Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Rehabilitation Center Of Bakersfield during CMS and state inspections, most recent first.
Food safety and sanitation deficiencies were identified in the dietary area when a dented can was found in dry storage, multiple expired or spoiled food items were observed in dry storage and the walk-in refrigerator, and several frozen items were uncovered, unlabeled, or undated in the walk-in freezer. A small freezer holding vanilla ice cream cups was at 11 degrees F instead of 0 degrees F or below, a cook was observed without a hair restraint while cleaning in the kitchen, and the C-Wing ice machine chute had visible buildup and residue.
Infection control deficiencies were identified when a resident was cohorted with a roommate who had shingles without a documented susceptibility assessment, isolation signage was missing outside multiple rooms, and staff did not consistently follow EBP/PPE requirements while caring for a resident with an MDRO history and tube feeding. Additional observations showed hand hygiene was not performed by staff during meal service and trash handling, an ice scoop was stored in the ice bucket, and trash was improperly discarded and left in the biohazard room.
Failure to respond promptly to a resident's call light resulted in a dignity and respect deficiency. A resident with Parkinsonism, urinary incontinence, and moderate cognitive impairment waited about 45 minutes after activating the call light for help with a soiled brief and clothing. An LVN told the resident to keep waiting because a CNA was on break, and the resident later described the delay as disrespectful. Facility policy required call alerts to be answered promptly and courteously.
Improper Storage of Disposable Care Equipment: Surveyors observed multiple unlabeled, undated, and uncovered disposable care items, including urinals, urine collection containers, and emesis basins, in resident bathrooms and at bedside. Some basins contained toothbrushes with dried whitish substance on the bristles, and staff interviews confirmed these items should be labeled, covered, and stored properly when not in use; the DON stated the facility had no policy on the care and disposal of residents’ bedside care equipment.
Failure to notify the SLTO of an urgent resident transfer. A resident receiving IV abx for an infection was sent to a higher level of care for AMS with a bed hold, but the transfer form showed no ombudsman notification. The CM and SSD both verified the SLTO was not notified, despite facility policy requiring notice as soon as practicable.
Inaccurate MDS Dialysis Status: A resident with ESRD, heart failure, and dependence on renal dialysis had an MDS that incorrectly indicated the resident was not on dialysis. Record review showed the resident was receiving dialysis M/W/F at an outside dialysis center, and the MDSC acknowledged the discrepancy and stated the annual MDS data was not accurately entered. The MDSC also stated the facility did not have a policy and procedure on data entry and followed RAI guidance.
A resident with dysphagia, gastrostomy status, and DM2 did not have baseline care plans developed within 48 hours for oral care and enteral feeding. The resident had severely cracked, painful lips and a red, cracked tongue with thick yellow scales, while a kangaroo pump was infusing tube feeding at the bedside. The DON confirmed the oral care plan was missing and the enteral feeding care plan was not completed until several days after admission.
Two residents did not receive ordered care. One resident with dysphagia, a G-tube, and DM had severe oral dryness and cracking, reported burning pain, and was only given oral care inconsistently despite an order for oral care every shift. Another resident with hemiplegia, weakness, and impaired gait was ordered PT 5x/week to improve ambulation, but treatment notes showed therapy was only provided twice in 10 days, and the DOR confirmed the missed sessions.
A resident with dysphagia, gastrostomy status, and type 2 DM was observed lying flat while receiving enteral feeding. The IP stated the resident needed to be sitting up during feeding, and the DON stated no resident should ever lay flat while receiving enteral feeding for aspiration risk. The resident’s PO ordered the HOB elevated 30-45 degrees during enteral feedings.
A resident with COPD, asthma, and continuous O2 use was observed receiving O2 via NC at 3 LPM, but the tubing was dated outside the required weekly change interval. The resident said she was unsure how often the tubing was changed, and an LVN confirmed the tubing should have been changed earlier. The facility policy required oxygen tubing and mask to be changed at least every 7 days and labeled with the date of change.
Cold Soup Served Below Required Temperature: A resident was served French onion soup that was cold on two attempts during a meal, and the resident refused it both times. The DM later checked the soup and found it measured 116 degrees F, while another cup from the warmer measured 145 degrees F; the recipe and facility P&P both listed higher serving temperatures for soup.
Outside Dumpsters Left Open and Overflowing: Four of four outside dumpsters were observed overflowing with trash so the lids could not close, with trash containing food scattered on the ground around the dumpsters. The DM confirmed the trash should not be on the ground and the lids should cover all trash, and the RD stated the dumpster lids should be fully closed to keep rodents out.
Lack of Antibiotic Monitoring and Stewardship Oversight: A resident with CKD stage 3 and DM2 received cefdinir for a UTI and azithromycin for prophylaxis, but the urine culture did not meet UTI criteria and the facility’s antibiotic tracking log showed no monitoring for either antibiotic. The IP confirmed there was no tracking or oversight of the resident’s antibiotic use, despite the facility policy requiring review of the antibiotic ordered, McGeer’s Criteria, cultures, therapy changes, and outcomes.
Missing Documentation for Flu and Pneumococcal Vaccine Offers: A resident admitted with metabolic encephalopathy and pneumonitis due to aspiration had no EMR documentation showing that influenza or pneumococcal vaccines were offered or given. The IP stated the immunizations should have been offered, but the record did not contain the required documentation of education, consent, administration, or refusal.
A resident with DM declined the COVID-19 vaccine, but the facility had no documentation that education on the risks and benefits was provided to the resident or RP. The facility also had no documentation verifying that a CNA was vaccinated for influenza and COVID-19, despite the IP stating the CNA had consented to both vaccines.
A resident with hypertension and coronary artery disease, care planned for blood pressure monitoring and listed as DNR, did not have current vital signs documented for several days. On one shift, a CNA attempted four times to obtain the resident’s BP with an electronic vitals tower, received only error indications, did not use a manual BP cuff, and later informed an LVN that the readings could not be obtained. The LVN acknowledged plans to recheck the BP manually but did not assess the resident’s vital signs before going to lunch and did not report the equipment issue. Later that evening, the resident was found unresponsive in bed, and the DON, MD, and family were notified. The DON stated that per facility policy, unsuccessful CNA attempts should have been followed by a nurse assessment and use of a manual BP monitor when there is a change in condition.
A resident was served lunch with meat and green beans at 100°F, which did not meet the facility's required serving temperature of greater than 140°F for hot foods. The salad was also above the required cold holding temperature. The resident, who had moderate cognitive impairment, reported the food was not hot enough, and the facility's policy confirmed the temperature standards were not met.
Two residents reported receiving late meals that were not at safe or appetizing temperatures, with observations confirming that both hot and cold foods were served outside required temperature ranges. The dietary supervisor acknowledged ongoing complaints about late meal service, and a review of food temperature logs revealed numerous missing entries for required temperature checks before meal distribution.
A resident did not receive a lunch meal tray, while their roommate did. Despite all lunch trays being distributed and returned to the kitchen, none of the CNAs delivered a meal tray to the resident. The DON confirmed the resident should have received a meal. The facility's policy requires providing meals that meet nutritional standards.
The facility experienced a medication error rate of 12.82%, exceeding the acceptable threshold of 5%. Errors included administering incorrect medications, late administration, and incomplete medication delivery via G-tube. These issues were due to non-compliance with the facility's medication administration policies.
The facility failed to implement infection control practices, including the absence of Enhanced Barrier Precautions signage and PPE for a resident with a gastrostomy tube, a structural hole between clean and dirty utility rooms, and a janitorial cart without a lid on its trash bin. These issues were confirmed by staff and contradicted the facility's policies.
A resident reported missing personal belongings, including a gold box, which were not documented on her Inventory of Personal Effects (IPE). The facility failed to review and update the IPE during the resident's quarterly care plan conference, as required by their policy. This oversight hindered the verification and potential replacement of the missing items.
The facility did not notify the ombudsman of the transfers of two residents to the hospital, as required by their policy. During a survey, it was found that the MDSC and SSA could not provide documentation of such notifications, which are necessary to ensure residents have an advocate for their transfer and discharge rights.
