communicated to the physician. The interdisciplinary care team failed to hold regular weight meetings, and the resident's dietary orders were not consistently reviewed or modified to address her needs. Throughout the period of weight loss, Resident 22's ability to communicate her needs deteriorated, and she became nonverbal, requiring a picture book for communication. Despite these challenges, the facility did not adequately involve the resident or her Durable Power of Attorney in care planning, and there was a lack of communication regarding her transition to comfort-focused treatment. The facility's inaction and failure to implement timely interventions contributed to Resident 22's severe weight loss and health decline.
Insufficient Nursing Staff Coverage in 2024
Penalty
Summary
The facility failed to provide sufficient nursing staff during the first and second quarters of 2024, as evidenced by the Payroll-Based Journal (PBJ) data reviewed. Specifically, the facility did not maintain 24-hour licensed nursing coverage on multiple dates across these quarters. In the first quarter, the absence of licensed nursing coverage was noted on ten specific dates, while in the second quarter, it was noted on four dates. During an interview and record review with the administrator, it was confirmed that the facility had reported these staffing deficiencies to the Centers for Medicare & Medicaid Services (CMS). The administrator acknowledged the submission of the nursing staff data to CMS and did not dispute the findings.
RN Staffing Deficiency in 2024
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during the first and second quarters of 2024. This deficiency was identified through a review of the facility's mandatory submission of staffing information based on payroll data, known as the Payroll-Based Journal (PBJ), which is required by the Centers for Medicare & Medicaid Services (CMS). Specifically, the facility did not have RN coverage on multiple dates across both quarters, including several days in October, November, and December of 2023, as well as in January, February, and March of 2024. During an interview and record review with the facility administrator, it was confirmed that the staffing data had been reported to CMS, and the administrator acknowledged the issue without contesting the findings.
Deficiencies in Dietary Staff Competency and Kitchen Operations
Penalty
Summary
The facility failed to ensure that the kitchen had sufficient and competent dietary staff to perform their duties effectively. Eight out of ten kitchen staff lacked the required competencies and training to fulfill their job requirements. Two staff members were unable to demonstrate or verbalize how to test the sanitizing solution and set up an emergency 3-compartment sink according to guidelines. Additionally, one staff member did not know the correct temperature for the walk-in freezer and failed to report issues to administrative staff. These deficiencies had the potential to result in foodborne illnesses for the 49 residents consuming food prepared in the facility. The report highlights several specific instances of non-compliance with training and competency requirements. For example, a Certified Dietary Manager (CDM) was hired part-time and later full-time but did not complete the required training until four months after hire. Similarly, a Dietary Aide (DA) was hired without the necessary Food Handlers Certificate and did not have any verification of job competency until several months later. Other staff members also lacked proper certification and competency verification, which contributed to the overall deficiency in the dietary department. Observations during the survey revealed further issues, such as improper use of the 3-compartment sink for dishwashing and failure to test water temperature and sanitizer levels. The walk-in freezer was found to be at an incorrect temperature, with food items not properly frozen, posing a risk of foodborne illness. The CDM confirmed that the dishwasher had been malfunctioning, and there was a lack of consistent oversight in the kitchen. The Registered Dietician (RD) also noted ongoing challenges with staffing and equipment, which were not adequately addressed by the facility administration.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by several observations and interviews. The freezer temperature was found to be significantly above the required 0 degrees Fahrenheit, with items such as ice cream, cheese, and deli meat being soft to the touch. This issue was not reported by the kitchen staff, who were unaware of the temperature discrepancy. Additionally, food items in both the refrigerator and dry storage were improperly dated, with many lacking received or use-by dates, contrary to facility policy. Sanitation practices in the kitchen were also found to be lacking. Two kitchen staff members were unable to properly demonstrate or verbalize the correct procedure for using a 3-compartment sink for dishwashing, and there was no documentation of water temperature or sanitizer levels. The sanitizer solution was found to be above the recommended concentration, and the staff did not know how to test it correctly. Furthermore, flies and other pests were observed in the kitchen, and there were instances of dirty equipment and improper hand hygiene by staff. The facility's management and oversight of the kitchen were inadequate, with the Certified Dietary Manager (CDM) working part-time and the Registered Dietitian (RD) visiting infrequently. The RD's audits revealed ongoing issues such as gaps in logs, equipment malfunctions, and improper storage practices. Despite these findings, there was no evidence of a consistent plan to address these deficiencies, and the facility lacked a full-time qualified CDM to oversee kitchen operations.
