Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valle Verde Health Facility during CMS and state inspections, most recent first.
POLST Not Signed by RP: A resident with absent decision-making capacity and severe cognitive impairment signed the POLST instead of the RP. The POLST included DNR, selective tx, hospital transfer only if comfort needs could not be met, and a trial of artificial nutrition. Record review showed other consents were signed by the daughter/RP, and LN confirmed the resident signed the POLST rather than the RP.
A resident with documented hearing impairment had no care plan initiated for the hearing problem and was observed without hearing aids in the common area. Another resident was observed with the call light out of reach, the bed alarm sensor improperly placed, and the body twisted in bed despite care plan interventions calling for the call light to be within reach and proper body alignment during positioning.
Failure to Serve Thickened Liquids per Diet Order: A resident with dysphagia and Bell’s Palsy was served coffee that was not thickened as ordered. The resident’s diet order specified minced and moist food with mildly thick liquids, and during dining room observation a CNA acknowledged the coffee had not been thickened before the resident sipped it; the CNA then added a Level 2 gel thickener to the remaining coffee.
The facility failed to ensure IPCP policies were reviewed annually and that staff followed manufacturer instructions when disinfecting a glucometer. The IP could not state when the policies were last reviewed, and the DON confirmed there was no tracking system for policy review dates. An LPN was observed cleaning a glucometer with bleach but could not state the correct dwell time; the IP later stated the bleach dwell time was 3 minutes.
A glucometer was not maintained in a safe operating condition because the logbook was missing QC entries for 17 consecutive days. The IP could not explain why the device was not checked, and stated it should have been checked daily by night shift. The facility competency checklist required high and normal QC controls on each day of use.
The facility failed to employ sufficient staff with the necessary skills to manage food and nutrition services, leading to unsafe food handling and unsanitary conditions. The Director of Dining Services was responsible for multiple operations but did not ensure proper cooling of TCS foods or maintain sanitary conditions, such as an unclean ice machine and improperly stored equipment. Additionally, the Registered Dietitian did not update outdated therapeutic diets for residents with diabetes, affecting their nutritional care.
The facility failed to maintain food safety and sanitation standards, with TCS foods not cooled properly, unsanitary ice machines, and unclean kitchen conditions. Macaroni pasta was not cooled to safe temperatures, and the ice machine had residue buildup. Kitchen floors and drains had food debris, and equipment was stored on unclean shelves. Leaking pipes and uncovered rodent bait stations further compromised safety.
The facility failed to ensure the Emergency Drug Supply Kit (E-kit) was accurately stocked according to its table of contents. An unopened E-kit was found with green locks, indicating it had not been opened by staff. The list indicated 2 capsules of Keflex 250 mg, but 8 capsules were found. The Infection Preventionist acknowledged the discrepancy, which did not align with the facility's policy requiring regular updates of the E-kit contents.
The facility failed to discard expired medications and maintain proper storage temperatures. Expired Lantus and budesonide ampules were found and used, contrary to policy. The medication refrigerator was consistently below the acceptable temperature range, with no adjustments or maintenance documented.
The facility failed to comply with IDDSI guidelines for the Mechanical Soft Chopped (Level 6) diet, serving residents with dysphagia foods not allowed under the IDDSI standards, such as whole Hawaiian sweet rolls and cilantro rice. The Registered Dietitian was unsure about the guidelines, and the facility's diet manual still referenced the outdated National Dysphagia Diet. This non-compliance posed a risk of adverse events for residents.
A resident admitted for aftercare following joint replacement surgery experienced a failure in accurate pain management documentation. Despite complaining of moderate pain, the resident's refusal of pain medication was not documented by an LPN. The MAR and TAR showed no administration of pain medication and indicated no pain complaints, leading to potential unrelieved pain.
A resident discharged after hip replacement surgery discovered their Norco medication missing after a social services staff member, unauthorized to handle controlled substances, took the resident's backpack back into the facility. Surveillance footage confirmed the policy breach, highlighting a failure to follow the facility's controlled substance handling procedures.
A resident with multiple health conditions experienced a fall resulting in a fracture during an occupational therapy evaluation because the therapist did not use a gait belt, contrary to facility policy. Interviews confirmed the oversight, highlighting a lapse in following safety protocols.
