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 Valley Healthcare Center during CMS and state inspections, most recent first.
Failure to Assess and Intervene for Repeated Falls and Skin Condition: A resident with severe cognitive impairment, dementia, and a history of falling had repeated falls with injuries despite limited interventions such as a fall mat, landing strips, lighting changes, orthostatic BP checks, psychiatry review, and room relocation. The DON stated a 1:1 had been recommended but not approved, and bowel/bladder retraining was not completed even though the resident was identified as a candidate. The resident later sustained a left femoral neck fracture requiring ORIF and rehab, and the report also states the resident was not accurately assessed for skin conditions, resulting in a facility-acquired stage III pressure injury.
The facility failed to maintain a functional call system in both shower rooms, where one shower room lacked any call system and the other had a wireless call button that did not activate an alarm at the nurses station. The MS confirmed there was no working call system in these areas and acknowledged that replacement wireless buttons frequently went missing. The DON stated that the shower room call systems had been nonfunctional as an ongoing issue and confirmed that two residents using the toilet in one shower room were at high risk for falls, with one resident having a high Morse Fall Scale score and another having severe cognitive impairment and a high fall risk score. One resident reported independently using the toilet in the shower room and confirmed there was no call system available, despite facility policy requiring call systems in toileting and bathing areas and designating bathroom call bells as emergency calls.
Unsafe and Unfinished Resident Room Conditions: Multiple resident rooms had unpainted plaster, exposed wires, loosened wall material, missing flooring, missing blinds, holes in walls, and unsecured ventilation tubing, and a shower room ceiling had slimy black textured dots identified by the MS as mold. The Administrator and MS observed these conditions and stated the room findings needed to be addressed. The facility policy required a safe, clean, comfortable, and homelike environment with cleanliness, order, and comfortable ventilation.
Missing CNA Competency Validation: The facility failed to ensure that three CNAs had completed required onboarding competency validation. During record review with the DSD, each CNA’s file lacked a completed competency worksheet and documented evaluation for hand hygiene, universal precautions, isolation technique, and applying/removing PPE. The facility policy stated new employees must complete orientation and competency validation before working independently, and the DSD is responsible for maintaining orientation and competency records.
The facility failed to follow its Drug Disposition P&P when two controlled medications, Ativan and lorazepam, were not documented on the medication disposition form by two licensed nurses as required. The facility also failed to authenticate Cresemba for a resident after the medication was brought in by family; staff copied the order from the bottle into the EMR without pharmacy validation and dispensed it to the resident.
Dishwasher Failed to Reach Required Sanitizing Temperature: The facility failed to follow its DISHWASHING P&P when the dish machine did not consistently reach the required 120°F sanitizing temperature and temperatures were not documented on multiple meal services. The DMTL showed several meal periods with no recorded temperature and multiple entries at 100°F, while the KS stated he was not made aware of the issue and would have had the machine serviced if notified.
The facility failed to develop and implement required care plans for three residents. One resident with mobility limitations and a right foot amputation was documented as preparing and using marijuana in his room, staying in his car all night blocking the entrance, and continuing to drive despite an unresolved surgical wound, yet no care plan addressed his substance use or driving. Another resident left the facility with an ex‑spouse and did not return for several days, and there was no care plan for this pattern of non‑compliance or leaving without informing staff. A third resident was receiving Cresemba per MD orders, but no care plan addressed this antifungal medication therapy. These omissions occurred despite a facility policy requiring comprehensive, person‑centered care plans based on assessed needs.
A cognitively intact resident with significant mobility limitations and a healing surgical foot wound repeatedly left the facility and drove a personal vehicle without a physician out-on-pass order, without notifying licensed staff, and without required nursing assessments before leaving or upon return, despite a facility policy mandating physician authorization, nurse assessment, and proper sign-out/sign-in. In a separate case, a resident with a GT and documented skin irritation around the GT site did not receive GT site care every shift as ordered by the physician, the dressing was observed to be soiled, not covering the insertion site, and leaking formula, CNAs did not report the condition to licensed staff, and no care plan was developed to address the GT-related skin irritation, contrary to the facility’s wound management policy requiring ongoing skin assessment and care planning.
Failure to follow the COC notification policy occurred for a resident with AFib and hypertensive heart disease. The resident had abnormal VS, including elevated BP and a HR of 145, and the record showed no documentation that the VS were rechecked or that the physician was notified. The resident also reported feeling ill when she did not receive her AFib medication and said she had considered going to the hospital because of it.
A resident received Zyprexa 5 mg nightly for psychosis-related symptoms, but the MAR showed no documented behavior episodes to support the order. The SSD stated the medication had previously been discontinued, may have been mistakenly restarted after a hospital stay, and was continued without IDT review, clinical justification, alternative interventions, or a care plan; the DON confirmed the IDT did not meet to review the new order.
Failure to Report Resident Fall With Fracture: A resident with dementia, weakness, poor coordination, and a history of falls was found on the floor with hip pain after a fall that later was documented to have caused a leg fracture, hospitalization, surgery, and rehab. The DON stated she was unaware of the fracture until reviewing the EHR and did not report the incident to CDPH, despite the facility policy requiring unusual occurrences to be reported within 24 hours by phone and then in writing.
Failure to provide individualized in-room activities for a resident with muscle weakness, lack of coordination, and dependence for personal care. The resident was observed lying in bed staring at the walls, and the FM reported the resident was in bed all the time and had requested in-room activities due to concern the resident was depressed. The AD could not verify attempts to engage the resident outside the scheduled activity hour or explain several "Not Applicable" entries in the activity log.
Oxygen Delivered at Incorrect Flow Rate: A resident with muscle weakness, hypertensive heart disease, and acute on chronic combined systolic and diastolic HF was ordered oxygen at 2 L via NC PRN for SOB, but during observation the resident was receiving oxygen at 1 L instead of the ordered rate. The TN confirmed the oxygen setting did not match the physician order.
Staff competency was not established for TPN, CNA direct care tasks, and dialysis catheter care. Two residents received TPN via PICC lines while the DON and multiple RNs stated there were no competency tests or documented training for TPN/PICC care, and one RN said he only had limited prior TPN experience. Three CNAs lacked onboarding competency validation for hand hygiene, universal precautions, isolation technique, and PPE use. Five RNs also lacked documented training for dialysis catheter care, while a resident with ESRD had orders to monitor the dialysis access site for infection and other complications.
Improper Storage of Prevnar Vaccine: Three boxes of Prevnar 20-valent Conjugate Vaccine were observed in the freezer at 20 degrees in the med room. The IP Nurse said the pharmacist instructed staff to store the extra boxes in the freezer, even though the vaccine label said do not freeze and the IFU required refrigeration at 36 degrees F to 46 degrees F.
Unmeasured cheese was used while preparing substitute quesadillas for three residents. An FC was observed making five quesadillas and dispensing cheese by hand without measuring it, and stated he did not know the recipe amount. The facility recipe required 1/2 cup cheese per tortilla.
Unlabeled food items, a heavily iced pastry refrigerator, and an inaccurate dry storage temp log were observed in the kitchen area. Multiple opened spices and three containers of whitish liquid had no labels or dates, the pastry refrigerator had 1 to 2 inches of ice buildup with food stored inside, and a DA stated the dry storage log entries were based on the A/C setting rather than the actual thermometer reading.
Failure to Conduct Required Infection Control Surveillance: The facility did not follow its Infection Prevention and Control Program when no surveillance was conducted on CNAs or LPNs/RNs for infection control practices. During interview and record review, the IP Nurse confirmed that surveillance records were reviewed and that no infection control audits had been completed for nursing staff, despite the facility P&P requiring the IP Nurse to conduct an infection control audit at least monthly.
Insufficient Room Space Per Resident: The facility failed to ensure 23 of 34 resident rooms provided at least 80 square feet per resident. Review of the CAA and RLR showed multiple rooms occupied by two or three residents with calculated space per resident ranging from 66 to 77 square feet. The Administrator acknowledged the rooms did not meet the required minimum, and the report stated no residents were negatively affected by the room size.
The facility did not submit the results of an investigation into an allegation of resident-to-resident abuse to CDPH within the required five-day period, instead providing the report ten days after the incident, contrary to facility policy.
A deficiency was cited for not ensuring a safe, clean, comfortable, and homelike environment for a resident, including the safe provision of treatment and daily living supports.
