Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards Post-acute during CMS and state inspections, most recent first.
A facility failed to support two residents’ rights to dignity and self-determination by not providing requested grooming services. One resident said staff often told her they were too busy when she asked for a shower and she felt unclean when going to PT, while another resident repeatedly requested a haircut but did not receive one and said his hair was too long and bothered him. Records showed the shower schedule and haircut documentation did not reflect the residents’ requests or refusals.
A facility failed to send required written transfer notices to the Ombudsman for a resident who was sent to the hospital multiple times for evaluation and treatment. The EMR had no written transfer notices for those hospitalizations, and SS stated the resident and Ombudsman were not notified and that no policy/procedure existed for written discharge/transfer notice.
Inaccurate Nutrition Intake Documentation: Two residents with nutrition-related care plans had inconsistent meal, meal substitute, and snack documentation that prevented accurate monitoring of intake. One resident left the dining room before lunch was served, later received a ham sandwich as a snack, and staff documented the snack intake in the meal field. Another resident was observed not receiving lunch in a timely manner, and staff documented a refused meal, a substitute meal, and snack intake that the CNA later said was not accurate because the resident only obtained items from a vending machine. The DON stated the inaccurate and inconsistent documentation prevented effective monitoring and implementation of the residents’ nutrition IDT care plans.
An LVN performed a resident’s nephrostomy tube dressing changes using clean dressings instead of sterile technique. The LVN stated she did not use sterile gloves or a sterile field, which was inconsistent with the facility P&P for nephrostomy tube care.
Failure to provide oral care was identified for a dependent resident who was NPO and receiving tube feeding. The resident was observed with dry, cracked lips and brown crusty material at the corners of the mouth, and the RN stated oral care was needed. The MDS showed the resident was dependent for oral hygiene, and facility policy required oral care for residents unable to perform ADLs independently.
Improper Head-of-Bed Positioning During Enteral Feeding: Two residents receiving enteral tube feeding were observed with the HOB below the facility's required range during administration. One resident was slightly elevated while feeding was running, and another was positioned at about 10 to 15 degrees during continuous pump feeding. Staff stated the HOB should have been elevated to about 35 to 45 degrees, consistent with facility policy requiring at least 30 degrees during tube feeding.
Oxygen therapy was not administered as ordered for two residents. Two portable O2 cylinders were observed empty while the residents were wearing NCs, and an LPN confirmed there was no oxygen flow. For one resident, the portable cylinder was also set at 4 L/min even though the order was for 2 L/min continuous O2 via NC. The facility policy required checking oxygen equipment and reviewing the physician order before use.
Unclean OTC Medication Storage Room and Missing Temperature Log: The OTC medication storage room had debris, dust, and a dirty floor, with a pill bottle and other items left in the area. RN, HSK/CSS, IP, DON, and AIT interviews showed the room was not being cleaned daily as expected and no temperature log was maintained for the medication storage area, despite facility policy requiring proper storage conditions and temperature control.
Failure to ensure timely dental follow-up for a resident with painful teeth. The resident had multiple bottom front teeth visible at the gumline and reported tooth pain; he had been seen by a dentist and was supposed to have extractions, but the treatment had not occurred months later. SS stated the resident wanted extractions only, and the facility did not have a process for ensuring needed dental treatment was completed.
Dietary Services Supervisor Qualification Deficiency: The facility failed to ensure the DDS met CA education requirements to supervise FNS operations. The DDS stated she was responsible for day-to-day foodservice operations and had completed ANFP coursework to sit for the CDM exam, but she had not taken the exam and was not a CDM. Record review showed the state pathway required CDM certification and related training, while the job description assigned the DDS responsibility for supervising the Dietary Department.
A dietary aide incorrectly removed pudding from a resident’s full liquid diet tray, stating it was not a liquid, even though the facility’s diet manual and kitchen cheat sheet listed pudding as an allowed item. The resident had dysphagia and other neurologic diagnoses, and the tray ticket and diet order both specified a full liquid diet.
Menu and Tray Card Not Followed for Resident Milk Service: A dietary aide placed whole milk or 2% milk on regular diet trays during tray line, while the RD stated either could be used if no preference was indicated. Record review showed a resident's tray ticket listed milk preferences, and the facility's menu and nutritional breakdown specified milk requirements for the regular diet, with tray card policy requiring beverage preferences and amounts to be documented.
Failure to honor resident food preferences: one resident who preferred sunny side up eggs could not receive them because the facility did not have pasteurized shell eggs available, and another resident’s lunch tray was served broccoli without the margarine listed on the tray card. The DDS, RD, and dietary staff confirmed the missing items and reviewed records showing the egg preference and tray card directions.
Improper Food Storage Practices: Surveyors observed opened dry pasta without open dates, an opened bag of pasta that was not sealed or labeled, an opened bottle of teriyaki sauce stored on a shelf despite the label stating to refrigerate after opening, an open bag of frozen fried eggs in the walk-in refrigerator, and frozen supplemental shakes without dates showing when they were placed in the refrigerator. The DDS acknowledged the storage issues, and facility policies required open dating, proper covering, labeling, and following manufacturer storage directions.
Infection surveillance was not performed, and the facility’s MISR showed increasing UTI counts over several months. A resident on EBP for an open wound had foam wrapped and taped around both upper bedrails, with tape pulling away and exposing adhesive. In addition, two CNAs did not follow EBP during direct care for another resident with a history of MDRO, as they provided care without the required gown and gloves.
A resident’s call light was observed on the floor beside the bed during an observation with an RN, and the RN stated the resident could not reach it. Facility policy states residents must have a means to call staff from the bed, toileting/bathing areas, and from the floor.
A resident with dementia, prior traumatic brain hemorrhage, contractures, and total dependence for toileting and bed mobility experienced a fall and head laceration while being provided toileting hygiene on a fully inflated LAL mattress. A longstanding MD order and care plan intervention for bilateral landing mats at the bedside were not implemented, and LNs did not document required shift checks of mat placement. The care plan for the resident, who had limited ROM, history of falls, and was totally dependent for ADLs, did not specify two‑person assistance during care on the LAL mattress, even though staff reported that residents on LAL mattresses were always treated as two‑person assists. During toileting care, a CNA, who had been told the resident was a one‑person assist, rolled the resident while changing chux; the resident tensed, his legs moved toward the bed edge, and he slid off the bed, with no landing mats in place. The resident was found on the floor with bleeding from the back of the head and was transferred to the hospital, where CT imaging showed a subarachnoid hemorrhage.
A resident with a history of UTI reported painful urination, and the physician ordered a one-time UA C&S. An SBAR documented the complaint and new order, but there was no documentation that urine was collected or that attempts were made to collect it for approximately two days. The DON confirmed that urine should have been collected as soon as possible and could not find records of collection or attempted collection until a later nurse’s note and SBAR indicated the specimen was finally obtained. The resident’s pain with urination increased, and the resident chose to go to the hospital rather than wait for UA C&S results; the ED later diagnosed a UTI. An LVN assigned when the order was received could not recall attempting to collect the urine, despite acknowledging responsibility to do so in a timely manner.
A resident's restroom was found to have torn and lifted linoleum flooring, creating an uneven surface. The Maintenance Director confirmed this presented a tripping hazard, and facility policy requires maintenance to keep the building in good repair and free from hazards.
After an allegation was made that a contracted phlebotomist was reusing needles on residents and at other facilities, the facility did not prevent the phlebotomist from entering and providing services during the investigation. The phlebotomist was allowed to return and perform a blood draw on a resident, despite facility policy requiring removal from resident contact during abuse investigations.
The facility failed to maintain clean linen carts and the laundry room in a sanitary condition. Linen carts were damaged and improperly disinfected, while the laundry room had unclean conditions, including a debris-covered fan blowing onto clean linens. Facility policies for maintaining cleanliness were not followed.
The facility failed to follow its infection surveillance policy, resulting in deficiencies in infection control and tracking. The Antibiotic Stewardship Log showed 64 infections without documented signs and symptoms, and the Infection Control Committee Report revealed untracked infections, except for UTIs. Additionally, 11 infections did not meet antibiotic treatment criteria, lacking organism or culture records. These failures compromised effective infection control and tracking.