The facility failed to implement individualized care planned interventions for monitoring and recording pain characteristics for two residents. Despite having care plans in place, the facility could not provide documentation that these interventions were carried out and documented by the nursing staff during the specified date ranges.
The facility failed to properly secure 60 oxycodone tablets upon delivery from the pharmacy. A nurse received and signed off for the tablets but left them on top of the medication cart, assuming another nurse would secure them. The tablets went missing, and the facility's policy for handling and storing narcotics was not followed.
POLST Not Signed by Responsible Party
Penalty
Summary
The facility failed to ensure the POLST for Resident 14 was signed by the Responsible Party. Resident 14’s POLST, dated 11/10/25, was signed by the resident and indicated DNR, Selective Treatment, transfer to hospital only if comfort needs could not be met in the current location, and a trial period of artificial nutrition including feeding tubes. However, the resident’s H&P dated 11/11/25 stated the patient’s ability to make health decisions was absent, and the MDS dated 11/17/25 showed a BIMS score of 2, indicating severe impairment. Record review also showed other consents in the medical record were signed by the resident’s daughter, identified as the RP, and the signature on those documents differed from the signature on the POLST. The facility’s Advance Directives policy stated that upon admission the interdisciplinary team assesses the resident’s decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. During a concurrent interview and record review on 1/6/26, LN 1 reviewed the POLST, H&P, and MDS and confirmed it was the resident who signed the form and not the daughter who was the RP.
Failure to Care Plan Hearing Impairment and Implement Call Light/Repositioning Interventions
Penalty
Summary
Resident 8 was assessed on the comprehensive assessment as having hearing impairment, but no care plan was initiated for the identified hearing problem. During observation, Resident 8 was in the common area near the activity room reading a newspaper without hearing aids and, when greeted, only stared at the surveyor. The resident’s RP stated that Resident 8 can be moody if not wearing the hearing aids and that this can lead to communication gaps and misunderstandings. The MDS Nurse confirmed the resident was assessed to be hard of hearing, and both an LN and the ADM reviewed the clinical record and confirmed there was no care plan initiated for the hearing impairment. Resident 11 was observed in room B with the call light hanging on the overhead reading light fixture above the resident’s head and beyond reach, the bed alarm sensor hanging on the right side of the bed below the quarter siderails, and the resident positioned in an awkward angle. The resident was lying supine with the head of the bed elevated at 30 degrees, but the body was twisted to the right side of the bed at approximately a 50-degree angle. During interview, an LN stated that the call light was not within reach, the bed alarm sensor was not where it needed to be, and the resident needed to be repositioned properly. The latest MDS showed severely impaired cognitive skills for daily decision making and functional limitations in upper and lower extremity range of motion, and the care plan included interventions to keep the call light within reach and maintain proper body alignment when positioning.
Failure to Serve Thickened Liquids per Diet Order
Penalty
Summary
The facility failed to follow a mechanically altered diet order for one resident with dysphagia, Resident 53, when staff served coffee without thickener. Resident 53 was admitted with diagnoses that included Bell’s Palsy, and the clinical record showed an order dated 12/30/25 for Minced and Moist, Level 5 texture with Mildly Thick, Level 2 liquids, with small sips of thin liquids allowed only with supervision. The resident’s MDS also indicated a mechanically altered diet requiring a change in texture of food or liquids. During an observation in the dining room on 1/6/26 at 12:18 p.m., Resident 53 was served a meal tray and then given a cup of coffee, which the resident sipped. The menu and attached diet-order strip next to the tray indicated that liquids were to be served at Mildly Thick Liquids Level 2 consistency. During concurrent observation and interview at 12:20 p.m., CNA1 acknowledged the coffee had not been thickened and stirred it with a spoon; the coffee appeared to have thin liquid consistency. CNA1 then left and returned with a Level 2 gel thickener packet, which was stirred into the resident’s remaining coffee. The facility policy stated that liquids would be thickened to the degree specified in the physician or designee’s orders.