A resident dependent on a G-tube and at risk for dehydration did not receive physician-ordered water flushes or documented hydration, despite a dietician's recommendation. Staff failed to obtain necessary orders, communicate recommendations, and monitor intake and output as required, resulting in the resident being hospitalized for sepsis, hypernatremia, and severe dehydration.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The QAPI committee did not identify or document non-functional restroom call lights, resulting in an unsafe environment for all residents. The Medical Director, Administrator, and Maintenance Supervisor were unaware of the issue, and facility records did not reflect any monitoring or corrective action regarding the call light system.
Surveyors found that call light systems in all resident bathrooms and shower rooms were non-functional or inaccessible, preventing residents from alerting staff for assistance while using these areas. Facility policy required operational call systems, but none were working or properly placed at the time of the survey.
Surveyors observed two medication carts left unsecured and unattended, with one cart's drawers unlocked and accessible, and a jar of Lactulose left on top of another cart while a nurse administered medications to a resident. The DON was unable to secure the cart's locking mechanism, and staff acknowledged the lapse in medication security, contrary to facility policy.
Three dietary staff did not follow CDC-recommended handwashing procedures, applying soap before wetting their hands and not adhering to the correct sequence. The facility's hand hygiene policy and posted instructions also did not match CDC guidelines. Additionally, the facility lacked a written inventory for PPE, relying on visual checks by the Supplies Supervisor rather than documented tracking.
A review of facility documentation and resident assignments revealed that 23 rooms did not provide the required 80 square feet per resident in multiple occupancy rooms, with some rooms offering as little as 66 to 77 square feet per resident. The Administrator confirmed the deficiency, and no residents were found to be negatively affected at the time of the survey.
A resident's diet was changed from regular to pureed at the request of the resident, but the responsible party was not notified of this change. The DON confirmed that nurses could downgrade diet consistency without physician notification, but there was no documentation that the responsible party was informed, contrary to facility policy.
Two residents receiving dialysis did not receive complete nursing assessments as required, with missing pain and respiratory assessments before and after dialysis sessions. Facility policy mandates such monitoring and documentation, but staff interviews and record reviews confirmed these steps were not followed.
Surveyors found that the kitchen's two compartment sink, used for washing produce and food, lacked an air gap for backflow prevention. Staff confirmed the absence of an air gap, and dietary staff were observed washing fresh strawberries in the sink. The facility did not have a policy addressing air gaps, and the Director of Maintenance stated it was not possible to create one in the current setup.
The facility failed to develop and implement care plans for two residents at high risk for falls, leading to potential accidents and injuries. One resident had a high fall risk score but no care plan, while another experienced two falls with injuries before a care plan was initiated. The facility's policy requires individualized care plans based on fall risk assessments, which was not followed.
The facility failed to notify the MDs of two residents and the RP of one resident about abuse allegations, as required by its Abuse Prevention and Prohibition Program policy. The DON and Administrator confirmed the absence of documentation in the residents' medical records, which should have been recorded in a progress note.
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. Despite allegations of abuse and neglect, the required psychosocial monitoring was not documented consistently over a 72-hour period, as confirmed by the DON.
The facility failed to provide reasonable access to a telephone that ensured privacy for three residents. Staff and residents confirmed that phone calls had to be made in non-private areas like the Administrator's office or the nursing station, and the facility lacked portable phones. This issue was acknowledged by multiple staff members and contradicted the facility's policy on telephone access.
A resident admitted with hemiplegia and reduced mobility was not assessed for pressure injury risk, and their left heel redness was not reported to a physician or treated. No care plan or IDT meeting was conducted, leading to the development of a Stage 3 pressure injury.
The facility failed to ensure accurate medical records for a resident, as confirmed by the DON. The resident's Wound Weekly Observation Tool indicated an SDTI, while the care plan incorrectly documented it as a stage 3 pressure injury. The facility's policy mandates accurate and chronological documentation, which was not followed in this case.
The facility failed to follow their policy on contacting APS when a resident with multiple health issues and moderate cognitive impairment left AMA. The resident's responsible party was not contacted, and arrangements for continued dialysis were not made.
The facility failed to ensure that air mattresses for three residents were set correctly according to their weights, leading to potential safety risks. Observations and interviews revealed that neither the nurses nor the maintenance worker were trained or responsible for setting the correct air mattress settings, and the facility lacked policies for such training.
A facility failed to provide oxygen per physician's orders for a resident with COPD, pneumonia, and respiratory failure. The resident was observed receiving oxygen at six liters per minute instead of the prescribed two liters per minute, contrary to the facility's policy and procedure for oxygen administration.
The facility failed to provide proper foot care for two residents, resulting in pain and discomfort. LVNs did not perform adequate skin assessments or develop care plans, and CNAs failed to report and document observations. The podiatrist did not provide appropriate treatment, leading to neglected foot conditions.
The facility failed to complete activity assessments for 16 residents within the required seven days of admission, as confirmed by the Activity Director. This oversight could impact the residents' physical, mental, and psychosocial well-being.
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. Interviews revealed that a Certified Wound Nurse did not receive on-the-job training, and the Director of Nursing admitted that no competency assessments were being conducted. The Director of Staff Development confirmed the absence of documented skills competency assessments, and the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff.
The facility failed to maintain kitchen sanitation, properly store and label food, ensure staff followed dress code policies, and serve food in a sanitary manner. Observations included a dirty ladder and scaffolding in the kitchen, unsealed and unlabeled food items, and staff with uncovered facial hair. Additionally, a Dietary Supervisor returned a plated portion of food to the serving line, which was deemed inappropriate.
The facility failed to ensure proper infection control practices for residents, including not wearing PPE, not performing hand hygiene, and not addressing bowel movement leakage. Staff also mishandled trash and laundry without proper hygiene, and the infection preventionist did not maintain records of surveillance activities or properly stock isolation carts.
The facility failed to ensure accurate records of Influenza and Pneumonia vaccinations for all residents. The Infection Control Preventionist could not provide vaccination records for 11 residents and could not verify pneumonia vaccination status for 40 residents. Only seven residents had signed declination statements, and the facility lacked a policy for these vaccinations.
The facility failed to ensure the Infection Preventionist (IP) maintained accurate records of employee COVID-19 vaccinations for 110 of 159 employees. The IP did not have a log of vaccinations and only had 49 vaccination cards on file. The IP admitted to requesting the cards verbally but did not follow up, resulting in incomplete records.
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 residents. No competency assessments or specific training for psychological or mental disorders were conducted, leaving staff unprepared to address residents' behavioral health needs.
The facility failed to ensure timely completion of MDS assessments for three residents. Quarterly and annual assessments were either not transmitted or still in progress, contrary to the facility's policy and procedures. This was confirmed during interviews and record reviews with the MDS Coordinator.
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents. The absence of these reviews was confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON).
Failure to Assess and Intervene for Repeated Falls and Skin Condition
Penalty
Summary
The facility failed to accurately assess, develop, and implement interventions for Resident 3, who was admitted with muscle weakness, unspecified dementia, depression, anxiety disorder, lack of coordination, and a history of falling. Resident 3 had a BIMS score of 6, indicating severe cognitive decline, and required assistance with multiple activities of daily living on the MDS, including dependent showering and partial/moderate assistance with toileting hygiene, dressing, footwear, and personal hygiene. During observation, Resident 3 was lying in bed on a low pressure air mattress, oriented to self, unable to identify how to call for assistance, and confused. From admission through hospitalization, Resident 3 experienced nine falls with injuries. The IDT records and DON interview showed repeated falls on 9/7, 9/8, 9/10, 10/6, 10/7, 11/3, 11/4, 11/12, and 12/1. Interventions documented after these falls were limited and varied, including not leaving the resident unattended in the bathroom, placing a fall mat, using landing strips, scheduling a neurology consult, keeping the overhead light on at night, weekly orthostatic blood pressure monitoring, a psychiatry referral, and moving the resident closer to the nurses' station. The DON stated there were no other interventions initiated after several of the falls, and after the final fall there was no new intervention added. The DON also stated she had recommended a 1:1 for the resident in the past, but it was not approved. Resident 3 also had a Bowel and Bladder Program screener indicating she was a good candidate for retraining, but the DON stated bowel and bladder retraining with care plans was not done and should have been done to address the resident's falls. After the final fall, the resident complained of hip pain and could not explain why she wanted to get up. The resident was later hospitalized after a ground-level fall, where workup revealed a left femoral neck fracture requiring open reduction and internal fixation, and she then required acute rehabilitation before returning to the facility. The report also states Resident 3 was not accurately assessed for skin conditions based on shower sheets and the Braden scale, resulting in a facility-acquired stage III pressure injury.