The facility failed to ensure staff communicated in a language understood by residents, affecting their dignity and self-esteem. A resident felt uncomfortable when staff spoke Spanish in front of them, while two others noted staff spoke in a language they couldn't understand. The facility's policy emphasizes promoting residents' well-being and self-esteem, which was not upheld.
The facility failed to obtain informed consents for psychotropic medications for three residents, potentially leaving them unaware of the risks and benefits of their treatments. A resident's consent form lacked dosage and frequency details for Divalproex and Olanzapine. Another resident was prescribed Lexapro without a signed consent, and a third resident received Xanax without prior consent. The facility's policy mandates informed consent for such medications, which was not followed.
The facility failed to maintain daily completed Direct Care Service Hours Per Patient Day (DHPPD) records from early January to late February 2025. This deficiency was confirmed during a review and interview with the Administrator, who acknowledged the absence of DHPPD documentation for the specified period. The facility's policy requires daily posting and maintenance of staffing records, which were not adhered to, potentially affecting resident care.
The facility did not complete annual performance evaluations for two CNAs, as required by its policy. CNA 1's last review was in 2023, and CNA 2's was in 2011. This oversight could lead to CNAs being unaware of needed improvements, potentially impacting resident care.
The facility did not act on the January 2025 Medication Regimen Review (MRR) for four residents, failing to document actions on 139 pharmacy recommendations. Issues included non-compliance with CMS guidelines for antipsychotic dose reduction, extended use of PRN psychotropic medications, and long-term use of Naproxen despite risks. The MRR was not completed within the expected timeframe, as confirmed by the DON.
The facility failed to manage and store medications properly, with expired medications found on a cart, improper storage of Bisacodyl suppositories with Ensure, and incomplete Controlled Drug Records lacking dual nurse signatures. Additionally, medications were found on bedside tables of three residents, posing risks of unauthorized access and administration errors.
A facility failed to maintain a clean and sanitary bathroom for a resident with a right leg amputation. The bathroom had dark brown stains and crumpled paper towels, and the CNA responsible was unaware of cleaning duties. The resident, who is cognitively intact, confirmed the lack of cleanliness, contrary to the facility's policy requiring clean and sanitary bathrooms.
The facility failed to complete quarterly smoking assessments for two residents, as required by their policy. A resident's smoking assessment was not completed upon admission or quarterly, and another resident, at risk of injury related to smoking, also did not have the required assessments. This failure resulted in the residents not being evaluated for safety while smoking, posing a potential risk of injury.
A facility failed to implement a care plan for a resident at high risk for falls. The resident was observed in bed with the bed in a high position, contrary to the care plan's directive to keep it low to reduce fall impact. The resident's care plan and Morse Fall Assessment indicated a high fall risk due to factors like a history of falls and unsteady gait. Despite these assessments, the facility did not follow the precautionary measure, risking serious injury.
A facility failed to check a resident's blood pressure before administering Losartan Potassium for hypertension, as required by the physician's order. The resident's MAR showed no blood pressure documentation for several days, which was confirmed by the ADON. This oversight violated the facility's medication administration policy, which mandates verifying vital signs when necessary.
A resident's catheter tubing and urine collection bag were not changed for two months, despite visible signs of discoloration and material buildup. Nurses acknowledged the need for a change but did not perform it. The resident had a history of UTIs, and facility policy suggested changes based on clinical indications.
A facility failed to follow its oxygen administration policy for a resident with a history of aspiration and pneumonia. The resident, who required continuous oxygen to maintain saturation above 92%, was found without a nasal cannula, resulting in an oxygen level of 90%. The facility's policy required periodic observation to ensure proper oxygen administration, which was not adhered to.
A facility failed to document and follow up on a resident's eyeglasses, leading to a deficiency. The resident, who was cognitively intact, reported waiting three months for her eyeglasses and experiencing poor vision. An eye consultation had been conducted two months prior, prescribing bifocal lenses, but the Social Services Director did not document any follow-up, contrary to facility policy.
The facility failed to reorder medications timely, resulting in two residents not receiving their prescribed medications. One resident experienced repeated unavailability of multiple medications, while another resident's Metformin was not available despite being reordered. The facility's policy required medications to be reordered at least three days before the last dose, but this was not followed.
A facility failed to maintain a functional call light system for a resident with quadriplegia and contracted hands, as observed during an inspection. The resident's care plan required a working call light within reach, but the system was non-functional, and the Environmental Service Director was unaware of the issue. The facility's policy mandates a functional call system and alternative communication means for residents with disabilities.
A resident's room was found with a ripped baseboard, approximately 10 inches long and 1 inch open, during an observation with the Housekeeper/Laundry Supervisor. Despite daily inspections by the maintenance department, the Environmental Services Director acknowledged the oversight. The facility's policy requires maintenance to keep the building in good repair and free from hazards.
A resident with a history of a right femur fracture and respiratory disorders was not readmitted to the facility after hospitalization, violating their rights. The facility cited refusal of care and low functioning as reasons, despite policy prioritizing readmission. The administrator acknowledged the resident should have been taken back.
A resident with a G-tube experienced aspiration pneumonia due to the facility's failure to follow enteral feeding protocols. The resident, with a history of respiratory issues, showed signs of vomiting and wheezing, but the LVN delayed notifying the physician for over four hours. The G-tube placement and residual volume were not checked, and medications were administered despite ongoing symptoms. The resident's condition worsened, leading to a hospital transfer.
The facility failed to document the administration of medications and treatments for two residents as per physician orders. One resident's antibiotic for osteomyelitis was not documented as given, and another resident's wound care treatments were not recorded on multiple occasions. The DON confirmed these documentation lapses, which violated facility policies.
The facility failed to ensure that an LVN and a CNA were competent in caring for residents with G-tubes. The LVN lacked skills in checking G-tube placement and monitoring for complications, while the CNA was not competent in resident positioning and care during feedings. This deficiency was identified during a review of employee files and confirmed by the DSD and DON, highlighting a failure to adhere to the facility's competency policy.
The facility did not follow its investigation report to monitor a resident's smoking privileges after a verbal altercation in the smoking area. The DON found no documentation of monitoring in the resident's record, despite the facility's policy requiring direct supervision for residents needing monitoring while smoking.
A resident with wound dehiscence did not receive physician-ordered wound care on two occasions, as documented in the Treatment Administration Record. The facility's staff failed to administer the treatment due to a shift change and lack of follow-up, resulting in a lapse in the facility's wound care policy.
A resident experienced severe abdominal pain for seven hours due to inadequate foley catheter care, as staff failed to assess the catheter for kinks or blockages. Despite the resident's complaints, pain medication was delayed, and the situation escalated until emergency services were called. The resident was diagnosed with a UTI after the catheter was unclogged, releasing over a liter of urine.
A facility failed to report and investigate an alleged abuse incident where a resident threw objects at another resident, causing fear and anxiety. Despite documentation of the aggressive behavior and the affected resident's expressed fear, the incident was not reported to the CDPH, nor was an investigation conducted, contrary to the facility's policy.
The facility's kitchen was found to be unsanitary, with black debris, scattered butter containers, and lifeless flies on the floor of the dry storage room. The walk-in freezer and area under the sink also had debris. The Dietary Director acknowledged these conditions, and the Administrator confirmed the absence of a contracted deep cleaning agency, despite the facility's policy recommending quarterly deep cleaning.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in resident rooms and the kitchen. Cognitively intact residents reported seeing cockroaches, and staff confirmed the issue, with sightings primarily at night. Observations in the kitchen revealed both dead and live cockroaches, and the Dietary Director acknowledged the problem. Despite the facility's pest control policy, the Administrator was unaware of the issue.
A resident with cognitive impairment was found with long, dirty fingernails and brown stains on the palm, indicating a lack of proper nail care and hand hygiene. The CNA did not trim the nails due to uncertainty about the resident's diabetic status, which was later clarified by an LVN. The facility's policy requires assistance with hygiene for residents unable to perform ADLs independently.
A resident fell and was assisted to the floor by a charge nurse, but the incident was not documented, and the Physician was not notified immediately. The resident later complained of leg pain, leading to a delayed hospital transfer.