A facility failed to document a verbal order for Glucagon in a resident's medical record, leading to an incomplete record. Additionally, an LVN administered an incorrect dose of a nutritional supplement to another resident, contrary to the prescribed dosage in the MAR.
A facility failed to follow a resident's RNA therapeutic program as per physician's orders, leading to inconsistent therapy sessions. The RNA was often reassigned, resulting in missed exercises, and failed to complete required weekly summaries to monitor the resident's progress. The facility's policy emphasized the need for documentation, which was not adhered to.
The facility failed to conduct an annual performance evaluation for a Supervisor Licensed (SL) employee, as required by its compliance policy. Despite being hired in December 2023, the SL's personnel file lacked any performance evaluation. The DON and DSD confirmed the necessity of annual evaluations, which are meant to ensure adherence to the facility's compliance program.
A facility failed to provide an adaptive call light for a resident with physical limitations, resulting in unmet needs. The resident, who had contractures in one hand and a limp arm, was unable to use the standard call light and resorted to whistling for assistance. A CNA confirmed the resident's inability to use the call light, and the DON acknowledged that the resident should have had an adaptive call light, as per facility policy.
A resident reported abuse allegations, but the facility failed to follow its grievance process. The resident was not informed of the investigation's outcome, and the grievance report was incomplete. The Administrator confirmed the oversight, which was against the facility's policy requiring a completed investigation report within five business days.
A facility did not follow its abuse investigation policy when a resident alleged physical abuse by a CNA. The DON, responsible for the investigation, failed to interview other residents cared for by the accused CNA, as required by the policy. The SSA and CM were not involved in the investigation, and the Administrator confirmed that the DON was solely responsible. The facility's policy mandates thorough investigations, including interviewing other residents.
The facility failed to involve a resident's conservator in the care conference and did not include individualized goals for another resident's restorative mobility in their care plan. The first resident, with severe cognitive impairment, had no documentation of conservator participation, while the second resident's care plan lacked interventions for upper extremity strengthening.
The facility failed to follow prescribed menus for two residents, resulting in smaller portion sizes than required. A resident on a large portion diet received fewer breakfast items than specified, and another resident on a renal diet received less corn than indicated. Staff interviews confirmed the discrepancies, and the facility's policy emphasized adherence to the written menu to meet nutritional needs.
The facility failed to document food temperatures for meals served, as confirmed by the Dietary Supervisor. This oversight was contrary to the facility's policy, which mandates recording temperatures to ensure food safety, potentially leading to foodborne illnesses.
A resident with cognitive impairments was subjected to disrespectful treatment by a CNA, who yelled at the resident and used dismissive language. The incident was witnessed by a marketer and confirmed through an investigation, revealing a failure to adhere to the facility's policy on treating residents with respect and dignity.
A resident with cognitive impairments reported missing money and giving money to a staff member for personal use. Despite multiple withdrawals from the resident's trust account, the facility delayed investigating the issue and failed to protect the resident from potential financial exploitation. The Activity Director denied taking money, but a written statement indicated a problem with their tire, which the resident mentioned as a reason for giving money.
A resident with dementia and bipolar disorder experienced multiple unwitnessed falls over five months due to the facility's failure to complete Post Fall Evaluations and update care plans as per their Fall Management Program. The resident sustained a femoral fracture requiring surgery after one fall. The Director of Nursing confirmed that care plans were not revised following specific incidents, contrary to facility policy.
A resident was found with discoloration and swelling on the right eye, but the injury was not reported or investigated by the facility staff. Interviews revealed that the injury was observed by a CNA and two LVNs, but not communicated to the DON or Administrator. The facility's policy requires prompt investigation of unexplained injuries, which was not followed in this case, leading to a deficiency.
A resident with severe cognitive impairments experienced a fall, but the facility did not follow its Fall Management Program. The necessary post-fall protocol, including neurological checks, fall risk assessment, and care plan updates, was not implemented. The facility's policy requires specific actions after a fall, which were not adhered to, resulting in a deficiency.
The facility failed to administer incentive spirometry (ISP) as ordered by the MD for three residents. Despite having intact cognition, two residents confirmed they had not used ISP since admission, and no ISP devices were observed in their areas. The DON confirmed that ISP was not administered to a third resident as well, despite orders. The facility's digital system auto-populated ISP orders for new admissions, but these were not executed, violating the facility's ISP policy.
A facility failed to accurately document ISP treatment for three residents, leading to falsified medical records. Despite MD orders for ISP every shift, the treatment was not provided, and MARs falsely indicated it was given. Interviews revealed ISP equipment was unavailable for months, yet documentation continued inaccurately. The DON confirmed the discrepancy and lack of policy availability.
A facility failed to follow its abuse prevention policy when a resident was not assessed for emotional distress after a family member confessed to financial abuse. Despite the resident's upset state, there was no documentation of assessment by licensed nurses or Social Services, as required by the care plan and facility policy.
A facility failed to complete an investigation of a financial abuse incident involving a resident within the required five working days. The resident's family member was suspected of taking money from the resident's account, which was confirmed through bank footage. The administrator did not follow up on the investigation timely, and the Social Services Director was unaware of the requirement to complete the five-day summary, resulting in a nine-day delay.
The facility failed to inform three residents about lab orders, compromising their dignity and privacy. A resident felt humiliated when CNAs entered her room without explanation to request a urine sample. Another resident, a dialysis patient, was asked for a urine sample despite not producing urine for years. CNAs were instructed by an LVN to collect samples but were not informed of the reasons. The facility's policy on resident rights was not followed.
The facility failed to consistently document and administer medications and treatments for three residents, as evidenced by multiple omissions in the Medication Administration Record (MAR). This included failures to change IV tubing, administer medications, flush PICC lines, and monitor for complications, potentially compromising treatment effectiveness.
A resident's urinary catheter collection bag was found on the floor, not in a dignity bag, contrary to the facility's policy and CDC guidelines. This failure in catheter care was confirmed by a CNA and could lead to catheter-associated UTIs.
The facility failed to verify the qualifications of the DON, as the application lacked education and employment history details. The background check was completed post-hire, violating the facility's policy. This oversight could compromise resident safety due to unverified qualifications.
The facility did not follow its 'Abuse-Prevention, Screening, & Training Program' policy by failing to complete the required two reference checks for a newly hired LVN. Only one reference check was conducted, despite the LVN having two previous employers and three personal references. This failure had the potential to expose residents to possible abuse.
A facility failed to follow its 'Abuse Reporting' policy when a CNA allegedly pulled a resident's pubic hairs. Although the CNA was suspended and an investigation began, the incident was not reported to the California Department of Public Health within the required timeframe. This delay in reporting was confirmed by the Regional Quality Assurances Consultant and had the potential to place all residents at risk.
A medication cart was found unlocked and unattended at a nurses' station, with a resident who had severely impaired cognition nearby. The facility's policy requires medications to be securely stored and accessible only to authorized personnel, which was not followed in this case.
A resident experienced delayed care and unnecessary nerve pain due to the facility's failure to administer medications as ordered and in a timely manner. The resident's morning medications, including those for neuropathy, were not given, and a pain-relief patch was repeatedly administered late. Interviews and record reviews confirmed these deficiencies, highlighting a significant oversight in medication management.
A facility failed to implement proper infection control practices, leading to a mix-up of Albuterol inhalers between two residents, one of whom was on COVID-19 isolation. The inhalers were not labeled correctly, resulting in cross-contamination. Additionally, a CNA did not follow hand hygiene protocols after handling items from an isolation room, increasing the risk of infection spread. These actions violated the facility's policies on medication administration and hand hygiene.