Failure to Maintain Functional Call System in Shower Rooms
Penalty
Summary
The facility failed to ensure that a functional call system was available in resident bathrooms and bathing areas, specifically in both shower rooms at station 2 and station 3. During an observation and interview in the station 3 shower room with the Maintenance Supervisor (MS), surveyors noted there was no call system present for residents using the toilet or shower. The MS confirmed there was no call system available and stated there should have been an alternative call system provided for residents in these areas. In the station 2 shower room, a black wireless call button with a bell logo was observed hanging on the handrail next to the toilet. When the MS pressed this button and then went to nurses station 1, no alarm was heard, and the MS acknowledged that an alarm should have sounded to alert staff that assistance was needed in the shower room. The MS reported that he would replace the black wireless call buttons in the shower rooms but that these buttons would go missing, and reiterated that there should have been a functional call system available for residents using the toilet and shower. The DON stated that the facility had two shower rooms (station 2 and station 3) and that the call system in these shower rooms had not been working, describing it as an ongoing issue. The DON confirmed that residents using the toilet in the station 3 shower room, including Resident 85 and Resident 14, were at risk for falls and that the absence of a call system in the shower rooms would put residents at risk for accidents and falls. Resident 85’s Morse Fall Scale (MFS), dated 12/9/25, showed a score of 55, indicating high fall risk, and Resident 14’s MDS showed a BIMS score of 6, indicating severe cognitive impairment, with an MFS score of 60. Resident 14 reported independently using the toilet in the station 3 shower room and stated there was no call system there. The facility’s policy titled “Communication – Call System” required the facility to provide a call system in resident rooms and toileting/bathing facilities and identified bathroom call bells as emergency calls that must be answered promptly.
Unsafe and Unfinished Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for nine residents. During a concurrent observation and interview with the Administrator and Maintenance Supervisor, multiple room and common-area conditions were identified, including unpainted plaster on walls in several resident rooms, exposed wires in one room, loosened wall material that moved with slight touch, an unsecured air conditioning tubing running through a window with outside air entering the room, missing flooring in multiple rooms and near a restroom entrance, missing blinds, a circular hole in a wall with cold air coming through, and broken wall sections with scratches exposing plaster. In the north wing shower room, a 12-inch by 12-inch area of slimy black textured dots was observed on the shower stall ceiling, and the Maintenance Supervisor stated it was mold. The affected residents were Resident 2, Resident 17, Resident 21, Resident 45, Resident 54, Resident 55, Resident 63, Resident 65, and Resident 72. The Administrator stated the room findings needed to be addressed. Review of the facility policy titled Resident Rooms and Environment, dated 11/1/17, stated the purpose was to provide residents with a safe, clean, comfortable, and home-like environment, and that staff would ensure residents could receive care and services safely while maintaining cleanliness, order, and comfortable ventilation.
Missing CNA Competency Validation
Penalty
Summary
The facility failed to ensure that three of three CNAs had successfully completed a nurse aide training or competency evaluation program. During a concurrent interview and record review with the DSD, CNA 1’s personnel file did not contain a completed competency evaluation worksheet for onboarding, and the DSD stated CNA 1 did not have competency evaluations completed for hand hygiene, universal precaution, isolation technique, or applying and removing PPE. The same findings were identified for CNA 2, whose personnel file also lacked a completed onboarding competency evaluation worksheet and competency evaluations for hand hygiene, universal precaution, isolation technique, and applying and removing PPE. During the same review, CNA 3’s personnel file was also found to be missing the completed competency evaluation worksheet for onboarding, and the DSD stated CNA 3 did not have competency evaluations completed for hand hygiene, universal precaution, isolation technique, or applying and removing PPE. The facility’s policy stated that all newly hired employees receive comprehensive New Employee Orientation before assuming independent job responsibilities, that no employee may work independently until required orientation components are completed, and that competency validation is required prior to independent work. The DSD’s job description stated the DSD coordinates and conducts orientation, maintains orientation and competency records, and provides hands-on training, skill validation, and competency assessment for nursing staff.
Medication Disposition and Authentication Failures
Penalty
Summary
The facility failed to follow its Drug Disposition policy when two controlled medications were not documented on the medication disposition form. During interview and record review, the DON stated that Ativan oral concentrate 2 mg/ml, unopened 30 ml container, and lorazepam 2 mg/ml with 7 ml remaining were not recorded on the disposition form. The DON stated the facility process required two licensed nurses to document discontinued controlled medications on the form with the medication name, prescription number, and both signatures, but this was not done for these medications. The facility also failed to authenticate Cresemba for Resident 56. During review of Resident 56's EMR, it was noted that the resident returned from the hospital and there was no order for Cresemba. The IP stated the medication was brought in by family and was not sent to the pharmacy for validation. The DON stated staff copied the order from the medication bottle into the facility EMR without validating it with the pharmacy and dispensed it to Resident 56.
Dishwasher Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to implement its policy and procedure titled DISHWASHING when the dishwasher did not consistently reach the required sanitizing temperature and the temperature was not documented on multiple occasions. During a concurrent interview and record review on 1/27/26 at 8:19 a.m. with the Kitchen Supervisor (KS), the Dish Machine Temperature Log was reviewed and KS stated the dish machine needed to reach at least 120 degrees Fahrenheit to sanitize resident dishware. The log showed no recorded temperature for dinner service on June 30 and August 28, no recorded temperature for dinner service on August 31, and temperatures of 100 degrees Fahrenheit at lunch service on August 31 and on October 17, 21, 22, 23, 28, and 29, 2025. The log also showed the dish machine recorded at 100 degrees Fahrenheit for breakfast service from November 15 through November 30, 2025, for a total of 15 days. KS stated he should have been made aware that the dish machine was not reaching temperature, but he was not. He also stated that if he had been contacted about the dish machine not reaching temperature, he would have had it serviced to fix the issue. The facility's 2023 Dish Machine Temperature Log instructed staff to record wash and rinse temperatures before each meal and stated wash temperatures must be at least 120 degrees Fahrenheit. The undated DISHWASHING policy stated all dishes would be properly sanitized through the dishwasher, the dishwasher would be kept in good working order, and if the temperature could not be achieved, staff were to alert the Director or cook, who would alert Maintenance and stop washing dishes.
Failure to Develop and Implement Care Plans for Substance Use, Non‑Compliance, and Antifungal Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents, as required by its care planning policy. For one resident with a BIMS score indicating intact cognition, documented functional limitations in range of motion, wheelchair dependence, and a right foot amputation, multiple behavior notes and staff interviews showed that he prepared and used marijuana in his room, stayed in his car all night blocking the entrance while playing loud music, and continued to drive his car despite his amputation and an unresolved surgical wound. The Social Services Director and DON confirmed that the resident had been seen using marijuana, had nearly hit several cars in the parking lot, and that there was no care plan addressing his use of illegal substances or his driving, with the DON stating the facility did not know how to keep him safe when driving and acknowledging that the care planning policy was not followed. A second resident left the facility with an ex‑spouse and did not return for several days, and the Social Services Director confirmed there was no care plan addressing this resident’s pattern of non‑compliance or leaving the facility without informing staff. For a third resident, record review showed an active physician order for Cresemba, an anti‑fungal (anti‑viral/fungal) medication, but the Infection Prevention Nurse was unable to provide evidence of any care plan developed and implemented to address this medication therapy. The facility’s written care planning policy, which requires a comprehensive person‑centered care plan for each resident based on assessed needs, including services required and any services not provided due to exercise of resident rights, was not followed in these cases.