Failure to Provide Requested Grooming Services
Penalty
Summary
The facility failed to support two residents in exercising their rights and maintaining dignity by not providing requested grooming services. One resident stated that when she requested a shower, staff often told her they were too busy, and she wanted showers more frequently than twice a week. She reported feeling unclean when attending physical therapy and said she believed she should be able to feel clean rather than smell of feces. Her BIMS score was 15, and the June 2026 skin care alert showed showers on 5/30/26, 6/3/26, 6/6/26, 6/10/26, and 6/13/26. The facility policy stated showers are intended to promote cleanliness and provide comfort. Another resident stated he had asked multiple times for a haircut but had not received one, and said his hair had become too long and bothered him. He liked to wear his hair short and could not recall the last time he had a haircut. His BIMS score was 12, and he required staff assistance to get out of bed. Facility records showed he received a haircut on 1/30/26, but activities staff and the Director of Activities stated there was no documentation showing he was offered or refused a haircut after that date. The Administrator stated the facility had no policy assigning responsibility for overseeing resident hair care services, although activities staff were currently overseeing hair care and the facility was responsible for ensuring residents were well groomed and felt good about themselves.
Failure to Send Required Transfer Notices to Ombudsman
Penalty
Summary
The facility failed to ensure that written discharge/transfer notices were sent to the Ombudsman for Resident 143 after the resident was transferred to the hospital for evaluation and treatment on 4/24/26, 5/6/26, and 5/28/26. During interview and record review, the resident’s EMR did not contain written notices of transfer for any of these hospitalizations, and Social Services stated that the facility did not provide written notification of transfer to the hospital to either Resident 143 or the Ombudsman. Social Services also stated that the facility did not have a policy and procedure for written notice of discharge/transfer.
Inaccurate Nutrition Intake Documentation
Penalty
Summary
The facility failed to ensure that the interdisciplinary comprehensive nutrition care plans for two sampled residents were effectively monitored and implemented because meal, meal substitute, and snack consumption documentation was inconsistent and inaccurate. The deficiency involved Resident 137 and Resident 2, both of whom had care plans addressing nutritional risk and required monitoring of intake at meals and snacks. During lunch service, staff were observed checking meal tray cards against trays while residents waited for trays to be distributed. For Resident 137, staff delayed meal service while waiting for a second cart to arrive, and the resident left the dining room upset before lunch was provided. Later observations showed no lunch tray in the resident’s room, and staff stated that no residents were waiting on a lunch tray. In record review and interview, CNA 4 stated Resident 137 ate 25% of lunch as reported by another CNA, then was offered a ham sandwich as a snack and ate 75-100% of it. CNA 4 stated she incorrectly documented the snack intake under the meal intake field, and the documentation survey report showed meal intake recorded as 76-100% and snack intake recorded separately as 51-75%. The DON stated the facility would be unable to monitor and implement Resident 137’s nutrition IDT care plan when staff were not accurately and consistently documenting food and fluid intake. For Resident 2, observations showed the resident leaving the dining room before lunch was provided, later stating he had not been given lunch and was hungry. Staff later distributed all trays from the meal cart, but Resident 2 was not provided a lunch tray. In interview, CNA 6 stated he brought the lunch tray to the resident in his room, but the resident refused it because it was cold. CNA 6 also stated he offered a snack when the snack cart came by, but the resident obtained items from a vending machine instead. The EMR documented the meal as refused, a substitute meal as 76-100% consumed, and a snack as 76-100% consumed, but CNA 6 stated this was not accurate because the resident did not consume a meal substitute and the documentation was intended to reflect only snack intake from the vending machine. The DON stated the facility would be unable to monitor and implement Resident 2’s nutrition IDT care plan when staff were not accurately and consistently documenting food and fluid intake.
Non-sterile nephrostomy tube dressing changes
Penalty
Summary
Resident 11 had an order for daily and as-needed cleansing of the left posterior flank nephrostomy tube surgical site with iodine and a split dressing, with monitoring for signs and symptoms of infection and notification of the MD if treatment was ineffective. During interview and record review, the LVN stated she completed the resident’s nephrostomy tube dressing changes on multiple days in June 2026, but the dressing changes were performed with a clean dressing rather than a sterile dressing. The LVN stated she did not use sterile gloves or a sterile field for the dressing changes and acknowledged that the dressing was not changed according to the facility’s policy and procedure for nephrostomy tube care, which required sterile gloves and sterile dressings.
Failure to Provide Oral Care for Dependent Resident
Penalty
Summary
The facility failed to ensure oral care was provided for one resident who was unable to perform activities of daily living independently. During a concurrent observation, interview, and record review, the resident was found sitting up in bed with dry, cracked lips and brown crusty material at the corners of the lips. The RN stated the resident's lips were dry and chapped, identified the brown crusty material as possibly dry skin, and stated the resident needed oral care. The RN also stated that residents who are NPO and receiving tube feeding would need oral care and chap stick to keep their lips moist. The resident's MDS dated 4/15/26 indicated the resident's BIMS was not conducted, the resident was rarely or never understood, and the resident was dependent for oral hygiene. The facility's DSD stated that CNAs should check residents who are NPO and receive tube feeding every two hours while providing care and oral care as needed. The facility policy stated residents unable to carry out ADLs independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including oral care.
Improper Head-of-Bed Positioning During Enteral Feeding
Penalty
Summary
Safe administration of enteral feeding was not ensured for two sampled residents, Resident 97 and Resident 127, because the head of bed was not maintained at the required angle during tube feeding. During an observation on 6/15/26 at 10:09 a.m. in Resident 97's room, Resident 97 was lying in bed with enteral tube feeding running and the head of bed was only slightly elevated. During a concurrent observation and interview at 10:18 a.m., LVN 4 stated that while the enteral tube feeding was running, Resident 97's head of bed should have been elevated to a 45 degree angle to help prevent aspiration, and stated she did not have anything to measure the angle of the bed. During a concurrent observation and interview on 6/16/26 at 1:38 p.m. in Resident 127's room, Resident 127 was receiving enteral feeding at a rate of 50 cc/hour and was positioned at a 10 to 15 degree angle during administration. RN 1 stated residents receiving enteral feeding should be at a 35 to 45 degree angle. The facility policy titled, Enteral Feedings - Safety Precautions, stated the head of bed should be elevated at least 30 degrees during tube feeding and at least 1 hour after feeding, and the policy titled, Enteral Tube Feeding via Continuous Pump, stated the head of bed should be positioned at 30 degrees to 45 degrees for feeding.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure prescribed oxygen therapy was administered according to physician orders for two sampled residents. During a concurrent observation and interview, one resident was observed in the dining room with a portable oxygen cylinder attached to a wheelchair and a nasal cannula in place, but the cylinder pressure gauge needle was in the red zone, indicating the cylinder was empty and not providing oxygen. The resident stated she had told staff earlier that morning that she did not think the oxygen cylinder attached to her wheelchair was working. A licensed vocational nurse later confirmed there was no oxygen flow and that the cylinder was empty. The resident’s order summary indicated oxygen at 2 L/min via nasal cannula continuously. A second resident was also observed in the dining room with a portable oxygen cylinder attached to a wheelchair and a nasal cannula in place, and the cylinder pressure gauge needle was in the red zone, indicating it was empty. A licensed vocational nurse confirmed there was no oxygen flow and stated the cylinder should have been changed before the resident was brought into the dining room. In addition, the first resident’s portable oxygen cylinder was observed set to dispense oxygen at 4 L/min, while the order summary indicated oxygen at 2 L/min via nasal cannula continuously. The nurse stated the resident was receiving oxygen at 4 L/min and later acknowledged the resident should have been receiving 2 L/min. The facility policy on oxygen administration required checking equipment to ensure it was in good working order and reviewing the physician’s order before turning on oxygen.