Food Storage, Freezer Temperature, Hair Restraint, and Ice Machine Sanitation Deficiencies
Penalty
Summary
Food storage and sanitation practices were not followed in the dietary department when a dented can of roasted diced tomatoes was found in dry storage during observation with the Dietary Manager. The Dietary Manager stated the can needed to be placed in the disposal pile because of the risk of botulism. The facility policy on food storage stated that dented or bulging cans should be placed in a separate area and returned for credit. Multiple expired and unusable food items were also observed in dry storage and the walk-in refrigerator. In dry storage, an opened gallon bottle of apple cider vinegar, a container of Classic Noodles, mayo packets, thickened orange juice, red onions, red potatoes, and potatoes were all past their use-by dates or visibly spoiled, with some items showing dark decaying spots, wilted condition, and sprouting. In the walk-in refrigerator, two bags of cauliflower and two bags of cabbage were found with expired use-by dates, and the Dietary Manager stated the items needed to be thrown away. The walk-in freezer contained multiple items that were not properly stored. An opened plastic bag with unknown pink meat was unlabeled and undated, and the Dietary Supervisor identified it as pork. A box of dinner rolls and boxes of chicken patties and chicken and vegetable protein enchiladas were uncovered and undated. In the kitchen, a small white freezer held vanilla ice cream cups that were not frozen, and the freezer temperature was later measured at 11 degrees Fahrenheit, below the facility standard of 0 degrees Fahrenheit or below. In addition, a cook was observed cleaning a stove top without a hair restraint, and the C-Wing ice machine chute had thick white buildup and a slimy brown residue when wiped, which Maintenance confirmed was dirty.
Infection Control Deficiencies in Cohorting, Precautions, PPE, Hand Hygiene, Ice Handling, and Waste Storage
Penalty
Summary
Resident 40 was cohorted in the same room with Resident 152, who had confirmed herpes zoster (shingles), without a documented assessment of Resident 40’s susceptibility or risk factors before the placement. Resident 40 was admitted with type 2 diabetes mellitus. During observation, Resident 40 stated that his roommate was on quarantine because of shingles and confirmed that he did not have shingles. Review of Resident 40’s record did not show a history of varicella-zoster virus, a varicella vaccination, or an assessment of risks related to being placed with a resident who had shingles. In Rooms 311, 314, 315, 316, 318, and 321, isolation carts were observed outside the rooms, but there was no signage posted to identify the required transmission-based precautions or enhanced barrier precautions for the residents in those rooms. Staff interviewed at the time stated they could not tell what type of isolation precaution was needed for some of the rooms. The infection prevention staff stated the carts should include clear identification of the type of infection or precaution and which resident was affected. Resident 15 had physician orders for enhanced barrier precautions due to a history of multidrug-resistant organism and tube feeding. During observation, an LVN and a CNA entered the room wearing gloves and masks, but not gowns, while providing care that included disconnecting the feeding tube and changing a soiled brief and providing personal hygiene. Two staff members, CNA 5 and HK 2, were also observed not following hand hygiene expectations during meal service and trash handling. In addition, one ice scoop was stored inside an ice bucket during dining service, and trash was observed improperly discarded and left in the C-Wing biohazard room, including multiple bags of trash and other items stacked around the receptacle.
Failure to Respond Promptly to a Resident's Call Light
Penalty
Summary
The facility failed to ensure that Resident 9 was treated with dignity and respect when the resident used the call light to request assistance and did not receive staff help for approximately 45 minutes. Resident 9 was admitted with Parkinsonism, a urinary tract infection, and a history of falls, and her MDS assessment showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Resident 9 stated that on 1/11/2026 at about 7:10 p.m., her urine leaked through her brief and clothing, and after activating the call light she waited about 30 minutes without a response before independently propelling herself in a wheelchair to the nursing station to ask for help. Resident 9 stated that after an additional 40 minutes, a staff member finally arrived and assisted her with changing her brief, and she later described the delay as disrespectful. RN 1 stated Resident 9 was frequently incontinent of bowel and bladder and should be assisted immediately upon request. CNA 2 stated call lights should generally be answered within five minutes and that it was unacceptable for a soiled brief to remain on a resident for approximately 45 minutes. LVN 1 confirmed that when Resident 9 requested help, she told the resident that CNA 1 was on break and that the resident needed to continue waiting. CNA 1 later confirmed she was assigned to care for Resident 9 and stated that when she was contacted, Resident 9 was upset and reported her call light had been on for 30 to 35 minutes. The facility policy required call alerts to be answered promptly and in a courteous manner, and the resident rights policy stated residents should receive care in a manner that promotes dignity, respect, individuality, and person-centered services.
Improper Storage of Disposable Care Equipment
Penalty
Summary
The facility failed to ensure residents’ disposable care equipment, including emesis basins, urinals, and urine collection containers, was maintained in a clean, sanitary, and safe manner. During initial rounds, surveyors observed multiple items that were unlabeled, undated, uncovered, or stored inappropriately in resident bathrooms and at bedside, including an unlabeled urinal hanging on a safety rail, an uncovered unlabeled urine collection container on the floor, and several unlabeled emesis basins containing toothbrushes with dried whitish substance on the bristles. One bathroom also contained an unlabeled half-filled bottle of body wash, and another room had an unlabeled urinal hanging on the bedrail. Additional observations included two unlabeled emesis basins in one bathroom, each containing a toothbrush with dried whitish substance covering the bristles, and another unlabeled emesis basin in a different bathroom with a toothbrush showing the same dried whitish substance. During interviews, CNAs stated that disposable care equipment should not be stored on the floor and should be covered with a clear plastic bag, labeled, and dated, and that such equipment is changed weekly. Infection prevention staff stated these items should be stored in a labeled plastic bag with the resident’s name and room number when not in use, disposed of when soiled, and labeled before use. The DON stated the facility had no policy on the care and disposal of residents’ bedside care equipment.
Failure to Notify Ombudsman of Urgent Transfer
Penalty
Summary
The facility failed to inform the Office of the State Long-Term Ombudsman when Resident 159 was urgently transferred to a general acute care hospital and later discharged from the hospital to an assisted living facility. Resident 159 was admitted for management of an infection requiring IV antibiotic infusion, and the order summary showed IV antibiotics were started on 10/20/2025 and were to continue through 11/2/2025. A physician order dated 10/26/2025 directed that the resident be sent urgently to a higher level of care for further evaluation of altered mental status, with a 7-day bed hold. The eINTERACT Transfer Form V5 for the transfer had no indication of ombudsman notification. During interviews, the case manager stated it was her responsibility to notify the ombudsman as soon as possible when a resident was urgently transferred, and verified this was not done. The Social Services Director stated it was her responsibility to track transfers, verified the resident was admitted to the acute care hospital and did not return to the facility, and verified the ombudsman was not notified. The facility policy titled Notice of Transfer / Discharge stated that when a resident's urgent medical needs require immediate transfer, the State Long Term Ombudsman is to be provided notice as soon as practicable.
Inaccurate MDS Dialysis Status
Penalty
Summary
The facility failed to ensure an accurate MDS for one resident, Resident 13, resulting in inaccurate data being transmitted to CMS. Resident 13’s admission record showed diagnoses including hypertensive and chronic kidney disease with heart failure, stage 5 chronic disease/end stage renal disease, and dependence on renal dialysis. During record review, the MDS Section O: J1-Special treatments dated 3/19/2025 indicated the resident was not on dialysis, but the MDS Coordinator stated the resident was admitted already on dialysis and that there was a discrepancy in the MDS entry, with the data not accurately entered for the annual MDS. The resident’s order summary report dated 3/5/2025 documented dialysis on Monday, Wednesday, and Friday for end stage renal disease at an outside dialysis center, with a 4:30 a.m. chair time and 4:00 a.m. pickup time. The MDS Coordinator later stated the facility did not have a policy and procedure on data entry and that they followed RAI guidance.
Failure to Develop Baseline Care Plans for Oral Care and Enteral Feeding
Penalty
Summary
Baseline comprehensive, person-centered care plans were not developed and implemented within 48 hours of admission for one resident who was readmitted with diagnoses including dysphagia, gastrostomy status, and type 2 diabetes mellitus. During observation and interview, the resident had severely cracked lips with flaking skin and a red, cracked tongue covered with thick yellow scales, and stated that the lips and tongue were hurting and burning. The resident also stated that staff were not consistent with providing daily oral care and that he was unable to do it himself. The resident’s physician orders included oral care every shift, but no care plan for oral care was in place. The same resident was observed with a kangaroo pump actively infusing enteral nutrition at the bedside. The resident stated that after a prior hospitalization he lost the ability to swallow and chose to have a tube placed in his stomach to receive nutrition. The physician orders directed administration of enteral feeding at 50 mL an hour for 20 hours a day. During record review, the DON confirmed that a care plan for enteral feeding should have been completed within 48 hours of admission, but it was not completed until five days after admission. The facility policy stated that the baseline care plan must be developed and implemented within 48 hours and include initial goals based on admission orders, physician orders, and dietary orders.