Failure to Follow Out-on-Pass and GT Wound Management Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its “Out on Pass” policy for a cognitively intact resident with significant physical limitations and an unresolved surgical wound. The resident’s MDS showed a BIMS score of 13, functional limitations in range of motion on one side of both upper and lower extremities, wheelchair dependence, inability to walk, and a need for supervision or touching assistance with transfers and setup assistance for wheelchair mobility. A medical progress note documented a history of need for assistance with personal care and generalized muscle weakness, with comments indicating a need for supervision and care 24 hours a day. The resident reported having all toes amputated on the right foot, with a healing surgical wound, and was observed with a dry dressing wrapped around the right foot. Record review showed that the resident purchased a vehicle and was leaving the facility without a physician out-on-pass order. The order summary report confirmed there was no physician order for out on pass. The facility’s out-on-pass log for the month showed multiple instances where the resident signed out but did not sign back in on return. Staff interviews revealed that the resident had been seen using marijuana in the facility and driving his car, with the social services director stating the resident had almost hit several cars in the parking lot. The DON and social services director both stated the resident would leave without notifying licensed nurses, preventing timely notification of the physician, and the DON confirmed the resident did not have a physician order to go out on pass. Further review of nursing notes showed that on one occasion the morning nurse reported the resident had signed out in the afternoon, was seen leaving during rounds, and had not returned by the time of the evening medication pass, with a later note documenting the resident’s return. The DON stated the resident was not assessed by a licensed nurse prior to leaving or upon returning to the facility, despite the facility’s written policy requiring a licensed nurse to assess the resident’s physical and mental status before leaving and to reassess upon return. The DON acknowledged that the policy, which also requires a physician order for passes and verbal notification to a licensed nurse before leaving, was not followed. The deficiency also includes the facility’s failure to follow its wound management policy and physician orders for treatment of a resident’s gastrostomy tube (GT) site. On admission, nursing documentation indicated the resident had a GT with skin irritation. The physician’s order summary directed staff to cleanse the GT site with normal saline, pat dry, apply zinc oxide to the peri-wound area, cover with a T-drain sponge, and secure with tape every shift. However, the treatment administration record showed the ordered treatment was only being performed on the day and evening shifts, not every shift as ordered. The treatment nurse confirmed the order was not followed and that there was no physician order to monitor the GT site as needed. During observation, the resident’s GT dressing was black, did not cover the insertion site, and the GT site was red and leaking yellow liquid. The treatment nurse stated the dressing was wet from leaking GT formula and that the moisture was causing irritation and redness around the site, and also stated the GT site should have been monitored as needed to keep it clean and dry. A CNA reported seeing the resident earlier with a black dressing that did not cover the GT site and acknowledged she did not notify the treatment nurse or any licensed nurse, stating she should have done so. Review of the care plan showed there was no care plan developed to address the skin irritation at the GT site, despite the DON stating the irritation was caused by leaking GT formula and that there should have been a care plan to monitor when the dressing needed to be changed. The facility’s wound management policy required a licensed nurse to perform skin assessments and develop a care plan based on physician recommendations, and the DON stated this policy was not followed.
Failure to Notify Physician and Recheck Abnormal Vital Signs
Penalty
Summary
The facility failed to follow its policy and procedure on Change of Condition Notification for one of three sampled residents, Resident 53. Resident 53 had diagnoses of atrial fibrillation and hypertensive heart disease without heart failure, and her MDS showed a BIMS score of 12. She told the surveyor that she had considered going to the hospital a few days earlier because staff did not give her her AFib medication, and she stated that she feels ill when she does not receive it and becomes scared when her heart rapidly beats. Resident 53 had an order for apixaban 2.5 mg twice daily for AFib, and the MAR showed daily vital sign monitoring. On 1/2/26, her vital signs were abnormal, including blood pressure readings of 147/100 and 148/100 and a heart rate of 145, with another entry showing blood pressure of 162/100 and heart rate of 145. The record review and interviews showed no documentation that the abnormal vital signs were rechecked, and the progress notes indicated she was going to be sent to the hospital for high blood pressure but the transfer was cancelled. The IP stated the nurse should have rechecked the vital signs and notified the physician, but there was no documentation that this occurred.
Unjustified continuation of Zyprexa without documented behaviors or IDT review
Penalty
Summary
The facility failed to have clear clinical justification for continuing Zyprexa 5 mg at bedtime for one resident with diagnoses including anxiety disorder, unspecified psychosis, and muscle weakness. The resident’s physician order sheet listed the medication for psychosis manifested by lack of motivation and trouble thinking, and the medication administration record showed the resident received Zyprexa nightly for 22 days in January 2026. However, the MAR section for monitoring episodes of lack of motivation and trouble thinking had no documented behavior episodes for that month. During interview and record review, the SSD stated the resident had previously been discontinued from Zyprexa in 2024 because it was no longer needed, but after a hospital stay the medication may have been mistakenly restarted and then continued per the hospital order. The SSD stated there was no IDT discussion about whether the medication should have been continued, no clinical justification identified for the resident to take Zyprexa, no alternative treatments trialed before restarting it, and no care plan created. The DON also stated the IDT did not meet for the new Zyprexa order and should have met to discuss its appropriateness and whether there was clinical justification.
Failure to Report Resident Fall With Fracture
Penalty
Summary
The facility failed to follow its policy and procedure for Unusual Occurrence Reporting when it did not report a resident’s fall with injury to the California Department of Public Health (CDPH). Resident 3, who had diagnoses including muscle weakness, unspecified dementia, depression, anxiety disorder, lack of coordination, and a history of falling, was found sitting on the floor on the left side of the bed and complained of hip pain. The resident was unable to explain why she tried to get up, and range of motion could not be completed because she was not following instructions. Record review showed that the fall resulted in a left leg fracture, followed by hospitalization, surgery to correct the fracture, and rehabilitation. During interview, the DON stated she was not aware of the fracture until reviewing the electronic record and that she did not follow up on the fall or report the incident because she had been unaware of the fracture. The DON later stated that the fall with femoral fracture was an unusual occurrence and should have been reported to CDPH according to facility policy, which required unusual occurrences to be reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.
Failure to Provide Individualized In-Room Activities
Penalty
Summary
The facility failed to provide individualized activities services for one resident who had muscle weakness, lack of coordination, and required assistance with personal care. During an observation, the resident was lying in bed staring at the walls. The resident’s family member stated that the resident was in bed all the time and had requested in-room activities because the family member felt the resident was depressed. The resident’s care plan indicated a goal for the resident to express satisfaction with the type of activities and level of activity involvement when asked. The Activities Director reviewed the resident’s in-room visits activity record, which showed entries such as hospital transfers, family visits, sleeping, CNA attendance, and several “Not Applicable” entries. The Activities Director stated the resident’s activities were scheduled for one hour on Mondays, Wednesdays, and Fridays, but could not verify that staff attempted to involve the resident at other times when family was present, when the resident was sleeping, or when a CNA was attending to the resident. The Activities Director also could not identify what “Not Applicable” meant and had no other log showing attempted activities or what activities were presented to the resident.
Oxygen Delivered at Incorrect Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when Resident 35 did not receive oxygen at the physician-ordered flow rate. Resident 35 was admitted with muscle weakness, need for assistance with personal care, hypertensive heart disease, and acute on chronic combined systolic and diastolic heart failure. The physician order sheet dated 1/25/26 ordered oxygen at 2 liters via nasal cannula as needed for shortness of breath. During a concurrent observation and interview on 1/26/26 at 8:48 a.m., Resident 35 was observed lying in bed with oxygen being delivered via nasal cannula. The Treatment Nurse observed the oxygen setting and stated it was at 1 liter, not the ordered 2 liters for shortness of breath. The facility policy titled Oxygen Administration stated that a physician's order is required to initiate oxygen therapy and that the oxygen should be turned on at the prescribed rate.