Unclean OTC Medication Storage Room and Missing Temperature Log
Penalty
Summary
The facility failed to maintain the over-the-counter (OTC) medication storage room in a clean condition. During a concurrent observation and interview with RN 2, the floor in the room contained debris including hair, the top portion of a broken white plastic spoon, and the shell of a flower seed, and the tile floor was discolored with grime. At the entry, a black plastic milk crate placed upside down with an air-cooling unit on top was covered in dust, the threshold had dust and a piece of paper on it, and a white plastic pill bottle behind the crate was also covered in dust. RN 2 stated the debris and pill bottle should not have been there. HSK/CSS stated she checked the room daily but only swept and mopped it every two to three days, while the IP stated housekeeping was expected to sweep and mop the room daily and as needed. The facility also failed to monitor and record the temperature of the OTC medication storage room. During observation and interview with RN 1, no room temperature log was found in the OTC medication storage room. RN 1 stated HSK/CSS was supposed to monitor the room temperature. HSK/CSS stated she checked the temperature but did not enter the temperatures into a log and did not know the temperature parameters for a room that stores medication. The DON and AIT stated the room should have a temperature log, and the DON stated the task should have been a nursing responsibility. The facility policy on storage of medication stated drugs and biologicals are to be stored in locked compartments under proper temperature, light, and humidity controls.
Failure to Ensure Timely Dental Follow-Up
Penalty
Summary
Provide or obtain dental services for each resident was not ensured for one sampled resident, Resident 5. During observation on 6/16/26, Resident 5 had multiple bottom front teeth visible at the gumline and stated that his teeth hurt. Resident 5 also stated he had been seen by a dentist at the facility and was supposed to have the teeth removed, but the dentist had not returned. Resident 5's BIMS score dated 5/26/26 was 12. Record review and staff interview showed Resident 5 was admitted on 8/25/25 and had a dental exam in January 2026. Social Services stated the exam notes indicated Resident 5 had discomfort, did not want dentures, and only wanted extractions. On 6/17/26, Social Services stated it had been approximately five months since the dental visit and Resident 5 had not received the dental treatment. Social Services also stated the facility did not have a process for ensuring residents receive needed dental treatment. The facility policy stated routine and emergency dental services are available and that social services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services.
Dietary Services Supervisor Did Not Meet State Qualification Requirements
Penalty
Summary
The facility failed to ensure the Director of Dietary Services (DDS) met the state education qualifications required to supervise Food and Nutrition Service operations. During interview, the DDS stated she was full-time and responsible for the day-to-day foodservice operation, and the consultant RD stated she worked at the facility 3 to 4 days a week. Record review showed the DDS had a certificate for the Pathway III(b) Nutrition & Foodservice Professional Training Program dated 8/14/2024, and the DDS stated this coursework made her eligible to sit for the Certified Dietary Manager exam, but she had not taken the exam and was not a CDM. Review of California Health and Safety Code 1265.4(b) Pathway 4 showed that qualification required graduation from a dietetic services program approved by the Dietary Managers Association, certification as a dietary manager, maintenance of that certification, and at least six hours of in-service training on California dietary service requirements before assuming full-time duties as a dietetic services supervisor. Review of Title 22 CCR 72035 defined a dietetic service supervisor as a person who completed the training requirements in HSC 1265.4(b). The facility’s job description for Director of Dietary Services stated the role included administrative authority and responsibility for supervising the Dietary Department, and the contract for RD services identified the facility’s appointed person of contact and the qualified dietetic services manager.
Dietary Aide Misunderstood Full Liquid Diet Requirements
Penalty
Summary
The facility failed to ensure competency of dietary aides regarding what constitutes a full liquid diet for one of two sampled residents. During a concurrent observation and interview in the kitchen during lunch trayline, a dietary aide removed pudding from a meal tray and replaced it with apple juice, stating she checked the tray against the ticket and removed the pudding because it was not a liquid, even though the tray was for a full liquid diet and included two bowls of soup. The registered dietitian later stated that pudding is okay to place on the tray for a full liquid diet. Resident 39 was admitted with diagnoses of dysphagia, weakness, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. The resident had a diet order for a full liquid diet, and the meal tray ticket also indicated full liquid for breakfast, lunch, and dinner. The facility’s diet manual listed pudding as part of the full liquid diet, and a facility document used as a cheat sheet for dietary aides also listed pudding as a full liquid diet menu option. The dietary aide’s action showed a misunderstanding of the diet order and the facility’s own guidance.
Menu and Tray Card Not Followed for Resident Milk Service
Penalty
Summary
The facility failed to follow the planned menu for the regular diet for one of six sampled residents, Resident 121. During a concurrent observation and interview on 6/16/26 at 12:25 p.m. with the Registered Dietitian in the kitchen during tray line, a dietary aide placed whole milk or 2% milk on regular diet trays. The RD stated that for a regular diet, it could be either milk if no preference was indicated. A review of Resident 121's Meal Tray Ticket dated 6/16/26 showed a puree diet with milk preferences listed for breakfast, lunch, and dinner. The facility's Winter Menus indicated that the regular IDDSI menu and regular CCHO menu included 4 oz milk, while the nutritional breakdown for the regular diet was based on whole milk. The Regular Diet/IDDSI Level #7 menu stated that the regular diet was designed to meet the nutritional needs of residents who do not need dietary modification or restrictions and that the dairy group included 16 ounces of milk each day with meals, using whole milk in the nutritional breakdown. The Resident Tray Card policy stated that tray cards should include beverages and the amount desired for each meal and that resident profiles should be updated after diet changes or updates to food preferences.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for two sampled residents. One resident’s nutritional assessment documented that he would only eat sunny-side up eggs and would not eat scrambled or boiled eggs. During kitchen observation, the facility had an open, unsealed bag of frozen fried eggs with hard yolk in the walk-in refrigerator, and the Director of Dietary Services stated the facility did not have pasteurized shell eggs available to safely prepare sunny-side up eggs. The Director also stated the facility had not been purchasing pasteurized shell eggs through its approved vendor inventory and could not provide receipts showing recent grocery store purchases of pasteurized shell eggs. Record review showed the facility’s food purchasing policy required all eggs to be Grade AA, inspected fresh pasteurized or pasteurized frozen. The resident’s tray card did not list sunny side up eggs as a preference, although the nutritional assessment did. The Director of Dietary Services stated that without pasteurized shell eggs, she would not honor a request for sunny side up eggs because it would not be safe food preparation. The Registered Dietitian stated the facility should have pasteurized shell eggs readily available to honor resident requests for sunny side up eggs. The facility also failed to follow a resident’s tray card during lunch trayline. A dietary aide placed a resident’s lunch tray on the delivery cart, and the tray card indicated margarine on vegetables. When the tray was reviewed, the resident was served cooked broccoli without margarine and without pats of butter on the tray. The dietary aide and the Registered Dietitian confirmed that margarine or butter should have been provided, and the resident’s care plan stated staff would honor food preferences as best as able because the resident was at risk for altered nutrition/weight loss.
Improper Food Storage Practices
Penalty
Summary
Food was not stored in accordance with professional standards in the kitchen dry storage and refrigerator areas. During observation with the Director of Dietary Services (DDS), a large opened bag of dry pasta was found without an open date, and another opened bag of uncooked dry pasta was not sealed or labeled. An opened bottle of Kikkoman Teriyaki Marinade and Sauce was stored on a wire shelf in the dry storage room, and when the DDS read the manufacturer's directions, the bottle stated to refrigerate after opening. In the walk-in refrigerator, an open, unsealed bag of frozen fried eggs was observed inside one box, and the DDS stated it should have been closed. Also in the walk-in refrigerator, two unopened cases/boxes of frozen Vital Mighty Shakes were present without a date showing when they were placed in the refrigerator. The DDS stated there was no date indicating when the boxes were placed there and identified dates on the cases as the dates the facility received the shakes from the vendor and placed them in the freezer. Facility policies and storage guides reviewed by surveyors stated that open food items must have open dates and use-by dates, refrigerated foods must be covered properly, opened staples such as pastas must be labeled and dated when placed into containers, sauces such as teriyaki must be refrigerated after opening, and thawed supplemental shakes must be dated when placed in the refrigerator and used within the manufacturer's recommended time frame.