Failure to Provide Ordered Oral Care and Physical Therapy
Penalty
Summary
Resident 44 did not receive oral hygiene in accordance with the assessed need and physician order. Resident 44 was readmitted with diagnoses including dysphagia, gastrostomy status, and type 2 diabetes mellitus. During observation, Resident 44 had severely cracked lips with flaking skin and a red, cracked tongue covered with thick yellow scales, and stated the lips and tongue were hurting with a burning feeling. Resident 44 also stated staff were not consistent with daily oral care and that he was unable to do it by himself. CNA 8 confirmed Resident 44 needed maximum assistance with oral care and said oral care was completed once a day on whichever shift could complete it, even though the physician order required oral care three times a day. The oral hygiene record showed oral care was not provided as ordered throughout the reviewed period, and the DON confirmed the resident should have received oral care three times a day. Resident 152 did not receive physical therapy services in accordance with the physician order. Resident 152 was admitted with diagnoses including hemiplegia following cerebral infarction affecting the left side, muscle weakness, abnormalities of gait and mobility, and muscle atrophy. During observation, Resident 152 was sitting in a wheelchair next to the bed and stated he was supposed to receive physical therapy five times a week but had only received it twice the prior week, and he wanted more therapy so he could get strong enough to go home. The physician order required physical therapy five times a week for four weeks with a goal of ambulating 150 feet with a walker, but treatment notes showed therapy was only provided two times in ten days. The DOR confirmed the resident did not receive therapy in accordance with the order for the week reviewed, and the ADOR stated she scheduled therapy five times a week but was unaware the resident did not receive it.
Improper Positioning During Enteral Feeding
Penalty
Summary
Safe administration of enteral nutrition was not ensured for Resident 44, who was readmitted with diagnoses including dysphagia, gastrostomy status, and type 2 diabetes mellitus. During a concurrent observation and interview on 1/12/2026 at 4:05 p.m., Resident 44 was observed lying flat while receiving enteral feeding in the room, and the Infection Preventionist stated the resident needed to be sitting up while receiving enteral feeding to prevent aspiration and infection. A review of the physician order dated 1/8/2026 showed an order to elevate the head of the bed 30-45 degrees while receiving enteral feedings. During an interview on 1/15/2026 at 1:45 p.m., the DON stated no resident should ever lay flat while receiving enteral feeding for risk of aspiration.
Oxygen Tubing Not Changed Within Required Weekly Interval
Penalty
Summary
The facility failed to ensure safe handling of oxygen treatment for one resident with COPD, asthma, and dependence on supplemental oxygen. During observation and interview, the resident was receiving oxygen via nasal cannula at 3 liters per minute and stated that the tubing was changed but she was not sure how often. The resident’s order summary indicated that oxygen tubing was to be checked every night shift every Sunday to ensure it was current for the week. During a concurrent observation with an LVN, the nasal cannula tubing was found dated 1/3/2026. The LVN stated that the tubing should have been changed on 1/10/2026 and also stated that the nasal cannula tubing was changed weekly, dated, and timed. The resident’s order summary also indicated oxygen at 3 LPM via nasal cannula continuously for COPD, and the facility policy stated that tubing and mask should be changed at least every 7 days and labeled with the date of change.
Cold Soup Served Below Required Temperature
Penalty
Summary
The facility failed to provide food at a palatable and safe temperature for one sampled resident, Resident 102, when cold French onion soup was served during the meal. During an observation in the dining hall, CNA 5 served Resident 102 a cup of French onion soup, and the resident took a sip and stated the soup was cold and did not want it anymore. CNA 5 then obtained a replacement cup of French onion soup and served it again to Resident 102, who again took a sip and stated that it was cold and pushed the cup away. During a concurrent observation and interview, the Dietary Manager checked Resident 102's second cup of soup and found it measured 116 degrees Fahrenheit, stating the soup should have been hotter. Later, the Dietary Manager checked a cup of soup from the warmer and found it measured 145 degrees Fahrenheit, stating soups should be served at 170 degrees Fahrenheit. The facility's Recipe: French Onion Soup indicated it should be served on the trayline at 170 F to 190 F, and the facility's policy on Food Temperatures listed the preferable serving temperature for soup as 160 F to 175 F.
Outside Dumpsters Left Open and Overflowing
Penalty
Summary
The facility failed to ensure that four of four outside dumpsters had closed lids. During a concurrent observation and interview on 1/12/2026 at 1:57 p.m. with the Dietary Manager outside in the trash area, all four dumpsters were observed overflowing with trash so the lids could not close, and multiple items of trash containing food were scattered on the ground around the dumpsters. The Dietary Manager confirmed that trash should not be on the ground and that the lids should cover all trash in the dumpsters. During a later interview on 1/14/2026 at 2:03 p.m., the Registered Dietician stated that she oversees the kitchen and that the dumpster lids should be fully closed to keep rodents out.
Lack of Antibiotic Monitoring and Stewardship Oversight
Penalty
Summary
The facility failed to ensure oversight and monitoring of antibiotic use for Resident 44, who was admitted with chronic kidney disease stage 3 and type 2 diabetes mellitus. During interview and record review, Resident 44’s physician orders showed azithromycin 500 mg for three days for prophylaxis and cefdinir 300 mg twice daily for 10 days for UTI. The resident’s lab results report dated 12/15/2025 indicated the urine culture did not meet UTI criteria and stated that, according to recent guidelines by multiple clinical societies, antibiotic therapy is not recommended. Resident 44’s MAR showed 13 doses of cefdinir from 12/12/2025 through 12/18/2025 and three doses of azithromycin from 12/16/2025 through 12/18/2025. The facility’s antibiotic tracking log did not show monitoring for azithromycin or cefdinir, and the Infection Preventionist confirmed there was no tracking or monitoring for Resident 44 while receiving the two antibiotics. The facility policy titled Antibiotic Stewardship stated that the IP is responsible for tracking antibiotic orders, whether the resident met McGeer’s Criteria when the antibiotic was ordered, whether cultures were ordered, changes in antibiotic orders during therapy, and outcomes of antibiotic therapy.
Missing Documentation for Flu and Pneumococcal Vaccine Offers
Penalty
Summary
The facility failed to maintain documentation verifying that influenza and pneumococcal immunizations were offered to one of five residents reviewed for immunizations, identified as Resident 2. Resident 2 was admitted to the facility with diagnoses including metabolic encephalopathy and pneumonitis due to aspiration of food and vomit. During a concurrent interview and record review, the Infection Preventionist stated she was unable to locate documentation in the resident’s electronic medical record showing that the influenza and pneumococcal vaccines were offered or administered, and stated these immunizations should have been offered, but the documentation was missing. Review of the facility’s Pneumococcal Vaccination policy dated 4/27/2023 showed that the facility would provide all residents the opportunity to receive the pneumococcal vaccine unless medically contraindicated or already immunized according to CDC recommendations or state/local public health guidelines. Review of the facility’s Influenza Prevention and Control policy dated October 2020 showed that residents are to be offered influenza immunization every year during flu season unless medically contraindicated or already immunized, and that the resident or representative must receive education and give consent, with refusal documented in the medical record.
Missing COVID-19 Vaccine Education and Staff Vaccination Documentation
Penalty
Summary
The facility failed to follow its infection prevention and control procedures for COVID-19 vaccination when Resident 124 declined the COVID-19 vaccine, but there was no documentation that education had been provided about the risks and benefits of the vaccine to the resident or the resident's responsible party. Resident 124 was admitted with a diagnosis that included Diabetes Mellitus. During interview and record review, the Infection Preventionist stated that the resident had declined the vaccine and that she could not locate documentation showing that education had been provided. The facility also lacked documentation verifying that CNA 1 was vaccinated for influenza and COVID-19. During interview and record review, the Infection Preventionist stated that CNA 1 had consented to both vaccines, but no documentation was provided confirming that the vaccines were administered. The facility's COVID-19 Vaccination Program policy stated that all health care personnel are required to be fully vaccinated.