Staff Competency Deficiencies for TPN, CNA Care, and Dialysis Catheter Care
Penalty
Summary
RN 1, RN 2, RN 3, RN 4, RN 5, and the DON were not competent to provide TPN care for two residents who were receiving TPN through PICC lines. One resident was admitted with muscle weakness, need for assistance with personal care, colostomy, mild protein-calorie malnutrition, electrolyte and fluid imbalance, and disorder of plasma-protein metabolism. The physician order required nightly TPN with separate lipid infusions, and the care plan directed staff to provide TPN as ordered. The IV MAR showed the resident received TPN on multiple dates in January 2026. During interview, the DON stated there were no competency tests or assessments for the RNs, including herself, to show competency in providing TPN care, and stated RN 1 had verbally instructed the other RNs without documented proof of competency training. RN 1 stated he taught the other staff how to provide TPN but had no documented proof of the education and said his prior TPN experience was limited to a patient in another country in 2022. A second resident had a care plan directing daily TPN for 24 hours with PICC line monitoring for signs and symptoms of infection and infiltration. The physician order required TPN to be mixed and infused every 24 hours, and the IV MAR showed the resident received TPN on many days across November and December 2025. During interview, the DON stated there was no training for PICC line or TPN prior to the resident receiving TPN. The facility policy for TPN stated that RNs complete pre-administration checks, use strict aseptic technique for central lines, administer TPN via infusion pump only, monitor lab values, blood glucose, intake/output, and vital signs, and that discontinuation of TPN is performed by an RN only. CNA 1, CNA 2, and CNA 3 did not have completed competency evaluations for onboarding, including hand hygiene, universal precautions, isolation technique, and applying and removing PPE. The DSD reviewed each personnel file and stated the competency evaluation worksheet for onboarding was not completed for each CNA. The facility’s new employee orientation policy stated that all newly hired employees receive comprehensive orientation before assuming independent job responsibilities and that no employee may work independently until required orientation components are completed. The DSD job description stated the DSD coordinates and conducts orientation and maintains orientation and competency records. Five RNs were also not competent to provide dialysis catheter care for a resident with dependence on renal dialysis and end stage renal disease. The resident’s POS directed staff to monitor the right femoral dialysis catheter site for signs and symptoms of infection and itching, and the care plan directed daily and as-needed checks of the shunt site for infection, pain, or bleeding. During interviews, the treatment nurse stated she had not had any training on dialysis catheter care, RN 1 stated he had not had any training on dialysis catheter care, and the DON stated she did not have complete documentation that staff were trained on dialysis catheter care. The facility policy stated competency validation was required prior to independent work, and the DON job description stated the DON evaluates all RNs in the facility.
Improper Storage of Prevnar Vaccine
Penalty
Summary
Medications were not stored at the proper temperature in the facility medication room. During observation and interview, three boxes of Prevnar 20-valent Conjugate Vaccine were found stored in the freezer at 20 degrees, and the Infection Prevention Nurse stated the pharmacist had told staff to store the extra boxes in the freezer. The box of Prevnar indicated "Do not freeze," and the vaccine's Instructions for Use stated it should be stored refrigerated at 36 degrees F to 46 degrees F after receipt and discarded if frozen. The facility's Drug Storage and Labeling policy stated drugs and biologicals must be stored in a safe, secure, and orderly fashion, with refrigerated drugs kept between 36 degrees F and 46 degrees F.
Unmeasured Cheese Used in Quesadilla Preparation
Penalty
Summary
The facility failed to provide the correct amount of ingredients to a meal per the facility recipe for three residents, identified in the report as Resident 21, Resident 51, and Resident 80. During a concurrent observation and interview in the kitchen, Facility [NAME] staff member 1 was observed making five quesadillas as a substitute meal and used his hands to grab cheese and dispense unmeasured amounts onto a tortilla. Staff member 1 stated he had not measured how much cheese was used for the quesadillas and did not know what the facility recipe required as far as amount. Review of the facility document titled RECIPE: CHEESE QUESADILLA, dated 2025, indicated to add 1/2 cup cheese per tortilla.
Unlabeled Food Items, Dirty Refrigerator, and Incorrect Dry Storage Temperature Log
Penalty
Summary
The facility failed to label and date opened food items in the kitchen and walk-in refrigerator. During observation with the Certified Dietary Manager, multiple opened spice containers were found without an open date or label, including paprika, ground thyme, ground rosemary, sesame seeds, ground cumin, lemon pepper seasoning, dill weed, and bay leaves. Three pink 32-ounce containers holding a whitish thick liquid substance were also observed in the walk-in refrigerator with no indication of what the liquid was. The CDM stated the spice items should have an open or use-by date and a label identifying the item, and stated the pitchers of liquid should have been labeled and dated when made. The facility’s Dry Storage policy stated opened dry food items such as spices will be tightly closed, labeled, and dated. The facility also failed to maintain a clean pastry refrigerator and accurately document the dry food storage temperature. The pastry refrigerator had three shelves that could not be observed because of about 1 to 1.5 inches of ice buildup, and the top inside of the refrigerator was covered in about 2 inches of ice. Boxes of French fries and raw cookie dough were stored inside, and the CDM stated the refrigerator needed to be defrosted and cleaned, but was not sure when it was last cleaned. In addition, the Dry Storage Temp Log showed repeated entries of 62 degrees Fahrenheit, but the Dietary Aide stated she recorded the air conditioner setting instead of reading the thermometer in the dry storage room and could not state the actual room temperature. The facility’s policy stated the dry food storage temperature log is used to monitor storage unit temperatures when the storage room becomes higher than 85 degrees Fahrenheit.
Failure to Conduct Required Infection Control Surveillance
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not follow its policy and procedure titled, Infection Prevention and Control Program, when no surveillance was conducted on nursing staff. During a concurrent interview and record review on 1/28/26 at 9:27 a.m. with the Infection Prevention Nurse, surveillance records used to audit staff infection control practices were reviewed. The Infection Prevention Nurse stated there was no surveillance conducted for CNAs or for Licensed and Registered Nurses for any infection control practices, and stated that it should have been done. Review of the facility policy and procedure titled, Infection Prevention and Control Program, dated 12/1/2021, showed under V. Gathering Surveillance Data, E. that at least on a monthly basis, the Infection Prevention Nurse will conduct an infection control audit.
Insufficient Room Space Per Resident
Penalty
Summary
The facility failed to ensure that 23 of 34 resident rooms measured at least 80 square feet per resident. During review of the facility document titled Client Accommodation Analysis, the room measurements listed included rooms measuring 132, 153, 154, 156, 210, 225, and multiple rooms measuring 220 square feet. During review of the Resident List Report dated 1/25/26, those rooms were occupied by either two or three residents, resulting in calculated space per resident amounts of 66, 70, 73, 75, 76.5, and 77 square feet in the identified rooms. During an interview on 1/29/26 at 9:41 a.m., the Administrator stated the above rooms did not measure at least 80 square feet per resident. The report also states that, during the survey, no residents in the rooms identified as providing fewer than 80 square feet per resident were negatively affected by the size of their rooms. The facility policy titled Maintenance Services stated that the Maintenance Department is responsible for maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.
Failure to Timely Report Investigation Results of Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of resident-to-resident abuse to the California Department of Public Health (CDPH) within the required five-day timeframe. According to the SOC 341 form, the facility became aware of the abuse allegation involving two residents and reported the initial incident to CDPH the following day. However, although the facility completed its investigative report, it did not submit the results to CDPH until ten days after the incident. The facility's own policy and procedures require that the state survey agent receive a copy of the investigative report within five days of the incident.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described.
Failure to Provide and Document Hydration for G-Tube Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on a gastrostomy tube (G-tube) for nutrition and hydration, and had an order for nothing by mouth (NPO), did not receive appropriate hydration management during their stay. The resident was identified as being at risk for dehydration, with a high score on the Dehydration Risk Screener. Despite this, there was no physician's order for water hydration or flushes, and no documentation that hydration was provided. The Registered Dietician (RD) recommended water flushes of 150 cc every six hours, but this recommendation was not communicated to the physician, not documented in the clinical record, and not implemented by nursing staff. The facility's staff, including the Licensed Vocational Nurse (LVN), Certified Dietary Manager (CDM), and RD, failed to ensure that the RD's hydration recommendation was followed. The LVN did not obtain a physician's order for water flushes, and both the LVN and CDM failed to document the RD's recommendation. The RD did not follow up within the expected timeframe to confirm that her recommendation was implemented. Additionally, the facility did not monitor or record the resident's intake and output (I&O) as required by facility policy for residents with feeding tubes. As a result of these failures, the resident did not receive documented water hydration during their five-day stay and was subsequently transferred to an acute care hospital with diagnoses of sepsis, hypernatremia, and severe dehydration. Facility policies required assessment and implementation of nutrition and hydration programs, as well as monitoring of I&O for residents receiving enteral feedings, but these were not followed in this case.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Identify and Address Non-Functional Restroom Call Lights
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, document, and correct a deficiency related to the physical environment, specifically the non-functional resident restroom call light system. During interviews and record reviews, it was revealed that the Medical Director, who participated in the QA committee, was unaware of any restroom call light deficits, despite acknowledging that nonfunctional call lights posed a safety concern. The facility's assessment tool and QAPI binder did not reflect any issues with the call light system, and there was no documentation indicating that the restroom call lights were not working. The Administrator confirmed that there was no record of the restroom call lights being nonfunctional, and the Maintenance Supervisor stated that there was no documentation of call light checks and was unaware of the issue. The facility's assessment tool and quality assurance policy both referenced the importance of maintaining the physical environment and communication systems, including call lights, for resident safety. However, the lack of monitoring and documentation led to the ongoing deficiency, affecting all 85 residents in the facility.