Infection Surveillance and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to implement its infection prevention and control program when infection surveillance was not performed. Review of the Monthly Infection Surveillance Reports showed 5 HAI for UTI in February 2026, 10 HAI for UTI in March 2026, and 13 HAI for UTI in April 2026. During interview, the Infection Preventionist stated she did not complete training or surveillance rounds to identify or prevent further infections. The facility policy stated surveillance tools are used to recognize current infections, record numbers and frequency, detect outbreaks and epidemics, monitor employee infection, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. The facility also failed to follow Enhanced Barrier Precautions for residents identified for EBP. Resident 101, who was on EBP for an open wound, was observed in bed with both upper bedrails covered by foam-like material secured with tape; the tape was pulling away and exposing adhesive underneath. The Infection Preventionist stated the tape was not changed every day and that it created a potential risk for infection. Resident 138, who had a physician order for EBP during high-contact time due to a history of MDRO, was observed receiving care from CNA 3 and CNA 4 without both staff wearing the required gown and gloves. CNA 3 was changing linens while wearing only gloves, and CNA 4 entered the room, donned gloves, and assisted with care without a gown.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident, Resident 127. During a concurrent observation and interview on 6/16/26 at 1:38 p.m. in the resident’s room, the resident’s call light was observed on the floor on the side of the bed, and RN 1 stated that Resident 127 could not reach the call light. A review of the facility’s policy titled "Call System, Residents" stated that residents are to be provided a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Implement Bedside Safety Devices and Appropriate Assistance on LAL Mattress Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for one resident with significant cognitive and physical impairments. The resident had diagnoses including traumatic cerebral hemorrhage, dementia, bipolar disorder, chronic pain, contractures, and abnormal posture, and was assessed as dependent for toileting hygiene and rolling in bed. An MDS showed the resident was unable to complete the BIMS interview and had both short- and long‑term memory problems, as well as impairments of both lower extremities. Despite these conditions, the facility did not consistently implement ordered and care‑planned safety interventions. A physician’s order dated 7/13/2020 directed that the resident "may have bilateral landing mats to sides of bed" and required an LN to check placement every shift, day and night. The resident’s care plan, under the focus of risk for pressure injury development, also included an intervention for bilateral landing mats to the sides of the bed. However, on observation in the resident’s room, no bilateral landing mats were present at the bedside. The DON confirmed that there was no documentation on the TAR or MAR for January that LNs had checked landing mat placement each shift, and stated that the mats were not in place at the time of the resident’s fall and that the physician’s order and care plan were not followed. CNA 2, who was providing toileting care at the time of the fall, also stated there were no bilateral landing mats at the bedside when the resident fell. The facility also failed to update and implement the care plan to reflect the need for two‑person assistance during toileting hygiene for a dependent resident on a low air loss (LAL) mattress. The resident’s care plan for risk of pressure injury indicated use of an LAL mattress for wound management and preventive measures, and the physician’s order and MAR documented that the LAL mattress was in place, functioning, and at correct settings on every shift up to the date of the fall. The care plans addressing contractures, limited ROM, history of falls, and functional loss did not specify two‑person assistance for ADL care. CNA 2 reported she had been told in report that the resident was a one‑person assist and described rolling the resident during toileting care when the resident tensed up and slid off the edge of the bed. CNA 3 stated the resident was totally dependent for ADLs and was always a two‑person assist, and that residents on LAL mattresses were always two‑person assists. The DSD stated she had educated CNAs that residents on LAL mattresses required two‑person assistance, one staff on each side of the bed, and that the LAL mattress was risky because it could move during care, and that the care plan should have been updated to indicate two‑person assistance. The facility did not have specific policies for following physician orders or for care of dependent residents on LAL mattresses, despite a general safety and supervision policy requiring identification of hazards, communication of interventions, assignment of responsibility, training, implementation, and monitoring of safety interventions. These failures culminated in a witnessed fall on the evening of 1/25/26 while CNA 2 was providing toileting care. According to the SBAR/COC, the resident was on a fully inflated LAL mattress with no fall mats present and was found lying on his back next to the bed with blood dripping from the back of his head. The narrative indicated that when the CNA turned the resident, his lower extremities shifted toward the edge of the bed; as the CNA moved to the other side to reposition his legs, he fell from the bed. The resident sustained a laceration to the back of the head and was transferred to an acute hospital, where a CT scan showed a trace subarachnoid hemorrhage in the right frontal and, to a lesser degree, parietal lobes. The resident was admitted to the hospital for three days and later readmitted to the facility with a diagnosis of traumatic subarachnoid hemorrhage status post fall.
Failure to Timely Collect Ordered UA C&S After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered urinalysis with culture and sensitivity (UA C&S) was collected in a timely manner after a resident experienced a change in condition with painful urination. The resident had a history of urinary tract infection and, on 11/5/25, the physician ordered a one-time UA C&S for painful urination. An SBAR dated 11/5/25 documented that the resident complained of pain while urinating, was given pain medication with effective relief, had vital signs within normal limits, and that new orders for a UA C&S were obtained. The Director of Nursing stated that the urine should have been collected as soon as possible and was unable to find documentation that the urine was collected on 11/5/25 or 11/6/25, nor any documentation of attempts or inability to collect the specimen during that time. Documentation shows that the urine was not collected until 11/7/25, as reflected in a nurse’s note and an SBAR on that date indicating that the resident’s urine was collected that morning due to painful urination. Later that day, the resident reported increased pain with urination, refused to wait for the UA C&S results, and requested transfer to the hospital, with family and the physician notified. Emergency department records from the acute hospital documented a discharge diagnosis of urinary tract infection. During an interview, the LVN assigned to the resident on the day shift when the order was received stated she could not recall if she attempted to collect the urine on that shift, and acknowledged she was supposed to collect the urine to ensure it was done on time and without delay of care. The facility’s policy on acute condition changes states that staff will monitor and document the resident’s progress and responses to treatment, and that the physician will authorize appropriate treatments.
Restroom Floor Covering in Disrepair Creates Tripping Hazard
Penalty
Summary
The facility failed to maintain the linoleum floor covering in good repair in one of five residents' restrooms, specifically in room [ROOM NUMBER]. During an observation and interview with the Maintenance Director, it was noted that the restroom floor covering was torn and lifted, resulting in an uneven surface. The Maintenance Director confirmed that this condition created a tripping hazard. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping the building in a safe and operable condition, including maintaining the building in good repair and free from hazards, in compliance with applicable regulations.
Failure to Protect Residents from Alleged Abuse by Contracted Phlebotomist
Penalty
Summary
The facility failed to follow its policy and procedure regarding the immediate protection of residents from potential abuse after being informed of an allegation against a contracted phlebotomist. After the Administrator was notified of a report that the phlebotomist was allegedly reusing needles on residents and then using them at other facilities, the Administrator stated he would initiate an investigation by contacting the agency and consultants. However, there was no immediate action taken to prevent the phlebotomist from entering the facility or having contact with residents during the investigation period. Subsequently, it was confirmed through interviews that the phlebotomist did return to the facility and performed a blood draw on a resident after the allegation had been reported to the Administrator. The Administrator later stated he was unaware that the phlebotomist had entered the facility following the report. The facility's policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete, but this was not followed in the case of the contracted phlebotomist.
Deficiencies in Linen Cart Maintenance and Laundry Room Cleanliness
Penalty
Summary
The facility failed to maintain clean linen carts in good repair, as observed during a survey. Three clean linen carts were found with ripped edges exposing metal frames and dark brownish discolorations. The Laundry Aide, when questioned, was unaware of the age of the carts, while the Housekeeping and Laundry Supervisor acknowledged the need for new carts. Additionally, the facility did not adhere to the manufacturer's guidelines for disinfecting the carts. The Laundry Aide admitted to not allowing the Clorox wipes to remain wet for the required 30-second contact time, as specified by the product instructions. Furthermore, the laundry room was not maintained in a clean and sanitary condition. An electric fan with thick grayish debris was observed blowing air onto folded clean linens, and the floor beneath the clean linen table was covered with similar debris. The Housekeeping and Laundry Supervisor confirmed that the fan had not been cleaned for a long time and that there was no cleaning log for the laundry room. The facility's policies and procedures for maintaining hygienically clean linens and clean floors were not followed, contributing to the potential for contamination and infection spread.