Infection Control Policy Review and Glucometer Disinfection
Penalty
Summary
The facility failed to ensure that its Infection Prevention Control and Program (IPCP) standards and policies were reviewed at least annually. During interview, the Infection Preventionist stated the IPCP policies and procedures were online and that the Interdisciplinary Team was responsible for reviewing them, but was unable to state when they should be reviewed or the last date of review. The Director of Nursing confirmed there was no tracking system to determine when the last infection control policy was reviewed. The facility’s Infection Prevention and Control Program policy, dated October 2018, stated the program is reviewed annually and updated as necessary. The facility also failed to ensure staff followed the manufacturer’s instructions when cleaning and disinfecting a blood sugar monitor machine (glucometer). During observation, a Licensed Nurse was seen cleaning a glucometer and stated it was sanitized with bleach and left to air dry for a couple of minutes, but was unable to verbalize the correct bleach dwell time. The Infection Preventionist later stated the bleach dwell time for disinfecting the glucometer was 3 minutes.
Glucometer Not Checked for 17 Consecutive Days
Penalty
Summary
The facility failed to ensure a glucometer was maintained in a safe operating condition. During a concurrent interview and record review on 1/7/26 at 10:01 a.m., the glucometer logbook for December 2025 was found to be missing test check result entries from 12/1/25 through 12/17/25. The Infection Preventionist reviewed the log and was unable to explain why the glucometer had not been checked for 17 consecutive days. The Infection Preventionist stated the glucometer should be checked daily by night shift (11 p.m. to 7 a.m.), but it was not. A facility competency checklist titled, Regulatory Review and Guidelines for QA/QC Protocols, indicated that quality control on each day of use requires two controls, high and normal, per instrument.
Deficiencies in Food and Nutrition Services Management
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. The Director of Dining Services (DDS) was responsible for multiple foodservice operations, including the main kitchen for the skilled nursing facility, community Meals on Wheels, and another contracted health facility. The DDS did not demonstrate the necessary managerial skills to ensure food safety, as evidenced by improper cooling of Time Temperature Control for Safety (TCS) foods, unsanitary conditions such as an unclean ice machine, incomplete cleaning schedules, and missed orientation and competency checks for an employee. Additionally, there were unsanitary conditions like clean foodservice equipment stored on unclean shelves, leaking pipes, and improperly contained rodent bait stations. The facility also failed to ensure effective management and organization of the food and nutrition services department due to a lack of frequent consultation by a Registered Dietitian (RD) with the Certified Dietary Manager/DDS. This lack of consultation led to system issues, including unsafe food handling and sanitation practices, which were not promptly addressed. As a result, 56 residents in the Health Center were at increased risk for foodborne illness due to these unsanitary conditions and unsafe food handling practices. Furthermore, the Registered Dietitian (RD) and Corporate Registered Dietitian (CRD) did not identify and communicate to leadership that an obsolete therapeutic diet, No Concentrated Sweets (NCS), was being implemented for diabetes care for residents. Eight residents were on this outdated diet, which did not align with current standards of practice for diabetes care. The RDs failed to utilize their expertise to develop resident care policies and procedures that met the nutritional needs of residents with diabetes, leading to the continued use of an ineffective diet for glycemic management.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service, resulting in multiple deficiencies. Time Temperature Control for Safety (TCS) foods were not consistently cooled down to safe temperatures. Specifically, macaroni pasta was not cooled from 135°F to 70°F within the required two hours, and further cooling to 41°F was not documented. The Director of Dining Services (DDS) and Lead Cook (LC2) confirmed the lack of documentation and the unsafe temperature of the pasta, which was found to be 67.8°F after five hours. This failure to follow the facility's policy and procedure for cooling potentially hazardous foods posed a risk of foodborne illness. The ice machine used for residents' hydration was not maintained in a sanitary condition. Observations revealed a buildup of white residue and blackish/brownish substances on the ice and water dispenser chutes, which were not cleaned by housekeeping staff. The Maintenance Supervisor (MS) and DDS acknowledged the unsanitary condition and the potential presence of mold. The facility's policy required regular cleaning of such equipment to prevent microbial growth, but this was not adequately followed. Additional unsanitary conditions were observed in the main kitchen, including a buildup of dried food debris on floors and drains, and clean equipment stored on unclean shelves. The facility's cleaning schedule was not adhered to, as evidenced by missing staff initials on the cleaning log. Furthermore, foodservice equipment was not maintained in good repair, with leaking pipes in the warewashing areas leading to pooled water that could attract pests. Uncovered rodent bait stations were also found in the dry food storage room, posing a risk of cross-contamination. These deficiencies indicate a failure to maintain a sanitary and safe food service environment.