Administrator's Oversight Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility's Administrator failed to ensure effective oversight and necessary resources to meet resident care services, resulting in several deficiencies. The Administrator did not ensure a full-time Registered Dietician (RD) or Certified Dietary Manager (CDM) was available to oversee dietary staff, leading to unsafe and unsanitary food service practices for all 49 residents. The RD and unqualified dietary manager failed to ensure dietary staff had the required competencies, and issues identified in kitchen audits were not resolved. This resulted in an Immediate Jeopardy situation due to the lack of qualified oversight and failure to maintain sanitary conditions in the kitchen. Dietary services did not adhere to national standards for kitchen cleanliness and food storage safety, increasing the risk of infection and foodborne illness among residents. The RD reported ongoing issues with the freezer and dishwasher, and the lack of consistent CDM oversight contributed to the kitchen's struggles. Observations revealed unsanitary conditions, such as flies in the kitchen, improper dishwashing procedures, and undated food items. The CDM was unable to locate logs for monitoring temperatures and sanitizer levels, further indicating a lack of proper oversight and documentation. The Administrator also failed to ensure proper care for individual residents. Resident 22 experienced severe weight loss due to the staff's failure to identify and address insidious weight loss. Social Services did not meet the needs of several residents, resulting in unnecessary medical treatment, missed care conferences, and lack of discharge planning. Additionally, fall care plans were not initiated or revised for residents at risk, leaving staff uninformed about residents' health status and necessary interventions. The Administrator admitted awareness of these issues but had not implemented a Performance Improvement Plan to address them.
Governing Body's Failure in Dietary Oversight Leads to Immediate Jeopardy
Penalty
Summary
The facility's Governing Body (GB) failed to effectively manage the dietary department, leading to an Immediate Jeopardy situation. The GB did not ensure adequate oversight and monitoring, resulting in numerous sanitation and operational issues in the kitchen. These issues were identified through various audits conducted by the Registered Dietician (RD), which highlighted problems such as debris in kitchen drawers, mold in the ice machine, and malfunctioning kitchen equipment like the oven and steam table. Additionally, there were gaps in sanitation logs, improper storage of supplies, and inadequate temperature regulation in storage areas. The RD communicated these findings to the facility's Administrator (ADMIN) and the GB, but there was a lack of effective response and corrective action. The RD noted that the Unqualified Dietary Manager (UDM) was not actively involved in kitchen operations and was still assisting with housekeeping duties. Despite the RD's recommendations for additional staffing and the presence of a Certified Dietary Manager (CDM) on weekends, the issues persisted. The ADMIN admitted awareness of the problems but failed to implement a Performance Improvement Plan (PIP) or track the issues effectively. Interviews with the ADMIN and the Regional Director of Operations (RDO) revealed acknowledgment of the deficiencies and the need for repairs and improvements. However, there was no evidence of a structured plan to address the deficiencies, and the facility had not started any specific PIP. The RDO confirmed that the RD, CDM, and ADMIN needed to work together to establish competencies and address the ongoing issues in the dietary department.
Ineffective QAPI Committee Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) committee, which resulted in several deficiencies. The facility did not have a full-time Registered Dietician (RD) or a Certified Dietary Manager (CDM) to oversee dietary staff, leading to unsafe and unsanitary food service for all 49 residents. This lack of oversight resulted in an Immediate Jeopardy situation, as there was no qualified personnel to conduct daily kitchen inspections, provide feedback, or ensure staff competency. Additionally, the dietary services did not adhere to national standards for kitchen cleanliness and food storage safety. The staff also failed to identify and address insidious weight loss in a resident, which is a gradual, unintended, and progressive weight loss over time. Furthermore, the Social Services Department did not meet the needs of several residents, and fall care plans were not initiated or revised timely for some residents. The facility's QAPI program was not effectively implemented, as evidenced by the lack of tracking and measuring performance, establishing goals, and identifying quality deficiencies. The administrator was aware of the issues but failed to take corrective actions. The QAPI committee meetings lacked proper documentation, and no Performance Improvement Plan (PIP) was initiated to address the deficiencies. The Regional Director of Operations acknowledged the issues but noted that necessary repairs and competencies were not in place.