Deficiencies in Infection Surveillance and Antibiotic Tracking
Penalty
Summary
The facility failed to adhere to its policy and procedure on Surveillance for Infections, resulting in several deficiencies in infection control and tracking. During a review of the Antibiotic Stewardship Log (ASL) for January 2025, it was found that 64 recorded infections lacked documentation of signs and symptoms. The Infection Preventionist Nurse (IPN) confirmed this absence of documentation. Additionally, the Infection Control Committee Report for December 2024 showed various infections, including skin, respiratory, gastrointestinal, and others, but the facility's Tracking Map did not track these infections, except for urinary tract infections (UTIs). The IPN admitted to only tracking the highest number of infections, which were UTIs. Furthermore, the ASL indicated that 11 infections did not meet the criteria for antibiotic treatment, and there was no record of organism or culture to justify the use of antibiotics. The facility's policy on Surveillance for Infections, dated September 2017, emphasized the importance of identifying infections and trends to guide interventions and prevent future infections. However, the facility's failure to document signs, symptoms, and organism information, as well as inadequate tracking of infection locations, compromised effective infection control and tracking, potentially leading to the spread and increase of infections.
Failure to Communicate in Resident's Language
Penalty
Summary
The facility failed to ensure that staff communicated in a language that three sampled residents could understand, which compromised the residents' right to a dignified existence and self-determination. Resident 74, who was cognitively intact with a BIMS score of 15, expressed discomfort when staff spoke Spanish in front of them, feeling as though the staff were talking about them. Similarly, Resident 88, also with a BIMS score of 15, reported that the morning shift staff spoke in their own language, which they could not understand. Resident 110, with a BIMS score of 15, also noted that staff spoke Spanish to each other. During an observation, a CNA and a housekeeper were overheard speaking loudly in Spanish in the hallway. When questioned, both staff members apologized for speaking Spanish, with the housekeeper explaining that they were asking questions. The facility's policy on dignity, dated February 2021, emphasizes that each resident should be cared for in a manner that promotes their sense of well-being and self-esteem. The failure to adhere to this policy by not communicating in a language understood by the residents potentially affected their feelings of self-worth and satisfaction with life.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and complete informed consents for psychotropic medications for three residents, which could result in them not being fully aware of the risks and benefits of their treatments. During a review of Resident 84's Informed Consent Verification Form, it was found that the form lacked information on medication dosage and frequency for Divalproex and Olanzapine. Licensed Vocational Nurse 2 acknowledged that this information should have been included on the consent form. Additionally, Resident 97 was prescribed Lexapro for depression and anxiety, but there was no signed informed consent for this medication, as confirmed by the Assistant Director of Nursing. Similarly, Resident 77 was prescribed Xanax for anxiety, but the Minimum Data Set Coordinator confirmed that there was no consent obtained before administering the medication. The facility's policy requires informed consent for psychotropic drugs, but this was not adhered to in these cases.
Failure to Maintain Daily DHPPD Records
Penalty
Summary
The facility failed to maintain daily completed Direct Care Service Hours Per Patient Day (DHPPD) records from January 1, 2025, to February 21, 2025. This deficiency was identified during a review of the facility's DHPPD records for the period from January 2025 to March 2025, which revealed a lack of completed DHPPD documentation for the specified dates. During an interview and concurrent record review on March 13, 2025, the Administrator confirmed that no DHPPD had been completed since January 1, 2025, to February 21, 2025. The facility's policy and procedures, titled 'Posting Direct Care Daily Staffing Numbers' and dated July 2016, require the posting of daily staffing numbers for each shift and the maintenance of these records for a minimum of eighteen months or as required by state law. The absence of these records had the potential to impact the provision of sufficient nursing care to all residents.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Assistants (CNA 1 and CNA 2), which was identified during an interview and record review with the Director of Staff Development (DSD). CNA 1's last performance review was conducted on April 5, 2023, while CNA 2's last review was on November 15, 2011, with no recent evaluations on file. The facility's policy and procedure, dated June 2010, mandates that employee performance be reviewed annually, with evaluations completed by department directors and supervisors, and reviewed by the HR Director and Administrator. The absence of these evaluations for CNA 1 and CNA 2 could result in them being unaware of areas needing improvement, potentially affecting resident care.
Failure to Act on Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly Medication Regimen Review (MRR) for January 2025 was reviewed and acted upon for four sampled residents. The MRR, dated January 30, 2025, contained 139 pharmacy recommendations, but there was no documentation indicating that these recommendations were acted upon. Specific issues included the continued use of Olanzapine and Depakote for a resident without following CMS guidelines for gradual dose reduction, the use of PRN psychotropic medications beyond the recommended 14-day duration for two residents, and the long-term use of Naproxen for another resident despite its associated risks. Interviews with the Pharmacist and the Director of Nursing (DON) revealed that the MRR was emailed to the facility on January 30, 2025, with the expectation that it would be completed within three working days. However, the DON confirmed that the January MRR was still incomplete as of March 13, 2025. The facility's policy and procedure for Medication Regimen Review, dated May 2019, emphasizes the importance of reviewing each resident's medication regimen monthly to prevent and resolve medication-related problems, but this was not adhered to in this instance.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper management and storage of medications, leading to several deficiencies. One of the medication carts contained expired medications, specifically Latanoprost and Brimonidine eye drops, which were opened beyond their recommended usage period of 42 and 30 days, respectively. Additionally, medications were improperly stored, with Bisacodyl suppositories found alongside Ensure nutritional supplements, which is against proper storage practices. Furthermore, the Controlled Drug Records (CDR) for several controlled medications lacked the required signatures from two licensed nurses, indicating a failure in the documentation process for controlled substances. The facility also failed to ensure the safe administration of medications for three residents. Medications were found on bedside tables, accessible to unauthorized individuals. For instance, Resident 8 had a vial of Cequa on their bedside table, and Resident 9 had Vitamin A&D ointment left out. Resident 4's bedside table contained Calmoseptine cream and antifungal powder, with the latter being part of the facility's supply. The Treatment Nurse confirmed that these medications should not have been stored at the bedside, especially since Resident 4 was unable to self-administer them. These lapses in medication management and storage practices posed potential risks for medication errors and unauthorized access.
Failure to Maintain Clean and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary bathroom environment for one of the sampled residents, Resident 72. During an observation, the bathroom used by Resident 72 was found to have a toilet seat and bowl with dark brown stains, crumpled paper towels on the floor, and a large dark brown stain under the sink. The Housekeeping and Laundry Supervisor indicated that Certified Nursing Assistants (CNAs) should clean when housekeepers are not available. However, CNA 4 stated that cleaning the bathroom was not her responsibility and she was unaware of where to find disinfecting wipes. Resident 72, who is cognitively intact and uses a wheelchair due to a right leg amputation, confirmed that the bathroom was not cleaned. The facility's policy requires that residents have access to a clean and sanitary bathroom, which was not adhered to in this instance.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, Resident 84 and Resident 70, as required by their policy. Resident 84's smoking assessment was not completed upon admission or quarterly, as confirmed by the Assistant Director of Nursing (ADON). Resident 70, who has a diagnosis of tobacco use and is at risk of injury related to smoking, also did not have the required quarterly smoking assessments completed, as confirmed by the Director of Nursing (DON). The facility's policy mandates that a resident's ability to smoke safely be re-evaluated quarterly, upon a significant change, and as determined by staff. This failure to conduct timely assessments resulted in the residents not being evaluated for safety while smoking, posing a potential risk of injury.