Failure to Obtain Complete Vital Signs After Unsuccessful Machine Readings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality when complete vital signs were not obtained for a resident with significant cardiac history after multiple unsuccessful attempts. The resident had diagnoses of essential hypertension and atherosclerotic heart disease of native coronary artery without angina and was care planned for coronary artery disease with an intervention to monitor blood pressure and notify the physician of abnormal readings. The resident was also documented as DNR. The Weights and Vitals Summary showed the resident’s last recorded vital signs were taken several days before the incident, despite the care plan requirement to monitor blood pressure. On the day of the incident, a CNA attempted to obtain the resident’s blood pressure at approximately 3 p.m. using a vitals machine tower and was unable to get a reading after four attempts. The CNA reported that the machine displayed three horizontal lines on the first two attempts and “ERR” on the third and fourth attempts, and did not attempt to use a manual blood pressure monitor. The CNA did not report any broken vitals machine tower to maintenance, and the Maintenance Supervisor later stated that none of the eight vitals machine towers had been identified as broken prior to his quarterly checks. The facility’s Owner’s Manual for the touchscreen vital signs monitor indicated that certain error codes required the monitor not be used and that service be contacted, and the DON explained that three horizontal lines meant the machine was trying to obtain a reading and “ERR” meant the cuff was not properly attached and the machine was not pumping air. The CNA notified an LVN at approximately 5:30 p.m. that she was unable to obtain the resident’s blood pressure using the vitals machine. The LVN stated she intended to use a manual blood pressure monitor because the machine’s cuff sometimes did not work, but she did not notify anyone that the vitals machine was not working and did not complete the vital sign assessment before going to lunch. When the LVN returned from lunch around 7 p.m., she was informed the resident was unresponsive; the LVN found the resident pale, cold, and without signs of life. An alert note documented that at 7:15 p.m. the resident was found unresponsive in bed and that the DON, physician, and family were notified. The DON later stated that if a CNA was unable to obtain vital signs, the nurse should have checked the vital signs and the CNA should have attempted to use a manual blood pressure monitor, consistent with the facility’s policies on change in condition and obtaining vital signs, which require reporting changes to a licensed nurse and having the nurse assess and determine appropriate interventions, including vital signs when there is a change in condition.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for one of three sampled residents. During an observation and interview, the Dietary Supervisor measured the temperature of the meat on a resident's lunch tray and found it to be 100°F, which was below the facility's policy requirement of greater than 140°F for meat and entrees. The green beans on a test tray were also measured at 100°F, and the salad at 50°F, which did not meet the policy requirement of less than 41°F for hazardous salads and desserts. The resident, who had a BIMS score of 12 indicating moderate cognitive impairment, stated that the food was not hot enough to his liking. The facility's policy and procedure for food temperatures was reviewed and confirmed these temperature standards.
Failure to Serve Meals at Safe and Palatable Temperatures and Maintain Temperature Documentation
Penalty
Summary
The facility failed to serve food and beverages to residents at appropriate, palatable temperatures and within scheduled meal times. Two residents reported that their meals were often delivered late, resulting in hot foods being served cold and cold foods being served warm or hot. One resident specifically mentioned that coffee was sometimes cold upon delivery, and another stated that milk was served warm. Observations confirmed that lunch was served late, and food temperatures taken at the time of service were outside the facility's policy standards, with hot foods below the required temperature and cold foods above the safe threshold. Interviews with the Dietary Supervisor Assistant revealed awareness of ongoing complaints about late meal service, particularly over the weekend. The facility's policy outlined specific meal service times and temperature requirements for various food items, but these standards were not consistently met. The last lunch tray on the day of observation showed multiple items not meeting the required temperatures, such as sweet potato fries and roast beef sandwich being served below 140°F, and milk, chocolate milk, and coleslaw being served above 41°F. A review of the Food Temperature Log for June showed numerous missing entries for required food and beverage temperature checks prior to meal distribution. The log lacked documentation for various meal components across multiple days, including main entrees, substitutes, milk, juice, and desserts. The Dietary Supervisor Assistant confirmed that temperatures should be recorded before serving meals and that the log should be reviewed daily to ensure compliance, as per facility policy.
Failure to Provide Meal Tray to Resident
Penalty
Summary
The facility failed to provide a lunch meal tray to one of the six sampled residents, identified as Resident 1. During an observation at 1 p.m., Resident 1's roommate received his meal tray, but Resident 1 did not. Approximately 34 minutes later, it was confirmed that Resident 1 still had not received a meal tray. Licensed Vocational Nurse (LVN) 1 confirmed that all lunch trays had been distributed and returned to the kitchen, but none of the Certified Nursing Assistants (CNAs) had delivered a meal tray to Resident 1. Interviews with CNA 2, who was assigned to Resident 1, and CNA 1 confirmed that neither had provided a meal tray to Resident 1. The Director of Nursing (DON) acknowledged that Resident 1 should have been provided a meal tray. The facility's policy and procedure on menus, dated April 1, 2014, indicated that the facility is responsible for providing meals that meet the nutritional requirements set by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, including planning for three meals and an evening snack.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.82% error rate for three of six sampled residents. This was identified during observations, interviews, and record reviews. For one resident, a Licensed Vocational Nurse (LVN) administered Mucus Relief instead of the prescribed Mucinex Allergy due to stock issues and failed to administer Fluticasone as documented. Another resident received Naproxen and Simethicone past the scheduled administration time. Additionally, a third resident did not receive all prescribed medications via their gastrostomy tube, as one crushed medication was left unadministered. The facility's policy and procedures for medication administration, dated January 2012, were not adhered to. The policy requires medications to be administered by a licensed nurse within one hour of the scheduled time, ensuring the right medication and time are observed. The documentation of medication administration was also found lacking, as the time and dose were not accurately recorded. These lapses in following the established procedures contributed to the medication errors observed during the survey.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. For one resident, identified as Resident 18, who was on Enhanced Barrier Precautions (EBP) due to a gastrostomy tube and risk of multidrug-resistant organism infections, there was no EBP signage or personal protective equipment (PPE) supplies outside the resident's room. This was contrary to the facility's policy, which required a brown bin with PPE and signage to be placed outside the room to alert staff of the necessary precautions. The Infection Prevention Nurse confirmed the absence of these supplies during an interview. Additionally, there was a structural issue in the facility where a hole was found between the clean and dirty utility rooms, which could compromise infection control. The clean utility room contained an ice machine used for residents, while the dirty utility room housed biohazard bins and soiled materials. The Director of Maintenance confirmed the presence and dimensions of the hole. Furthermore, a janitorial cart was observed without a lid on its trash bin, which was acknowledged by both the Housekeeping Supervisor and the janitor as not meeting the facility's housekeeping policy requirements.
Failure to Update Resident's Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the management of personal property for a resident, identified as Resident 13. During an interview, Resident 13 reported missing personal belongings, including a gold box shaped like an egg, which she had received as a Christmas gift. The facility's Inventory of Personal Effects (IPE) form for Resident 13, last updated on 7/23/23, did not accurately reflect her current personal belongings, listing only a white fan, mattress, 32-inch television, and a dresser. The IPE did not include the missing items, which hindered the facility's ability to verify and potentially replace them. The Social Services Assistant (SSA) confirmed that the facility's policy requires the Interdisciplinary Team (IDT) to review and update the resident's inventory for accuracy during quarterly care plan conferences. However, during Resident 13's quarterly care plan conference on 10/22/24, the IPE was not reviewed or updated. The SSA acknowledged that the facility should have updated the IPE at that time, as per their policy. This oversight resulted in the inability to verify missing items and the potential for those items not being replaced, as they were not documented on the IPE.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Notice of Transfer/Discharge' by not notifying the ombudsman of the transfer of two residents, Resident 24 and Resident 69, to the hospital. During interviews and record reviews, it was revealed that the Minimum Data Set Coordinator (MDSC) and Social Services Assistant (SSA) were unable to provide documentation indicating that the ombudsman was notified of these transfers. Specifically, Resident 24 was transferred to the hospital on October 2, 2024, and Resident 69 on March 31, 2024, without the required notification to the ombudsman. The facility's policy, dated 2017, mandates that before a transfer or discharge occurs, the resident, responsible party, and ombudsman must be notified, and this must be documented in the resident's clinical record. The failure to notify the ombudsman as per the policy potentially deprived the residents of having an advocate to review their admission, transfer, and discharge rights and options. This oversight was identified during a survey conducted on January 9, 2025, through interviews with the MDSC and SSA, who confirmed the absence of the necessary documentation for both residents.