Non-Functioning Call Light Systems in Resident Bathrooms and Shower Rooms
Penalty
Summary
The facility failed to ensure that operational call light systems were available and accessible in all resident bathrooms and shower rooms. During an observation and interview with the Maintenance Supervisor, it was found that none of the bathroom call light systems in the facility were functioning. When activated, the call lights in multiple resident bathrooms and shower rooms did not trigger any visual or auditory alarms outside the rooms or at the nurse's station. In some cases, call lights were not accessible to residents using the toilet or shower, and in certain bathrooms and shower rooms, no call light system was present at all. Facility policy and procedure documents indicated that the Maintenance Department was responsible for maintaining all mechanical, electrical, and patient care equipment in safe operating condition, and that the facility was to provide a call system to enable residents to alert nursing staff from their rooms and toileting/bathing facilities. Despite these policies, the lack of functioning call light systems in 18 resident bathrooms and three shower rooms meant that all 85 residents potentially could not call for help if they required assistance while using these areas.
Failure to Secure Medication Carts and Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were securely stored and labeled in accordance with professional standards, as required by its own policy and procedure. During an early morning observation, Medication Cart 2 was found unattended and unlocked in a hallway near the nurse's station, with all drawers except the controlled medication drawer accessible. The Director of Nursing was present and able to open the unlocked drawers, and was unable to secure the cart's locking mechanism. The Director acknowledged that the unlocked cart could allow residents to access medications. In a separate incident, a registered nurse prepared medications for a resident, including Lactulose, and left the medication jar unattended on top of Medication Cart 1 while administering medications in a resident's room. The nurse later stated that she usually does not leave medications unattended on the cart. Review of the facility's policy confirmed that medications are to be stored safely and securely, accessible only to authorized personnel. These observations demonstrate a failure to follow established procedures for medication security.
Hand Hygiene and PPE Inventory Deficiencies
Penalty
Summary
Three dietary staff members failed to follow proper handwashing procedures as outlined by CDC guidelines. Specifically, each staff member applied soap to their hands before wetting them under running water, contrary to the recommended sequence of wetting hands first, then applying soap, lathering, scrubbing for at least 20 seconds, rinsing, and drying. The facility's posted handwashing instructions and its written policy and procedure on hand hygiene did not align with CDC guidelines, omitting the correct order and steps for effective hand hygiene. These observations were confirmed during interviews and a review of the facility's policies. Additionally, the facility did not maintain a written inventory of its personal protective equipment (PPE) such as gowns, gloves, masks, goggles, and face shields. Instead, the Supplies Supervisor monitored PPE stock visually and ordered more supplies when it appeared that inventory was running low. The facility's policy stated that appropriate PPE should be available at all times, but there was no documentation or record-keeping to ensure this requirement was consistently met.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 23 out of 34 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined by a review of the Client Accommodations Analysis and the Resident List Report. Specific room measurements and resident assignments showed that several rooms provided less than the required space per resident, with some rooms offering as little as 66 to 77 square feet per resident in double occupancy, and 70 to 75 square feet per resident in triple occupancy. The Administrator confirmed during an interview that these rooms did not meet the 80 square feet per resident requirement. No residents in the affected rooms were identified as having experienced negative effects due to the insufficient room size at the time of the survey. The facility's policy and procedure for Maintenance Services indicated that the Maintenance Department is responsible for maintaining the building in compliance with federal, state, and local regulations, but the documented room sizes and resident assignments did not meet these regulatory requirements.
Failure to Notify Responsible Party of Diet Change
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident's diet texture was changed from regular to pureed. The responsible party became aware of the change only after the resident mentioned over the phone that she was being fed 'baby food.' The Director of Nursing (DON) confirmed that the resident had requested a pureed diet after observing another resident eating it, and that nurses were permitted to downgrade diet consistency without informing the physician. However, there was no documentation in the nurse's notes indicating that the responsible party had been informed of this change. A review of the resident's physician orders showed that the prescribed diet was regular with thin consistency, and the progress notes documented the change to pureed. The facility's policy required timely notification of residents, families, legal representatives, and physicians regarding changes in a resident's condition. Despite this policy, the responsible party was not informed of the change in diet consistency, as confirmed by the DON.
Failure to Complete Required Assessments for Dialysis Residents
Penalty
Summary
The facility failed to complete required nursing assessments for two residents receiving dialysis services. For one resident, the Nursing Dialysis Communication Record (NDCR) showed that a pain assessment was not performed after dialysis, which was confirmed by a registered nurse who stated that such an assessment was important for early identification of complications. For the second resident, the NDCR indicated that a respiratory assessment was not completed before dialysis, and a pain assessment was not performed after dialysis. The registered nurse acknowledged that these assessments should have been conducted as part of the resident's care. Review of the facility's policy and procedure for dialysis care revealed that the facility is responsible for monitoring residents before and after each dialysis treatment and for maintaining all related documentation in the medical record. The Director of Nursing confirmed that the policy was not followed in these instances, resulting in incomplete assessments and documentation for both residents who required dialysis services.
Lack of Air Gap in Kitchen Food Preparation Sink
Penalty
Summary
The facility failed to ensure that the two compartment sink in the kitchen, which was used for washing produce and food for residents, was equipped with an air gap as required for backflow prevention. During multiple observations, it was noted that the sink lacked an air gap, and dietary staff were seen washing fresh strawberries in this sink. Both the Consultant Dietary Services Manager and the Director of Maintenance confirmed during interviews that the sink did not have an air gap, and the Director of Maintenance stated that it was not possible to create one in the current setup. Additionally, the facility did not have a policy or procedure addressing air gaps for sinks used in food preparation. A review of the FDA Food Code and the facility's own maintenance policy highlighted the requirement for backflow prevention devices such as air gaps to prevent contamination of the water supply. The absence of an air gap in the food preparation sink created a situation where contaminated water could potentially flow back into the clean water supply, posing a risk to food safety. The deficiency was identified through direct observation, staff interviews, and review of relevant policies and regulations.
Failure to Implement Fall Risk Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents who were at high risk for falls, leading to potential accidents and injuries. Resident 1's Fall Risk Assessment (FRA) dated 11/28/24 indicated a high fall risk score of 45, yet no fall risk care plan was noted in the clinical record. The Director of Nursing (DON) confirmed the absence of a fall risk care plan for Resident 1 during a review of the FRA. Resident 2's FRA dated 4/3/24 showed a high fall risk score of 60. Despite this, Resident 2 experienced two falls, on 6/21/24 and 7/12/24, resulting in injuries such as an abrasion on the mid-back, bruising to the left thumb, and a skin tear on the right lower arm. The DON confirmed that a fall risk care plan was only initiated on 7/15/24, after these incidents. The facility's policy requires the development of individualized care plans based on fall risk assessments, which was not adhered to in these cases.
Failure to Notify MDs and RP of Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program policy and procedure when it did not notify the medical doctors (MD) of two residents and the responsible party (RP) of one resident regarding allegations of abuse. Specifically, the Director of Nursing (DON) confirmed that there was no documentation indicating that the MDs of two residents and the RP of one resident were informed about the abuse allegations. This lack of documentation was acknowledged during a review of the residents' medical records and confirmed by the DON and the Administrator. The facility's policy, revised on January 31, 2020, mandates that the attending physician and responsible party, if applicable, be notified of any allegations and the outcome of the investigation. However, the facility did not adhere to this policy, as evidenced by the absence of documentation in the medical records of the involved residents. The Administrator confirmed that such notifications should be documented in a progress note, but this was not done, leading to a deficiency in the facility's abuse prevention and reporting procedures.