Failure to Implement Fall Precaution Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as being at high risk for falls. During an observation, the resident was found lying in bed with the bed in a high position, contrary to the care plan's directive to keep the bed in the lowest position to minimize fall impact. The resident's care plan, dated December 19, 2024, highlighted the resident's risk factors, including a history of falls, medications, poor safety awareness, and an unsteady gait. The Morse Fall Assessment conducted on December 18, 2024, scored the resident at 50, indicating a high risk for falls. Despite these assessments and care plan interventions, the facility did not adhere to the specified precautionary measure, posing a potential risk for serious injury to the resident.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to adhere to professional standards of quality by not checking the blood pressure of Resident 8 before administering blood pressure medication. Resident 8 had a physician order for Losartan Potassium Tablet 25 MG to be given at bedtime for essential hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. However, a review of the Medication Administration Record (MAR) for March 2025 revealed that there was no documentation of blood pressure readings from March 3 to March 12, 2025. This was confirmed by the Assistant Director of Nursing (ADON) during an interview and record review. The facility's policy on administering medications, dated April 2019, requires that medications be administered safely, timely, and as prescribed, including verifying vital signs if necessary. The lack of blood pressure documentation indicates a failure to comply with these requirements.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as Resident 91, whose catheter tubing and urine collection bag had not been changed for two months. During observations, the catheter exhibited thick whitish to grayish material, and the urine collection bag showed dark brownish discoloration. Treatment Nurse (TN) and Licensed Vocational Nurse (LVN) 5 acknowledged the need for a change but did not perform it. The Medication Administration Record (MAR) for January, February, and March 2025 indicated that the catheter drainage bag was last changed on January 19, 2025, and there was no documentation of recent changes, despite the order being PRN (as needed). Resident 91 had a history of urinary tract infections (UTIs), as evidenced by the administration of antibiotics such as Flagyl and Macrobid for UTIs and ESBL in the urine. The facility's policy and procedure for catheter care, dated September 2014, suggested changing catheters and drainage bags based on clinical indications such as infection or obstruction. The failure to adhere to these guidelines and the lack of timely catheter care had the potential to contribute to Resident 91's repeated UTIs.
Failure to Follow Oxygen Administration Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedures for oxygen administration for one of the residents, identified as Resident 99. The physician's order for Resident 99 specified that oxygen should be administered at 3 liters per minute via nasal cannula continuously, with adjustments to maintain oxygen saturation above 92%. The resident's care plan also highlighted the risk of impaired gas exchange due to a history of aspiration and pneumonia, with interventions including the application of oxygen as per the medical doctor's orders. During an observation and interview, it was noted that Resident 99 was not wearing the nasal cannula, and the Licensed Vocational Nurse (LVN) confirmed that the resident required supplemental oxygen. Upon checking, the resident's oxygen saturation level was found to be at 90%, below the prescribed threshold. The facility's policy on oxygen administration emphasized the need for periodic observation to ensure oxygen is being tolerated, which was not followed in this instance, leading to the deficiency.
Failure to Document and Follow Up on Resident's Eyeglasses
Penalty
Summary
The facility failed to ensure that the Social Services Department documented and followed up on a resident's eyeglasses, which resulted in a deficiency. A resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported during an interview that she had been waiting for her eyeglasses for three months and was experiencing poor vision. The resident's eye consultation, conducted two months prior, indicated a prescription for bifocal lenses. However, the Social Services Director admitted to not documenting any follow-up on the resident's eyeglasses, which was a requirement according to the facility's policy and procedure for social services. This lack of documentation and follow-up had the potential to affect the resident's vision quality.
Medication Reordering Deficiency
Penalty
Summary
The facility failed to ensure the timely reordering and availability of medications for two residents, resulting in them not receiving their physician-ordered medications. Resident 8 had multiple medications that were not available, including Ketorolac Ophthalmic Solution, Prednisolone Acetate Ophthalmic Suspension, Losartan Potassium, Omeprazole, and Clobetasol Propionate Ointment. The progress notes indicated repeated instances where these medications were not available, and the pharmacy was notified, but no alternative orders were obtained. Resident 8 expressed that their medication, Omeprazole, had run out, and this was a recurring issue. The Director of Nursing acknowledged that medications should be reordered at least five days prior, and there was an over-the-counter supply of Omeprazole available in the facility. Resident 1 also experienced a lack of medication availability, specifically Metformin, which was not available when the LVN was preparing medications. The LVN stated that the medication was reordered the previous day, but no dosage was available at the time. The facility's policy and procedure for ordering and receiving medications indicated that medications should be reordered not less than three days before the last dosage is administered to ensure availability. However, this policy was not adhered to, leading to the deficiency in medication management for the residents.
Non-Functional Call Light System for Resident with Limited Mobility
Penalty
Summary
The facility failed to maintain a functional call light system for one of its residents, identified as Resident 99. During an observation and interview, it was noted that Resident 99's call light did not activate when used, and the resident was unable to move his hands due to contractures. A Licensed Vocational Nurse (LVN) confirmed that the call light was non-functional and acknowledged that Resident 99 would benefit from a push call light due to his limited hand mobility. The resident's care plan, which addressed his musculoskeletal status and quadriplegia, emphasized the importance of having the call light within reach and responding promptly to requests for assistance. Further interviews revealed that the Environmental Service Director was unaware of the non-functional call light. The facility's policy on the resident call system, dated September 2022, mandates that each resident should have a means to call staff directly for assistance and that the system should remain functional at all times. Additionally, if a resident has a disability that prevents them from using the call system, an alternative means of communication should be provided and documented in the care plan. This deficiency highlights a failure to adhere to the facility's policy and ensure the safety and communication needs of Resident 99.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident's room in good repair, as observed in room [ROOM NUMBER], where a baseboard was found ripped from the wall, measuring approximately 10 inches long and 1 inch open rip. This issue was identified during a concurrent observation and interview with the Housekeeper/Laundry Supervisor (HLS). Despite the maintenance department's daily inspections of each room, the Environmental Services Director (EVSD) admitted that they had not noticed the baseboard rip in room [ROOM NUMBER]. The facility's policy and procedure, titled Maintenance Service and dated December 2009, mandates that maintenance services should ensure the building is in good repair and free from hazards, which was not adhered to in this instance.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, violating the resident's rights to return to the facility. The resident, who had a history of a right femur fracture and respiratory disorders, was initially admitted to the facility and later discharged to an acute hospital. Upon being ready for discharge from the hospital, the facility refused to readmit the resident, citing reasons such as refusal of care and low functioning. Interviews and record reviews revealed that the facility's marketing director communicated the refusal to the hospital's case manager, and the facility's administrator acknowledged that the resident should have been readmitted. The facility's policy on readmission, which prioritizes residents returning from hospital or therapeutic leave, was not followed. This oversight had the potential to negatively impact the resident's well-being.
Failure to Follow Enteral Feeding Protocols Leads to Aspiration Pneumonia
Penalty
Summary
The facility failed to adhere to its policy and procedure for enteral feedings, resulting in a significant deficiency in the care of a resident with a gastrostomy tube (G-tube). The resident, who had a history of acute and chronic respiratory failure, paraplegia, dysphagia, and gastrostomy status, was on continuous G-tube feeding. The facility did not check the G-tube placement or gastric residual volume before administering medications, nor did they report signs and symptoms of complications to the physician in a timely manner. These oversights led to the resident being transferred to an acute hospital and diagnosed with aspiration pneumonia. The resident exhibited symptoms of nausea, vomiting, and wheezing shortly after the start of a shift, but the Licensed Vocational Nurse (LVN) on duty delayed notifying the physician for over four hours. During this time, the resident continued to vomit, and the G-tube feeding was stopped without a specific time being documented. The LVN administered medications via the G-tube despite the resident's ongoing vomiting and wheezing, which were not immediately reported to the physician. The resident's condition worsened, leading to labored breathing, diaphoresis, and cyanosis, prompting the staff to eventually send the resident to the hospital. Interviews with the Director of Nursing (DON) and review of the resident's medical records confirmed the lack of documentation regarding G-tube placement checks and residual volume assessments. The DON acknowledged that the physician should have been notified immediately after the first signs of vomiting and wheezing. The facility's policy on enteral feedings emphasized the importance of checking tube placement, monitoring for respiratory distress, and promptly reporting complications, all of which were not followed in this case.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering medications and treatments as prescribed by physicians for two residents. For one resident, the facility did not document the administration of cefazolin, an antibiotic prescribed to treat osteomyelitis, at the scheduled 5 a.m. time on October 8, 2024. The Director of Nursing confirmed the absence of documentation, which was contrary to the facility's policy requiring timely and accurate recording of medication administration. For another resident, the facility did not document the administration of prescribed treatments on multiple occasions. Specifically, treatments for a keloid, moisture-associated skin damage, and a suprapubic catheter site were not documented as administered during the 6 a.m. shift on October 17 and October 25, 2024. The Director of Nursing confirmed these omissions, which violated the facility's wound care policy that mandates detailed documentation of wound care procedures, including the date, time, and signature of the person administering the treatment.