Failure to Document Verbal Order and Administer Correct Medication Dosage
Penalty
Summary
The facility failed to ensure that a verbal order for a medication was properly documented in the medical record for a resident. During an interview and record review, it was found that a Licensed Vocational Nurse (LVN) administered Glucagon to a resident who was experiencing low blood sugar, based on a verbal order from the resident's doctor. However, the LVN did not enter this verbal order into the medical record, resulting in an incomplete record. The facility's policy requires that telephone orders be documented with specific details, but this was not followed in this instance. Additionally, the facility did not adhere to its medication administration policy when an LVN administered an incorrect dose of a nutritional supplement to another resident. The LVN gave 200 ml of Med Plus 2.0, while the Medication Administration Record (MAR) indicated that only 120 ml should be administered. This discrepancy was confirmed during an interview and record review, highlighting a failure to comply with prescribed dosage guidelines as outlined in the facility's policy.
Failure to Follow RNA Program and Document Progress
Penalty
Summary
The facility failed to adhere to the physician's orders for a Restorative Nursing Assistant (RNA) therapeutic program for a resident, identified as Resident 64. The orders specified that the resident was to receive RNA therapy five times a week, including exercises using a rickshaw, active range of motion (AROM) for lower extremities, and a leg ergometer. However, the resident reported that the RNA was often reassigned to work as a Certified Nursing Assistant (CNA), resulting in missed exercise sessions. The electronic medical record (eMR) tasks confirmed that the resident's therapy sessions were inconsistent, with several instances marked as 'Not Applicable,' indicating that the therapy was not provided on those days. Additionally, the RNA failed to complete the required weekly summaries for the resident's RNA program, which are essential for monitoring the resident's progress towards regaining independence in daily activities. The Director of Nursing (DON) acknowledged that the RNA weekly summaries were not being completed as required. The facility's policy and procedure for the Restorative Nursing Program emphasized the importance of documenting measurable objectives, interventions, and the frequency of the RNA program, which were not adhered to in this case.
Failure to Conduct Annual Performance Evaluation for Supervisor Licensed Employee
Penalty
Summary
The facility failed to ensure that a Supervisor Licensed (SL) employee had an annual performance evaluation completed, which is a requirement for maintaining compliance with the facility's policies. During an interview, the Director of Nursing (DON) confirmed that all employees must have annual performance evaluations. A review of SL 3's personnel file revealed that despite being hired on December 24, 2023, there was no record of a performance evaluation. The Director of Staff Development (DSD) acknowledged that SL 3 should have had an annual performance evaluation. The facility's policy, titled 'Compliance as a Component of Employee Performance,' mandates that employee performance evaluations include adherence to the compliance program, which was not adhered to in this case.
Failure to Provide Adaptive Call Light for Dependent Resident
Penalty
Summary
The facility failed to provide an adaptive call light for a dependent resident, identified as Resident 80, who had physical limitations. During an observation and interview, it was noted that the call light was wrapped around the right upper side rail, and Resident 80, who had contractures in his right hand and a limp left arm, stated he could not use the call light and instead whistled to call for assistance. A Certified Nursing Assistant confirmed that Resident 80 would not be able to use the call light as it was positioned. The Director of Nursing acknowledged that all residents should have accessible call lights and mentioned that the facility had house-shaped call lights designed for dependent residents, which Resident 80 should have had. The facility's policy indicated that adaptive call bells should be provided according to residents' needs.
Failure to Follow Grievance Process for Abuse Allegation
Penalty
Summary
The facility failed to adhere to its grievance process for a resident who reported abuse allegations. The resident filed a grievance with the Social Service Assistant, but the facility did not follow up with the resident regarding the grievance. The Resident Grievance/Complaint Investigation Report (RGCIR) for this grievance was incomplete, with several sections left blank, including the response to the grievance, confirmation of the grievance, and notification to the concerned party. During a review of the facility's policy and procedure on grievances, it was noted that the Administrator, who is the Grievance Official, is responsible for overseeing the grievance process and ensuring that grievances are tracked to their conclusion. The policy requires a completed investigation report within five business days, but this was not done in this case. The Administrator confirmed that the RGCIR was not completed and that the resident was not informed of the investigation's outcome or any corrective actions.
Failure to Follow Abuse Investigation Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Abuse Investigation and Reporting' concerning an allegation of physical abuse involving a resident. The Director of Nursing (DON) 2 was responsible for investigating the allegations against a Certified Nursing Assistant (CNA) but did not interview other residents who received care from the accused CNA, as required by the facility's policy. Interviews with the Social Services Assistant (SSA) and Case Manager (CM) revealed that they were not involved in the investigation, contrary to the stated responsibilities. The Administrator confirmed that DON 2 was solely responsible for the investigation and was not involved herself. The facility's policy, revised in December 2016, mandates that all reports of abuse be thoroughly investigated by facility management, including interviewing other residents cared for by the accused employee.
Deficiencies in Care Planning and Conservator Involvement
Penalty
Summary
The facility failed to adhere to its policy and procedure for Comprehensive Person-Centered Care Planning for two residents. For the first resident, the facility did not ensure the participation of the resident's conservator in the care conference. The resident, diagnosed with dementia and severe cognitive impairment, was unable to make healthcare decisions independently. Despite this, there was no documentation indicating the conservator's attendance at the care conference, which is a requirement according to the facility's policy. For the second resident, the facility did not include individualized goals and interventions for restorative mobility in the comprehensive care plan. The care plan lacked specific interventions for strengthening the resident's upper extremities, which is necessary for the resident's mobility and function potential. The facility's policy requires that all goals, objectives, and interventions from the baseline care plan be included in the comprehensive care plan, and that the care plan be updated with any changes to the Restorative Nursing Program.
Failure to Follow Prescribed Menus for Residents
Penalty
Summary
The facility failed to ensure that menus were followed for two residents, resulting in them receiving smaller portion sizes than prescribed. Resident 1, who was on a regular-large portion diet, reported receiving only one egg and one piece of bread for breakfast, contrary to the facility's Winter Menus, which specified two fried eggs and two slices of wheat toast, among other items. This discrepancy was confirmed by a Certified Nursing Assistant and a staff member, who acknowledged that the portions served did not align with the menu requirements. Additionally, during the lunch meal service, Resident 2, who was on a renal diet, received a smaller portion of corn than specified. The facility's Winter Menus indicated that residents on a renal diet should receive a #8 scoop of corn, but a staff member used a #12 scoop instead. The Registered Dietitian and Certified Dietary Manager both confirmed that the kitchen staff should adhere to the spreadsheet, which calculates the necessary nutrients for residents. The facility's policy and procedure on menus emphasized the importance of adhering to the written menu to meet the nutritional needs of residents.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to ensure that food prepared and served was in accordance with professional standards for food service safety, which had the potential to cause foodborne illnesses among residents. During a review of the facility's menu for specific dates, it was noted that meals such as French toast with breakfast meats and a dinner of crispy fish fillet with sides were served. However, during an observation in the facility's kitchen, it was found that food temperatures were not documented for these meals, which is a critical step in ensuring food safety. The Dietary Supervisor confirmed that the meals were prepared and served in the facility's kitchen, but acknowledged that no food temperatures were recorded for the breakfast and dinner services on the specified dates. The facility's policy and procedure for food temperatures, which requires recording temperatures at the beginning of the tray line and ensuring foods are served at proper temperatures, was not followed. This lack of documentation and adherence to the policy indicates a failure in maintaining food safety standards.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA 3) and Resident 2. Resident 2, who was admitted with conditions including hemiplegia, hemiparesis, aphasia, and anxiety disorder, was unable to complete a mental status interview due to cognitive impairments. During an incident, CNA 3 was overheard yelling at Resident 2, telling them to stop yelling and using the phrase 'Earth to [Resident 2]' in a loud voice. This behavior was confirmed by a marketer who witnessed the event and heard the exchange from her office. The facility's investigation revealed that CNA 3 admitted to the behavior and showed no remorse, questioning the decision to suspend her due to staffing issues. The facility's policy on Resident Rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this instance. The deficiency was identified through interviews and record reviews, highlighting a failure to uphold the resident's right to be treated with respect and dignity, potentially causing emotional distress to Resident 2.