Inaccurate Stocking of Emergency Drug Supply Kit
Penalty
Summary
The facility failed to ensure that the Emergency Drug Supply Kit (E-kit) was accurately stocked according to its table of contents. During an observation and interview with the Infection Preventionist (IP), an unopened E-kit was found in the medication storage room with green locks, indicating it had not been opened by facility staff. The list of contents on the E-kit indicated it should contain 2 capsules of Keflex 250 mg, but upon inspection, 8 capsules were found. The IP acknowledged that the E-kit stock did not match the table of contents. The facility's policy and procedure for the E-kit, dated January 8, 2025, requires that the contents be determined by the medical director in collaboration with the pharmacy provider and approved by the governing body, with a list of medications, including quantities and strengths, maintained and updated regularly.
Expired Medications and Improper Storage Temperatures
Penalty
Summary
The facility failed to ensure that expired medications and biologicals were properly discarded and not available for staff use. During observations, a vial of Lantus with an open date of December 1, 2024, and an expiration date of December 28, 2024, was found in a medication cart and had been administered to a resident. Additionally, a box of budesonide ampules with an open date of August 2, 2024, was found in the medication room, despite the manufacturer's instructions to use the ampules within two weeks of opening. A bottle of Stomahesive protective powder with an expiration date of January 1, 2025, was also found in a treatment cart. The facility's policies indicated that expired medications should not be administered, yet these expired items were still present and used. The facility also failed to maintain the medication refrigerator at the correct temperature range of 36-46 degrees Fahrenheit. Observations and record reviews revealed that the refrigerator's temperature was consistently below the acceptable range on several occasions, with no documented evidence of temperature adjustments or maintenance work orders being completed. The facility's policy required temperature adjustments and maintenance work orders if the temperature was not within the acceptable range, but these actions were not documented or performed, potentially compromising the effectiveness of stored medications.
Non-Compliance with IDDSI Guidelines for Dysphagia Diets
Penalty
Summary
The facility failed to ensure that the planned menu for the therapeutic Mechanical Soft Chopped (Level 6) diet was developed and prepared in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines. The menu incorporated unsafe foods based on an outdated National Dysphagia Diet (NDD), which is no longer nationally recognized. This resulted in the co-mingling of the outdated diet with the IDDSI Level 6 diet, potentially leading to confusion and errors in diet texture for residents with dysphagia. Seven residents with a mechanical soft diet order were affected by this deficiency. During observations and interviews, it was noted that residents with a Level 6 IDDSI diet order were served a whole Hawaiian sweet roll and cilantro rice, which are not allowed under the IDDSI standards for a Level 6 diet. The Registered Dietitian (RD) was unsure about the IDDSI guidelines, particularly regarding the prohibition of regular dry bread and the requirement for rice to not separate into individual grains. The facility's recipe for cilantro rice did not comply with IDDSI standards, as it described the rice as fluffy and separated into individual grains. The facility's diet manual and menu planning policies were not aligned with the IDDSI framework, as they still included references to the outdated NDD. The Corporate Registered Dietitian confirmed that the facility was still in the process of transitioning to IDDSI, despite the IDDSI framework being the only professionally recognized standard since October 2021. This lack of compliance with IDDSI guidelines posed a risk of adverse events, including choking, for residents with dysphagia.
Inaccurate Pain Management Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of pain assessment and management for a resident following a surgical procedure. The resident, who was admitted for aftercare following joint replacement surgery, complained of intermittent pain rated as 5 out of 10 on the pain scale. Despite this complaint, there was a lack of documentation regarding the resident's refusal of pain medication, as noted by Licensed Nurse 2 (LN 2). LN 2 confirmed that the resident was offered pain medication but refused it, yet this refusal was not documented in the medical record. Further review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the relevant period showed no administration of pain medication when needed and an entry indicating no complaint of pain. The administrator acknowledged the discrepancies in the pain documentation, confirming the absence of documentation regarding the resident's refusal of pain medication. This lack of accurate documentation had the potential to result in extended and unrelieved pain for the resident.