Ineffective QAA Program and Oversight in Dietary and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, as evidenced by several deficiencies. There was no full-time Registered Dietician (RD) or Certified Dietary Manager (CDM) to oversee dietary staff, resulting in an Immediate Jeopardy situation due to the lack of qualified oversight for daily kitchen inspections and staff competency. Additionally, dietary services did not adhere to national standards for kitchen cleanliness and food storage safety. The staff also failed to identify and address insidious weight loss in a resident, and the Social Services Department did not meet the care needs of multiple residents. Furthermore, fall care plans were not initiated or revised in a timely manner for several residents. During a review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes, it was revealed that the facility had not started any Performance Improvement Plans (PIPs), as evidenced by a blank document presented by the administrator. This lack of action and oversight contributed to the deficiencies identified during the survey.
Equipment Failures in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment, leading to several deficiencies. The communication call light systems in two rooms were not functioning properly, as observed during a facility tour. Residents in these rooms reported that their call lights were not working, causing delays in receiving assistance. The Plant Operations Supervisor confirmed that the call lights were intermittently turning on and off due to disconnected wires, which had been an issue for at least six weeks for one resident. Additionally, the walk-in freezer was not maintaining the required temperature of 0 degrees Fahrenheit or below. Service invoices indicated issues with the defrost timer and evaporator coil, leading to ice buildup and a freezer temperature of 35 degrees Fahrenheit. The Certified Kitchen staff and administrators were unaware of the temperature issue, which resulted in food items being improperly stored. Furthermore, the dishwasher in the kitchen was not operational due to a faulty electrical breaker, which had been an issue for over a week. The Registered Dietician expressed concerns about the sanitary conditions in the kitchen due to these equipment failures.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and other pests throughout the building. Observations and interviews revealed that flies were landing on residents during meals, compromising their right to a pest-free home environment. The facility's pest control policy, dated 2024, outlined measures to remove and contain common household pests, but these measures were not effectively implemented. A Registered Dietician's inspection of the kitchen noted a gap under the screen door, which was identified as a potential entry point for flies. Subsequent sanitation findings and interviews confirmed the presence of flies and other pests in the kitchen and dining areas. Residents expressed dissatisfaction with the pest situation, with 11 out of 14 residents reporting flies everywhere, and one resident specifically mentioning flies on their food. Observations also noted flies in resident rooms and on food trays. The Plant Operations Supervisor installed flytraps in various locations, including the entrance lobby, main dining hall, and kitchen, and applied weather stripping to the kitchen door to address the issue. However, these actions were insufficient to prevent the ongoing pest problem, as evidenced by continued resident complaints and observations of flies in the facility.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in a room with less than 80 square feet per resident, leading to safety hazards and a lack of dignity and independence for Resident 35. Resident 35, who uses a wheelchair due to heart failure and bilateral below-knee amputation, reported insufficient space to access personal belongings and perform oral hygiene tasks independently. The room was overcrowded with three beds, a portable air conditioner, and multiple fans, creating obstacles and trip hazards. Resident 35 expressed discomfort with a fan blowing on him and difficulty accessing the bathroom due to space constraints. Observations and interviews with staff confirmed the room's overcrowded conditions and the presence of unsecured cords and trip hazards. The Director of Nursing acknowledged the room's limitations and the residents' refusal to remove the fans, but no alternative solutions were offered to ensure safety. The facility's policy on accommodating resident needs emphasizes maintaining independence and dignity, which was not upheld in this situation, as evidenced by the residents' restricted mobility and access to personal items.