Failure to Investigate and Protect Resident from Financial Exploitation
Penalty
Summary
The facility failed to timely investigate and protect a resident when the resident reported missing money and giving money to a staff member. The resident, who had a history of dementia, bipolar disorder, and schizophrenia, reported missing money and stated that they had given money to a staff member, the Activity Director, for personal use. The resident's cognitive impairment was noted with a BIMS score indicating moderately impaired cognition. Interviews and record reviews revealed that the resident had made multiple withdrawals from their trust account for personal needs, with significant amounts withdrawn over a few months. The Licensed Vocational Nurse filed a grievance on behalf of the resident, noting that the resident was looking to give money to the Activity Director, which should not have been happening. The Activity Director denied taking money from the resident, although a written statement later indicated a problem with their tire, which the resident had mentioned as a reason for giving money. The Director of Nursing acknowledged that the grievance should have been reported as financial abuse, as there was missing money and the resident was giving money to a staff member. The investigation was delayed, starting over two months after the initial report, and no protection was provided to the resident during this time. The facility's policy on abuse prevention and management was not followed, as there was no timely investigation or intervention to protect the resident from potential exploitation.
Failure to Follow Fall Management Program Leads to Multiple Falls
Penalty
Summary
The facility failed to adhere to its Fall Management Program policy and procedure for a resident, resulting in multiple falls over a five-month period. The resident, who was admitted with diagnoses including dementia and bipolar disorder, experienced several unwitnessed falls. The facility did not complete the Post Fall Evaluation (PEE) forms for these incidents, leaving sections such as Fall Details, Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions blank. This lack of documentation hindered the identification of possible causes of the falls and the development of strategies to prevent future incidents. The resident's care plan was not updated following the falls on specific dates, despite the facility's policy requiring such updates. The Director of Nursing confirmed that care plans were not developed after the falls on three occasions. The resident's care plan, which focused on high fall risk due to dementia, gait instability, and a history of recurrent falls, was not revised to address the specific incidents, contrary to the facility's policy. The resident sustained a left intertrochanteric femoral fracture requiring surgical repair after one of the falls. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that the post-fall evaluations were intended to inform care plan updates to prevent future falls. However, the evaluations were not completed, and the care plans were not revised, contributing to the resident's repeated falls and subsequent injury.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for one of the residents. The incident involved a resident who was noted to have discoloration and swelling on the right eye, as documented in the SBAR communication tool on 10/9/24. Interviews with staff, including a CNA and two LVNs, revealed that the injury was observed but not reported to the Director of Nursing (DON) or the Administrator. The LVNs acknowledged that such injuries should be investigated, as they could potentially indicate abuse. However, the Director of Staff Development (DSD) confirmed that there was no documentation explaining the cause of the injury in the resident's medical record. The Administrator stated that she was not informed about the resident's eye discoloration and swelling, and therefore, no investigation was conducted. The facility's policy and procedure for injuries of unknown origin require that all unexplained injuries be promptly and thoroughly investigated to protect resident safety. The policy defines an injury of unknown source as one that is not observed by any person or cannot be explained by the resident, and is suspicious due to its extent or location. The failure to adhere to this policy resulted in a deficiency, as the injury was neither reported nor investigated, potentially compromising the resident's health and safety.
Failure to Implement Fall Management Protocol
Penalty
Summary
The facility failed to adhere to its Fall Management Program policy and procedure for a resident who experienced a fall. The resident, who had severe cognitive impairments and required substantial assistance with mobility, was found crawling on the floor by a CNA. Despite the incident being classified as a fall, the facility did not implement the necessary post-fall protocol. This included the absence of neurological checks, a fall risk assessment, a post-fall assessment, and an update to the resident's fall care plan. The facility's policy mandates specific actions following a fall, such as conducting a post-fall evaluation, updating the care plan, and performing neurological checks for unwitnessed falls or those with potential head injuries. Additionally, the policy requires notifying the DON, the resident's physician, and responsible party, as well as conducting a Post-Fall Huddle and documenting the incident for IDT review. These steps were not followed, leading to a deficiency in the facility's management of the resident's fall incident.
Failure to Administer Incentive Spirometry as Ordered
Penalty
Summary
The facility failed to follow Medical Doctor (MD) orders for incentive spirometry (ISP) for three residents, resulting in orders not being followed. Resident 1 had an MD order for ISP to be administered every shift until a specified date, but during an observation, no ISP device was present in the resident's area, and the resident confirmed not having used ISP since admission. Similarly, Resident 2 had an MD order for ISP every shift, but no device was observed, and the resident confirmed non-use. Both residents had intact cognition scores, indicating they were capable of understanding and following ISP instructions if provided. Resident 3 also had an MD order for ISP every shift with no end date, but the Director of Nursing (DON) confirmed that the resident was not receiving ISP as ordered. The DON reviewed the Medication Administration Records (MAR) for all three residents and confirmed the absence of ISP administration. The facility's digital system was auto-populating ISP orders for new admissions, but the orders were not being executed. The facility's policy on ISP, which outlines its purpose and proper utilization, was not adhered to, leading to the deficiency.
Falsification of ISP Documentation in LTC Facility
Penalty
Summary
The facility failed to accurately document the provision of incentive spirometry (ISP) for three residents, resulting in falsification of medical records. The deficiency was identified through observations, interviews, and record reviews. Residents had medical doctor orders for ISP to be administered every shift, but the treatment was not provided. Despite this, the Medication Administration Records (MAR) indicated that the ISP was given, which was confirmed to be false by multiple facility nurses during interviews. Resident 1, Resident 2, and Resident 3 were all affected by this deficiency. Resident 1 and Resident 2 had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. During interviews, both residents confirmed they had not received ISP treatment, although their MARs falsely documented otherwise. The Director of Nursing (DON) acknowledged that the facility's digital system was auto-populating ISP orders for new admissions, which contributed to the inaccurate documentation. Interviews with several facility nurses revealed that ISP equipment had not been available for at least three months, yet the MARs continued to reflect that the treatment was administered. Nurses admitted to documenting ISP as given or refused, despite not having the equipment to provide the treatment. The DON confirmed that the documentation did not reflect the actual care provided and that the facility's policy and procedure for nursing documentation were not available upon request.
Failure to Assess Resident for Emotional Distress After Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure on abuse prevention and management when a resident was not assessed for signs of emotional distress following a reported abuse incident. The incident involved a resident whose family member confessed to taking money from her account without permission. Despite the resident expressing upset feelings about the situation, there was no documentation of any assessment for emotional distress by the licensed nurses or the Social Services Director (SSD). Interviews with the Licensed Vocational Nurse (LVN), SSD, and Acting Director of Nursing (ADON) confirmed the lack of monitoring for emotional distress. The resident's care plan indicated a risk for psychosocial distress due to the alleged financial abuse and included interventions such as notifying the Medical Director of signs of emotional distress and having Social Services monitor the resident daily for three days. However, these interventions were not documented as being carried out, which was a deviation from the facility's policy titled 'Abuse Prevention and Management.'
Delayed Investigation of Financial Abuse Incident
Penalty
Summary
The facility failed to complete an investigation of an abuse incident within the required five working days for a resident. The incident involved a financial abuse allegation where the resident's family member was suspected of taking money from the resident's account. The resident's daughter discovered the issue when she found the account balance was zero and confirmed through bank camera footage that the family member was responsible. The family member admitted to taking the money and apologized. Despite the facility's policy requiring a written report of the investigation results to be submitted to the California Department of Public Health within five working days, the administrator did not follow up on the investigation in a timely manner. The administrator was waiting for the Social Services Director to provide the investigation's conclusion, but the Social Services Director was unaware of the requirement to complete the five-day summary. As a result, the investigation summary was completed nine days overdue, contrary to the facility's policy.