Inconsistent Implementation of Care Plans for Residents
Penalty
Summary
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. An interview with the Director of Nursing (DON) revealed that management received an email from a former employee alleging abuse against three residents. Registered Nurse (RN) 1 stated that for allegations of abuse, a care plan for delayed injury and psychosocial outcomes would be created and monitored for 72 hours. However, upon reviewing the care plans for two residents, it was found that the intervention to monitor psychosocial well-being for 72 hours was not consistently documented. The care plans for the residents were initiated following alleged incidents of physical abuse and neglect. Despite the facility's policy and procedure indicating that care plans should address medical, nursing, mental, and psychosocial needs, the documentation of psychosocial monitoring was inconsistent. The DON confirmed during a record review that the required monitoring was not documented consistently over the 72-hour period for the two residents involved.
Lack of Private Telephone Access for Residents
Penalty
Summary
The facility failed to provide reasonable access to a telephone that ensured privacy for three sampled residents. Interviews with staff and residents revealed that residents had to use the phone in the Administrator's office, the facility main office phone, or the nursing station, none of which provided privacy. The facility lacked portable phones, making it difficult for residents to have private conversations. This issue was confirmed by multiple staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, who acknowledged the lack of private phone access for residents. Resident 1, who was cognitively intact, expressed concerns about the inability to have private conversations. Resident 2, with moderate cognitive impairment, also confirmed the lack of privacy for phone calls. The Administrator in Training admitted that the facility had no portable phones since June 2023, and calls were either made at the nursing station or through staff members' cell phones. The facility's policy on telephone access, dated November 1, 2017, stated that residents should have access to private phone lines, but this was not being followed.
Failure to Implement Pressure Ulcer Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for a resident who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and reduced mobility. Upon admission, the resident was not assessed for the risk of developing pressure injuries as the Braden Scale for Predicting Pressure Sore Risk was left blank. This oversight was confirmed by the Director of Nursing (DON) during a record review. Additionally, the resident's left heel redness, noted one day after admission, was not reported to the physician, and no treatment was documented in the Treatment Administration Record (TAR). The DON confirmed that the physician was not notified to obtain treatment for the left heel redness. Furthermore, the facility did not develop a care plan to address the resident's left heel redness, as confirmed by the DON during a record review. The resident's condition worsened over time, with the left heel redness progressing to a suspected deep tissue injury (SDTI) and eventually to a Stage 3 pressure injury. The resident reported that the wound care provider had been treating the wound, which prevented the resident from being discharged. The Treatment Nurse (TN) stated that the facility's process for new admissions with wounds was not followed, as the necessary steps such as measuring the wounds, contacting the physician, developing a care plan, and performing weekly wound assessments were not completed. Additionally, the facility failed to conduct an interdisciplinary team (IDT) meeting to address the resident's left heel redness. The DON confirmed that no IDT meeting was held in March 2024 to discuss the resident's condition. The facility's policy and procedure for pressure ulcer prevention, which includes risk identification, assessment, care planning, and ongoing monitoring, were not adhered to, resulting in the resident developing a Stage 3 pressure injury to the left heel.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one of the three sampled residents. During an interview and record review, the Director of Nursing (DON) confirmed that the medical record for a resident contained inaccurate information. Specifically, the Wound Weekly Observation Tool (WWOT) dated 4/4/24 indicated that the resident had a suspected deep tissue injury (SDTI) to the left heel, while the care plan incorrectly documented it as a stage 3 pressure injury. The care plan was initiated on 4/4/24, but the interventions were noted to have started on 4/3/24, one day before the care plan initiation. The DON acknowledged that the documentation was not accurate. The facility's policy and procedure (P&P) on Completion & Correction, revised on 5/1/19, mandates that medical records should be completed and corrected in a standardized manner to ensure the highest quality and accuracy in documentation. The P&P specifies that entries should be recorded promptly, be complete, legible, descriptive, and accurate, and should follow a chronological sequence. The policy also states that events should never be documented before they occur. The failure to adhere to these guidelines resulted in the inaccurate documentation of the resident's medical condition.
Failure to Notify APS for Resident Leaving AMA
Penalty
Summary
The facility failed to follow their policy and procedure on contacting Adult Protective Services (APS) when a resident left the facility against medical advice (AMA). The resident, who had a diagnosis of metabolic encephalopathy, muscle weakness, alcohol abuse and withdrawal, hemiparesis/hemiplegia, noncompliance with medication, and end-stage renal disease, signed himself out of the facility. Despite the resident's moderate cognitive impairment and periods of confusion, as indicated by his Minimum Data Set (MDS) and History and Physical Examination (H&P), the facility did not notify APS as required by their policy. The resident was not his own responsible party, contrary to the administrator's initial statement, and arrangements for his continued dialysis were not made. The Social Services Director (SSD) confirmed that attempts to contact the resident's family member, who was listed as the responsible party and emergency contact, were unsuccessful. The SSD also confirmed that APS was not notified of the resident's AMA discharge, which was a violation of the facility's policy and procedure titled 'Discharge Against Medical Advice.'
Failure to Ensure Safe Air Mattress Settings
Penalty
Summary
The facility failed to ensure that air mattresses for three residents were in safe operating condition. During observations and interviews, it was found that the air mattress settings for Resident 1, Resident 2, and Resident 3 were incorrectly set at 290 lbs, 350 lbs, and 1000 lbs, respectively, despite their actual weights being 110 lbs, 158 lbs, and 448 lbs. Licensed Vocational Nurse (LVN) 1 and the Treatment Nurse (TN) were unaware of how to properly set up the air mattresses, and the Facility Maintenance Worker (FMW) believed that the nurses were responsible for setting the correct settings. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that no training had been provided to the nurses on how to set up the air mattresses according to resident weight. The lack of training and clear responsibility for setting up air mattresses led to improper settings that could potentially harm the residents. The facility's Licensed Nurse List indicated that none of the 28 nurses had received training on air mattress setup. Additionally, the facility did not have any policies or procedures in place for licensed nurse training and competencies related to air mattress settings. This deficiency in training and policy had the potential to impact the safety and well-being of the residents using air mattresses for pressure relief and wound prevention.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide oxygen per physician's orders for one of three sampled residents. During an observation and interview, a Licensed Vocational Nurse (LVN) noted that a resident was receiving oxygen at six liters per minute via nasal cannula, while the physician's order specified two liters per minute. The resident had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and respiratory failure. The facility's policy and procedure for oxygen administration required checking the physician's order and setting the oxygen at the prescribed rate, which was not followed in this instance.
Neglect of Foot Care for Two Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, resulting in pain, discomfort, and neglect. Licensed Vocational Nurses (LVNs) did not perform adequate skin assessments, develop care plans for foot conditions, or notify the attending physician about the residents' foot conditions. Certified Nursing Assistants (CNAs) also failed to report and document their observations of the residents' feet. The podiatrist did not provide appropriate medical foot care and treatment, as evidenced by the condition of the residents' feet during observations and interviews. Resident 15, an elderly male with multiple diagnoses including Type 2 Diabetes Mellitus with Polyneuropathy and Hemiplegia, had severely neglected feet. Observations revealed foot drop, wounds, redness, swelling, dry and scaly skin, and fungal infections. Despite these conditions, the resident's feet had not been properly cleaned or assessed for months. The podiatrist's last visit did not result in adequate treatment, and the resident's care plan did not address his foot issues. Weekly assessments by LVNs were found to be incomplete and often copied and pasted without proper evaluation. Resident 36 also suffered from neglected foot care. The resident had thickened, discolored toenails and dry, flaky skin, causing discomfort. Despite a physician's order for podiatry care, the resident had not received any treatment since the last documented visit several months prior. The facility's policies on grooming and showering were not followed, as changes in the residents' skin and nails were not reported to the attending physician or documented in their care plans.