Lack of Staff Competency in G-Tube Care
Penalty
Summary
The facility failed to ensure that two staff members, an LVN and a CNA, were competent in caring for residents with gastrostomy tubes (G-tubes). During an interview and record review with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that the LVN lacked competencies in checking G-tube placement, monitoring gastric residual volume, recognizing signs of respiratory distress, identifying complications, and reporting these to a physician. Similarly, the CNA did not have competencies related to resident positioning and care during feedings for residents with G-tubes. The DSD acknowledged the importance of these competencies to ensure staff have the necessary knowledge to care for residents effectively. The facility's policy and procedure on the competency of nursing staff, revised in May 2019, outlines that all nursing staff must meet specific competency requirements as defined by state law. It also mandates participation in a facility-specific, competency-based staff development and training program. The policy emphasizes the need for staff to demonstrate competencies necessary for resident care, including carrying out physician's orders, person-centered care, communication, and basic nursing skills. Competency evaluations are to be conducted upon hire, annually, and as needed based on facility assessments. However, the lack of competencies for the LVN and CNA in caring for residents with G-tubes indicates a failure to adhere to these policies, potentially affecting resident well-being.
Failure to Monitor Resident Smoking Privileges
Penalty
Summary
The facility failed to adhere to its Five-Day Investigation Report by not implementing follow-up monitoring for a resident involved in a verbal altercation in the smoking area. The report, dated 9/17/24, indicated that the resident's smoking privileges would be closely monitored following the incident. However, during an interview and record review on 9/30/24, the Director of Nursing (DON) could not find documentation of such monitoring in the resident's clinical record. The DON acknowledged that the staff responsible for monitoring the resident's smoking privileges was not documenting it. The facility's policy and procedure titled 'Smoking Policy-Residents,' dated August 2022, requires that any resident with smoking privileges needing monitoring must be directly supervised by a staff member, family member, visitor, or volunteer worker at all times while smoking. This policy was not followed, as evidenced by the lack of documentation and monitoring for the resident involved in the altercation.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatment as ordered by the physician for a resident, which had the potential to result in delayed wound healing. The resident had glue stitches on her right groin and right upper thigh, which later developed into wound dehiscence. The physician's orders required daily and as-needed wound care, including cleansing with normal saline, applying medicated ointments, and covering with a dry dressing. However, the Treatment Administration Record indicated that no wound treatment was provided on two specific days. Interviews with facility staff revealed that the wound care was not administered due to the resident returning from an appointment during a shift change, and the subsequent shift did not follow up on the treatment. The facility's policy and procedure for wound care required documentation of the type of wound care given, the date and time, any changes in the resident's condition, and assessment data. However, there was no documentation of the wound treatments being performed on the specified days, indicating a lapse in following the facility's wound care policy.
Inadequate Foley Catheter Care Leads to Resident Discomfort and UTI
Penalty
Summary
The facility failed to provide adequate foley catheter care for a resident, leading to significant discomfort and potential health risks. The resident, who was cognitively intact with a BIMS score of 15, experienced severe abdominal pain for approximately seven hours due to a lack of catheter assessment. Despite the resident's complaints of pain, the catheter was not checked for kinks or blockages during this period, as required by the care plan. The resident's pain was not addressed with medication until much later, and there was no documentation of pain reassessment. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty did not assess the catheter during her shift, and the Certified Nursing Assistant (CNA) reported the resident's pain to the LVN without any action being taken. The situation escalated to the point where the resident was yelling and cursing due to the pain. Eventually, the resident had to call 911, and emergency medical technicians unclogged the catheter, releasing over a liter of urine. The resident was diagnosed with a urinary tract infection, as documented in the emergency department records.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not report an allegation of abuse involving Resident 1 to the California Department of Public Health (CDPH) and did not complete an investigation of the incident. The incident involved Resident 2 throwing a tray lid and a glass plate at Resident 1, causing the plate to shatter near Resident 1's foot. Resident 1 expressed feeling unsafe and scared due to Resident 2's aggressive behavior. The Minimum Data Set (MDS) for Resident 1 indicated a Brief Interview for Mental Status (BIMS) score of 15, suggesting cognitive intactness. The Situation, Background, Assessment, and Recommendation (SBAR) and Social Services Notes documented Resident 2's aggressive behavior towards Resident 1 and another roommate. Despite these documented incidents and Resident 1's expressed fear, the Director of Nursing (DON) confirmed that no report was filed to the CDPH, and the Social Services Assistant (SSA) acknowledged that no investigation summary was completed. The facility's policy required immediate reporting and thorough investigation of such incidents, which was not followed in this case.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could lead to food contamination and the spread of infectious diseases. During an observation, black debris, scattered small containers of butter, and lifeless flies were found on the floor of the dry storage room. The walk-in freezer floor had debris and unidentified particles, and the area under the sink also had black debris. The Dietary Director acknowledged the presence of these unsanitary conditions during an interview. Additionally, the facility's cleaning schedule policy indicated that deep cleaning by an outside agency should occur quarterly, but the Administrator confirmed there was no contracted deep cleaning agency in place.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of cockroaches in three resident rooms and the kitchen. Resident 1, who was cognitively intact with a BIMS score of 15, reported seeing cockroaches crawling on the floor and even on a neighbor's face. The resident described the issue as occurring primarily at night, with staff members, including a CNA, confirming the presence of cockroaches and taking measures to kill them. Resident 2 and Resident 3, both also cognitively intact with BIMS scores of 15, reported similar sightings of cockroaches in their bathrooms. In the kitchen, an observation revealed both dead and live cockroaches under the sink area. The Dietary Director acknowledged the presence of cockroaches and indicated a need to contact the Administrator for pest control intervention. However, the Administrator stated that no reports of cockroaches had been made to them. The facility's pest control policy, dated May 2008, indicated an ongoing program to keep the building free of insects and rodents, but the observations and interviews suggest that this program was not effectively implemented.
Failure to Provide Nail Care and Hand Hygiene
Penalty
Summary
The facility failed to provide adequate nail care and hand hygiene for a resident, which was observed during a survey. The resident, who was non-verbal and had cognitive impairment, was found lying in bed with long fingernails containing black debris and brown stains on the right palm. The resident's care plan indicated a need for assistance with personal hygiene due to a self-care performance deficit and a high risk for functional decline. The Minimum Data Set (MDS) assessment confirmed the resident required substantial assistance with personal hygiene. During interviews, a CNA admitted to not trimming the resident's nails, citing uncertainty about the resident's diabetic status, which was later clarified by an LVN as non-diabetic. The CNA also mentioned the resident's brown stains were due to picking at his buttocks. The LVN stated that CNAs are responsible for nail care but did not recall being informed about the resident's nail condition. The facility's policy on Activities of Daily Living (ADLs) emphasized providing appropriate care and services for residents unable to perform ADLs independently, including hygiene support.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of the Physician when a resident fell, resulting in a delay in medical intervention. On 5/3/24 at approximately 2:20 am, a resident was found half off the bed with legs dangling and was assisted to sit on the floor by the charge nurse. The incident was not documented as a fall, and the Physician was not notified immediately. Later that day, the resident complained of right leg pain, which was not relieved by the ordered medication. It was only at 6:30 pm that the Physician was called, and an order for hospital transfer was obtained. Interviews with the staff revealed that the Licensed Vocational Nurse (LVN) assigned to the resident during the night shift was unaware that assisting a resident to the floor constituted a fall and did not notify the Physician. The facility's policies and procedures clearly state that any incident involving a resident, including falls, should be reported to the attending Physician immediately. The failure to follow these protocols led to a delay in addressing the resident's medical needs promptly.
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 237 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Joaquin Nursing Center And Rehabilitation Cent | 0.6 mi | ★★★★★ | 17 | 0 |
| Valley Healthcare Center | 1.5 mi | ★★★★★ | 28 | 0 |
| The Rehabilitation Center Of Bakersfield | 2.3 mi | ★★★★★ | 23 | 0 |
| Height Street Skilled Care | 2.4 mi | ★★★★★ | 19 | 0 |
| Kern River Transitional Care | 3.1 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 October 2026) and official state health department websites.