Failure to Inform Residents of Lab Orders
Penalty
Summary
The facility failed to ensure that three residents were informed in advance about laboratory orders, which compromised their dignity and privacy. Resident 1 reported feeling humiliated when three CNAs entered her room without prior explanation and requested a urine sample. She initially refused to provide the sample until an RN later explained the reason for the test. Resident 3 experienced a similar situation, where CNAs requested a urine sample without prior notice, and he only complied after receiving an explanation from an RN. Resident 2, a dialysis patient who had not produced urine for five years, was also approached by CNAs for a urine sample, which she could not provide. The CNAs involved stated that they were instructed by an LVN to collect the urine samples, but they were not informed of the reasons for the tests. The LVN claimed she would typically explain the need for lab tests to residents and would not ask CNAs to collect samples without assistance. The RN involved stated she was directed by the Director of Nursing to obtain urine samples and had placed the orders, asking LVNs to collect them. The facility's policy on resident rights emphasizes treating residents with respect and dignity, including maintaining their privacy and confidentiality, which was not adhered to in these instances.
Failure to Document and Administer Medications and Treatments
Penalty
Summary
The facility failed to consistently carry out physicians' orders for three residents, leading to potential adverse outcomes. For Resident 4, the Medication Administration Record (MAR) showed multiple instances where intravenous (IV) tubing for protonix was not documented as changed, and pantoprazole was not documented as administered. Additionally, the flushing of the PICC line was not documented on several occasions. These omissions in documentation suggest that the necessary medical procedures may not have been performed, compromising the effectiveness of the treatment. Resident 5's MAR also revealed significant documentation gaps. The dressing and cap change for the PICC line was not documented as completed, and the IV tubing for vancomycin was not documented as changed on multiple dates. Furthermore, the administration of vancomycin was not documented on several occasions, and the flushing of the PICC line was not recorded. Monitoring of the PICC line for signs of complications was also not documented, indicating a lack of adherence to the prescribed care plan. For Resident 6, the MAR indicated that the flushing of the central line was not documented as administered on two occasions. Additionally, monitoring of the central line for redness, swelling, bleeding, or pain was not documented as completed on two shifts. These documentation lapses suggest that the facility did not consistently follow its own policies and procedures for medication administration and monitoring, as confirmed by the Director of Nursing.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, as observed during a survey. The resident's urinary catheter collection bag was found lying on the floor outside their room, not placed in a dignity bag, which was confirmed by a Certified Nursing Assistant (CNA). This action was contrary to the facility's policy and procedure for catheter care, which mandates that catheter tubing, bags, or spigots should not touch the floor to prevent catheter-associated urinary tract infections (UTIs). The facility's policy also aligns with the CDC guidelines, which emphasize maintaining unobstructed urine flow and keeping the collecting bag below the bladder level without resting it on the floor.
Incomplete Verification of DON's Qualifications
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) possessed the necessary skills and qualifications to ensure residents' safety. During an interview and record review, it was found that the DON's application was incomplete, lacking details about education, previous employment, and references. The Administrator admitted that the normal procedures for verifying the qualifications of employees were not followed, as the DON's background check was completed after the date of hire, contrary to the facility's policy. The facility's Employee Handbook and the Director of Nursing Services Job Description both require that background checks and verification of credentials be completed before hiring. However, these procedures were not adhered to in the case of the DON. The facility's policy on abuse prevention also mandates obtaining at least two reference checks from previous employers, which was not done. This oversight in the hiring process had the potential to compromise the safety and care of the residents due to the lack of verification of the DON's qualifications.
Failure to Complete Required Reference Checks for LVN
Penalty
Summary
The facility failed to adhere to its own policy and procedure titled 'Abuse-Prevention, Screening, & Training Program' by not completing the required reference checks for a newly hired Licensed Vocational Nurse (LVN 4). According to the facility's policy, at least two reference checks from previous or current employers must be obtained prior to hiring an applicant. However, during a review of LVN 4's employment application and verification documents, it was confirmed that only one reference check was completed, despite LVN 4 having two previous employers and three personal references listed. This oversight had the potential to expose the facility's residents to possible abuse.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Abuse Reporting' concerning a reported incident involving a resident. The incident involved a Certified Nursing Assistant (CNA) allegedly pulling a handful of pubic hairs from a resident. This incident was documented in the Resident Grievance/Complaint Investigation Report dated August 29, 2024. Despite the initiation of an investigation and the suspension of the CNA involved, the facility did not report the allegations to the California Department of Public Health in a timely manner. During an interview with the Regional Quality Assurances Consultant (RQAC) on September 5, 2024, it was confirmed that the allegations were not reported promptly as required by state and federal regulations. The facility's policy, revised on January 8, 2014, mandates that known or suspected instances of physical abuse must be reported to the proper authorities within 24 hours if the event does not result in serious bodily injury. This includes making a telephone report to local law enforcement and a written report to the local Ombudsman, the California Department of Public Health, and local law enforcement. The delay in reporting had the potential to place all residents at risk for abuse.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that medication carts were secured and accessible only to licensed nursing staff, as observed with one of six sampled medication carts. During an observation at the nurses' station, a medication cart was found unlocked with no licensed nurse in sight, and a resident in a wheelchair was directly in front of the cart. The resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The facility's policy stated that medications should be stored safely and securely, accessible only to authorized personnel, but this was not adhered to in this instance.
Medication Administration Failures
Penalty
Summary
The facility failed to adhere to its own medication administration policy, resulting in a delay in care and unnecessary nerve pain for a resident. On a specific day, the resident was unable to receive her morning medications, which included essential treatments for neuropathy and other conditions. Despite the resident's efforts to locate a nurse, the medications were not administered, and the nurse's notes indicated that the medical doctor was aware of the situation. This lapse in medication administration was confirmed through interviews and record reviews, highlighting a significant oversight in the facility's medication management process. Additionally, the facility did not administer medications in a timely manner, as evidenced by the late administration of a pain-relief patch on multiple occasions. The facility's policy allows for medications to be given one hour before or after the scheduled time, but records showed that the patch was administered several hours late on numerous dates. Interviews with nursing staff and the Director of Nursing confirmed these delays, with some nurses reportedly documenting the administration later than it occurred. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and documenting them immediately after administration. However, the repeated failure to follow these guidelines resulted in delayed care for the resident, particularly concerning the administration of a pain-relief patch. The Director of Nursing acknowledged the issue, confirming that medications should be documented right after they are given, which was not consistently practiced in this case.
Infection Control Lapses in Medication Handling and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the sharing of medication between two residents. Resident 1, who was on isolation due to a COVID-19 infection, was given an Albuterol inhaler that was not properly labeled, leading to a mix-up with Resident 2's inhaler. Both residents had different colored inhalers, but the containers were not marked with their names, only the boxes they came in. This mix-up was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the cross-contamination and the need for a system to identify individual inhalers. Additionally, a Certified Nursing Assistant (CNA) failed to follow hand hygiene protocols, which are crucial for preventing the spread of infections. The CNA was observed taking a water pitcher from Resident 1's isolation room without washing her hands and then entering Resident 3's room to assist with lunch. This action was in direct violation of the facility's hand hygiene policy, which requires handwashing before and after entering resident rooms, especially when dealing with residents in isolation. The facility's policies on medication administration and hand hygiene were not adhered to, leading to potential risks of infection spread among residents. The DON confirmed the expectations for staff to conduct hand hygiene before and after entering resident rooms, highlighting the importance of these practices in preventing infection transmission. The failure to label medications correctly and maintain hand hygiene standards contributed to the deficiencies observed during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 218 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) |
|---|---|---|---|---|
| Height Street Skilled Care | 0.4 mi | ★★★★★ | 25 | 0 |
| The Orchards Post-acute | 2.3 mi | ★★★★★ | 2 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 2.3 mi | ★★★★★ | 18 | 0 |
| Bakersfield Post Acute | 2.3 mi | ★★★★★ | 41 | 0 |
| Valley Healthcare Center | 3.2 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.