Failure to Complete Activity Assessments
Penalty
Summary
The facility failed to ensure activity assessments were completed for 16 of 16 sampled residents. During interviews and record reviews, it was found that none of the residents had their activity assessments completed within the required seven days of admission. The Activity Director (AD) confirmed that the assessments were not done for residents admitted on various dates, ranging from February to March 2024. The AD acknowledged that the purpose of the activity assessment is to determine the best activities for each resident to improve their mental health, and this was not achieved due to the lack of timely assessments. The facility's policy and procedure, dated 2021, mandates that an activity assessment should be completed within seven days of a resident's admission to develop an individualized care plan. However, the review revealed that this policy was not followed for any of the sampled residents. The AD admitted that the assessments were not completed as required, which could potentially impact the residents' physical, mental, and psychosocial well-being. The failure to conduct these assessments as per the facility's policy was a significant oversight in the care provided to the residents.
Failure to Ensure Staff Competencies
Penalty
Summary
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. During interviews, it was revealed that a Certified Wound Nurse did not receive on-the-job training and had to figure out the computerized medical record system independently. The Director of Nursing admitted that while there used to be a competency checklist, it was currently unavailable as it was being updated, and no competency assessments were being conducted. The Director of Staff Development confirmed that there were no skills competency assessments documented for any of the licensed nurses. Additionally, the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff. A review of the facility's Policy and Procedure on On-the-Job Training indicated that training programs should be conducted to assist employees in performing their tasks, starting from the first day of employment and continuing until the department director is satisfied with the employee's performance. However, the lack of documented competency assessments and performance evaluations for the nursing staff indicates a failure to adhere to this policy, potentially resulting in harm to residents.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, properly store and label food, ensure employees followed the dress code policy, and serve food in a sanitary manner. During an observation, a dirty ladder and scaffolding with paint supplies were found in the kitchen, and the Maintenance Supervisor admitted to not removing them after completing ceiling repairs. Additionally, food items in the freezers and dry storage were found unsealed and without proper labeling, which was confirmed by the Certified Dietary Manager. The facility's policy required all food items to be labeled and dated, but this was not followed. Two staff members, including the Dietary Supervisor and a cook, were observed with uncovered facial hair, contrary to the facility's dress code policy. Furthermore, the Dietary Supervisor was seen returning a plated portion of turkey breast to the tray serving line, which was acknowledged as inappropriate by both the supervisor and the Registered Dietitian. These actions and inactions had the potential to spread foodborne illnesses throughout the facility, affecting all 71 sampled residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices for four sampled residents, leading to potential transmission of infectious diseases. For instance, a treatment nurse did not wear a gown while attending to a resident with MRSA, and another nurse did not perform hand hygiene before applying a clean dressing to a resident with bowel movement smears. Additionally, a resident with an ostomy had bowel movement leakage while eating, which was not addressed promptly, violating the facility's hygiene policy. Staff also failed to implement proper infection control practices for handling trash, transmission-based precautions, and laundry services. A CNA and a housekeeper were observed not performing hand hygiene after disposing of trash, and a laundry aide did not perform hand hygiene after sorting soiled linens. The infection preventionist admitted that the isolation cart was not fully stocked with necessary PPE, and there was no hand sanitizer available outside a resident's room. The facility did not conduct effective infection prevention surveillance activities. The infection preventionist admitted to not having records of hand hygiene monitoring and relied solely on visual observation. There were no indicators for surveillance, no data collection, and no analysis of surveillance activities. Additionally, the infection control committee meetings were conducted casually without proper documentation, and the infection preventionist could not provide meeting minutes.
Failure to Maintain Accurate Vaccination Records
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist (IP) maintained accurate records of Influenza and Pneumonia vaccinations for all current residents. During an interview and record review, it was found that 11 out of 71 current residents were not included in the immunization report, and the IP could not provide influenza vaccination records for these residents. Additionally, the IP was unable to verify the receipt or refusal of pneumonia vaccinations for 40 out of 71 residents. The IP confirmed that the facility census was 71, but only 60 residents were listed on the Immunization Report. Furthermore, only seven residents had signed declination statements for either the influenza or pneumonia vaccine, leaving a significant number of residents without documented consent or refusal for these vaccinations. The facility was unable to provide a policy and procedure related to influenza and pneumonia vaccinations when requested. According to the Centers for Disease Control (CDC) Guidelines, healthcare providers should incorporate immunization needs assessments into every clinical encounter, recommend needed vaccines, and maintain up-to-date records. The facility's failure to adhere to these guidelines and maintain proper vaccination records had the potential to compromise the health and well-being of the residents by not ensuring their immunity against certain infectious diseases.
Failure to Maintain Accurate Employee COVID-19 Vaccination Records
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) maintained an accurate record of employee COVID-19 vaccinations for 110 of 159 employees. During an interview and record review, it was revealed that the IP did not have a log of the employee COVID-19 vaccinations, either manually or electronically. The IP kept a binder with some employee vaccination cards but acknowledged that not all employees had provided proof of vaccination. The IP admitted to requesting the vaccination cards verbally but did not follow up to ensure compliance. At the time of the review, only 49 employee vaccination cards were on file out of 159 active employees. The facility's policy and procedure titled 'Infection Prevention and Control Program' indicated that the IP was responsible for monitoring the health status of all employees and ensuring they received necessary health screenings and vaccinations. However, the IP's failure to maintain accurate records and follow up on missing vaccination cards resulted in an incomplete employee COVID-19 vaccination record. This deficiency was identified during a concurrent interview and record review with the IP, highlighting a significant gap in the facility's infection prevention and control measures.
Failure to Train Staff on Behavioral Health Requirements
Penalty
Summary
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 sampled residents. During interviews and record reviews, it was revealed that no competency assessments were being conducted for any staff, and there was no documentation of training specific to psychological or mental disorders. The Director of Nursing confirmed the lack of competency assessments, and the Director of Staff Development confirmed the absence of behavioral health training for the nursing staff. The Administrator provided a Diagnosis Report indicating that the facility had residents with various psychiatric diagnoses, including anxiety disorder, major depressive disorder, schizophrenia, and psychosis. The Facility Assessment Tool indicated that the facility was equipped to manage psychiatric and mood disorders, but it also highlighted the necessity for staff training and competencies in caring for residents with mental and psychosocial disorders. Despite this, the facility had not provided the required training, leaving the staff unprepared to address the behavioral health needs of the residents. This deficiency had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that three of five sampled residents had their Minimum Data Set (MDS) assessments completed in a timely manner. Resident 43's Quarterly MDS assessment, dated 12/31/23, was completed on 3/20/24 but had not been transmitted. Resident 52's Quarterly MDS assessment, dated 12/29/23, was also not sent and was late. Resident 3's Annual MDS assessment, dated 1/24/24, was still in progress and had not been submitted. These delays were confirmed during interviews and record reviews with the MDS Coordinator. The facility's policy and procedures, dated 11/19, require comprehensive assessments of residents' needs to be conducted at intervals designated by OBRA and PPS requirements. Specifically, quarterly assessments must be conducted not less frequently than three months following the most recent OBRA assessment, and annual assessments must be conducted not less than once every twelve months. The failure to adhere to these timelines had the potential to result in unidentified health problems for the residents involved.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents in the facility. For Resident 15, the Medication Administration Record (MAR) indicated the use of Abilify, Oxcarbazepine, and Depakote for bipolar disorder and Seasonal Anxiety Disorder, but there was no record of MRR conducted for the last three months. Similarly, for Resident 55, the MAR indicated the use of Quetiapine Fumarate, Donazepil, Memantine, and Lorazepam for psychosis and unspecified dementia, but there was no record of MRR for the last three months. The Minimum Data Set Coordinator (MDSC) confirmed the absence of these reviews during interviews and record reviews. Additionally, the Director of Nursing (DON) confirmed that the Pharmacy Consultant had not reviewed the medication regimens for a significant number of residents over several months. The facility's Census Report and Medication Regimen Review Report indicated that a large number of residents' medication regimens were not reviewed by the pharmacist on multiple dates. The facility's policy and procedure stated that the consultant pharmacist should review each resident's medication regimen at least monthly, but this was not adhered to, as confirmed by the DON and the facility's records.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 215 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
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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) |
|---|---|---|---|---|
| The Orchards Post-acute | 1.5 mi | ★★★★★ | 2 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 2 mi | ★★★★★ | 18 | 0 |
| Rosewood Health Facility | 2.7 mi | ★★★★★ | 16 | 0 |
| Parkview Julian Healthcare Center | 2.8 mi | ★★★★★ | 24 | 0 |
| The Rehabilitation Center Of Bakersfield | 3.2 mi | ★★★★★ | 23 | 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.