Failure to Follow Controlled Substance Handling Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the handling of controlled substances during the discharge of a resident. The resident, who had been admitted for post-hip replacement recovery, was discharged with prescribed Norco medication. However, upon reaching the airport, the resident discovered that the medication was missing from their belongings. The resident had been escorted out of the facility by a social services staff member, who had handled the resident's backpack containing the medication. A review of the facility's surveillance footage revealed that the social services staff member had taken the resident's backpack back into the facility for approximately 90 seconds before returning it to the resident. This action was in violation of the facility's policy, which states that only authorized licensed nursing or pharmacy personnel are permitted to handle controlled substances. The facility's administrator confirmed that the social services staff member was not authorized to carry or handle items containing controlled substances, leading to the potential for drug diversion and unaddressed pain for the resident.
Failure to Use Gait Belt Results in Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was wearing a gait belt during an initial occupational therapy evaluation, which led to a fall and a mildly displaced fracture of the right ankle. The resident, who had been admitted with conditions including cellulitis, restless leg syndrome, and cutaneous abscesses, was not cleared to be up on their own at the time of the fall. Despite the facility's policy requiring the use of gait belts unless a resident is cleared to be independent, the occupational therapist did not use one during the evaluation. Interviews with the occupational therapists and the Director of Nursing confirmed that the gait belt should have been used according to the facility's policy. The facility's policies on injury prevention and safe lifting emphasize the use of safety equipment like gait belts when indicated by the patient's condition. The failure to adhere to these policies created a potential for an unsafe environment for the resident.
Failure to Implement Pain Monitoring Interventions
Penalty
Summary
The facility failed to implement individualized care planned interventions for monitoring and recording pain characteristics for two residents. Resident 1 was at risk for episodes of pain related to a gastrointestinal bleed, polyosteoarthritis, a right wrist fracture, decreased mobility, and general pain and discomfort. The care plan for Resident 1 included an intervention to monitor and record pain characteristics every shift and as needed, starting from 3/20/24. Similarly, Resident 2 was at risk for episodes of pain related to a left femur fracture, decreased mobility, and general pain and discomfort, with a care plan intervention to monitor and record pain characteristics every shift and as needed, starting from 3/21/24. However, the facility could not provide documentation indicating that these interventions were carried out and documented by the nursing staff during the specified date ranges for both residents. During a concurrent record review and interview with Licensed Nurses 7 and 8 and the Administrator, it was confirmed that the facility did not have documentation to show that the pain monitoring and recording interventions were implemented as per the care plans for Resident 1 and Resident 2. The facility's policy and procedure for comprehensive person-centered care plans, dated 12/16, indicated that the interdisciplinary team, in conjunction with the resident and their family or legal representative, should develop and implement a comprehensive, person-centered care plan for each resident. This failure to document and implement the care plans as required had the potential for nursing staff to inadequately capture and report the residents' self-reported pain.
Failure to Secure Schedule II Narcotics
Penalty
Summary
The facility failed to properly secure 60 oxycodone tablets, a Schedule II drug, upon delivery from the pharmacy. The incident began when a Licensed Nurse (LN 1) received and signed off for the 60 oxycodone tablets and their corresponding narcotic sheets. Instead of securing the tablets in the medication cart and updating the narcotic logbook, LN 1 left the tablets and sheets on top of the medication cart where another Licensed Nurse (LN 2) was working, assuming LN 2 would complete the process. However, LN 2 reported never seeing the tablets and only briefly seeing the narcotic sheets before they disappeared. LN 2 later resigned from the facility. Interviews with the facility's Administrator, Director of Nursing, and Nurse Educator revealed that LN 1 did not follow the facility's policy and procedures for handling and storing narcotics. The facility's policy requires that Schedule II medications be stored in a separately locked compartment within the medication cart and logged into the narcotic logbook upon receipt. The failure to follow these procedures resulted in the facility being unable to account for the 60 oxycodone tablets, potentially impacting a resident's pain management treatment.
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 35 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 Santa Barbara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Park Healthcare Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Samarkand Skilled Nursing Facility | 1.2 mi | ★★★★★ | 5 | 0 |
| Channel Islands Post Acute | 1.2 mi | ★★★★★ | 3 | 0 |
| The Californian | 1.8 mi | ★★★★★ | 0 | 0 |
| Buena Vista Care Center | 3.5 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Valle Verde Health Facility.
100% money-back within 48 hours.
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.