Failure to Revise Care Plans After Incidents
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) reviewed and revised the care plans for three residents following significant incidents. Resident 15 experienced multiple falls, including two without injury and one with injury, yet the care plan was not updated to address the risk of falls. Despite recommendations for a medication review, rehab referral, and care plan revision after the falls, no fall care plan was developed or reviewed. The Minimum Data Set Licensed Vocational Nurse (MDSLVN) confirmed the absence of a fall care plan for Resident 15, despite the falls occurring on three separate occasions. Resident 8, who was cognitively intact but physically dependent due to quadriplegia, experienced two incidents involving improper use of a Hoyer lift. In both cases, the care plan was not revised to address the issues with the Hoyer lift, despite the Director of Nursing (DON) acknowledging the incidents and the need for a short-term care plan. The lack of timely care plan revision left the staff without updated guidance on handling Resident 8's transfers safely. Resident 52, with severe cognitive impairment and a high fall risk, had two falls resulting in injuries, including a hip fracture. Despite these incidents, no care plan was created or revised to address the fall risk. The DON confirmed the absence of a care plan for these incidents, indicating that the shift nurse should have initiated a short-term fall care plan. The failure to update care plans for these residents potentially left staff uninformed about the residents' health status and the necessary interventions.
Failure to Assess and Reevaluate Suprapubic Catheter Needs
Penalty
Summary
The facility's nursing staff failed to assess and reevaluate the continued need for a suprapubic urinary catheter for Resident 12, leading to a significant delay in identifying a change in condition. Resident 12, who was admitted with a suprapubic catheter and other medical conditions such as type 2 diabetes and neuromuscular dysfunction of the bladder, experienced a urinary tract infection (UTI) and pain. Despite an active order for a urology evaluation, there was no documentation of a consult occurring. The resident was treated for a UTI with antibiotics, but the facility did not adequately monitor or address the resident's ongoing symptoms and pain. Interviews and record reviews revealed that Resident 12 reported kidney pain and cloudy urine, but the facility's response was inadequate. The Director of Nursing (DON) noted the resident's pain and cloudy urine but did not perform a urine assessment initially. When a urinalysis (UA) was eventually conducted, it showed bacteria and blood in the urine, indicating an infection. However, the results were not signed by the physician, and there was a lack of communication between the facility staff and the physician regarding the resident's symptoms and pain. The situation escalated when Resident 12 experienced increased back pain and vaginal bleeding, prompting a hospital visit where the UTI was confirmed, and antibiotics were prescribed. The DON and the physician had conflicting accounts regarding the UA results, with the physician stating he was not informed of the resident's symptoms and pain. The facility's failure to follow through with the urology referral and inadequate communication and documentation contributed to the resident's emergent hospitalization and treatment for the UTI.
Deficiencies in Social Services and Care Planning
Penalty
Summary
The facility failed to provide appropriate medically-related social services for four residents, leading to deficiencies in their care. For Resident 6, a weekly telehealth psychiatric assessment was ordered despite the resident not exhibiting any behavioral issues. This was confirmed by the family, a licensed vocational nurse, the medical director, and the social services director (SSD), who mistakenly believed the resident had anxiety. The unnecessary psychiatric evaluations continued without justification, as the resident had severe cognitive impairment and no behavioral symptoms. Resident 8 did not have a quarterly care conference arranged, which is a requirement for discussing and addressing care concerns. Although the resident was cognitively intact and capable of making her own healthcare decisions, she did not recall attending any care conferences. The SSD acknowledged that a care conference was not rescheduled after the resident initially refused to attend, and there was no communication among the interdisciplinary team to ensure the resident's care needs were met. Resident 303 did not have a discharge care plan developed, which is essential for preparing residents emotionally and practically for discharge. The SSD admitted that the discharge care plan should have been completed within the first 72 hours of admission but was not. Additionally, Resident 12 did not receive a urology consult as ordered, despite having a suprapubic catheter and a care plan indicating the need for such a consult. The SSD was unaware of the referral, and there was no documentation of a urology consult in the resident's records.
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 28 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 Red Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Red Bluff Health Care Center | 1.2 mi | ★★★★★ | 22 | 0 |
| Oak River Rehab | 19.4 mi | ★★★★★ | 0 | 0 |
| Veterans Home Of California - Redding | 23.8 mi | ★★★★★ | 6 | 0 |
| Marquis Care At Shasta | 27.2 mi | ★★★★★ | 22 | 0 |
| Crestwood Wellness And Recovery Center | 27.6 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.