Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and a history of behavioral issues twice became physically and verbally aggressive toward roommates and others, including grabbing another resident by the ankles, spitting, and throwing objects. After the first episode, staff did not update the aggressor’s care plan or document any IDT review, despite facility policies requiring reassessment and care plan revision after significant behavioral changes. For the resident who was assaulted and another roommate who witnessed the event and expressed safety concerns, there were no IDT notes or care plan revisions documented, even though social services recorded their fears and the use of a wheelchair to block a shared bathroom door. A fourth resident, who was the aggressor’s roommate during the second incident and whose daughter intervened to protect him, also had no care plan updates documented related to the event, indicating a broader failure to document IDT evaluation and revise care plans after serious resident-to-resident aggression.
A resident with multiple comorbidities and a recent subdural hematoma had two active PRN lorazepam orders with different dosages but identical indications for anxiety with aggressive behavior. The DON, DMR, and nursing staff confirmed that both orders were active and lacked distinct parameters, resulting in LPNs using their own judgment to choose between 0.5 mg every 12 hours or 1 mg every 24 hours based on perceived agitation and comfort level, rather than clear MD-directed criteria. The consultant pharmacist later identified that the second, higher-dose order had been added after the monthly review and stated that the combined orders could allow up to 2 mg in 24 hours and should have been clarified or consolidated, contrary to facility policies requiring clear indications, appropriate dosing, and defined administration instructions for PRN psychotropic medications.
Three residents experienced unwitnessed falls, and the facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes. One resident returned from hip surgery after a fall with no new care plan addressing post-operative needs. A second resident, identified as high fall risk, had a care plan requiring 72-hour neuro checks after an unwitnessed fall, but only the initial check was documented and no IDT note was entered despite the team meeting. A third resident, also high fall risk, had a care plan requiring q2h rounding for pain, positioning, and toileting after a fall, yet no documentation of these checks could be found in the EMR. These failures occurred despite facility policies requiring IDT-based care planning, fall risk assessment, and complete, accurate documentation of care and changes in condition.
A resident with multiple medical conditions and no cognitive impairment reported missing a pair of shoes and a hinged knee brace at discharge. Staff did not follow facility policy to investigate, document, or offer replacement or reimbursement for the lost items, resulting in the resident's belongings not being recovered or compensated.
Two storage sheds containing filing cabinets with resident PHI and staff private information were broken into and left unsecured for several days. Facility staff, including the ESD, MRD, ADON, DON, and ADM, were unaware of the contents and did not secure the information, despite facility policy and HIPAA requirements for confidentiality and protection of sensitive data.
A resident with multiple diagnoses, including dementia and anxiety, was given lorazepam earlier than the physician's order specified due to a nurse not verifying the timing of the previous dose and being distracted during medication administration. The nurse also failed to document the administration on the MAR as required, although it was recorded on the controlled substance sheet. Facility policy mandates adherence to the five rights of medication administration and timely documentation, which were not followed in this instance.
A resident with multiple medical conditions was given lorazepam earlier than prescribed, and the RN did not verify the timing of the last dose before administration. The medication administration was not documented on the MAR as required, and the incident was not fully recorded in the clinical record or through an incident report, resulting in incomplete and inaccurate documentation.
A resident with multiple medical conditions developed a lump and extensive bruising of unknown origin on the right shoulder and chest. Although the injury was assessed and medical interventions were initiated, staff did not report the incident to CDPH and the ombudsman within the required two-hour timeframe, as mandated by facility policy and state regulations. This failure delayed investigation and placed the resident at risk for harm.
A resident with a history of TIA, hypertension, and muscle weakness developed a new lump and bruising on the right shoulder and chest. Although the change in condition was assessed and reported, the care plan remained generic and lacked individualized, measurable goals and interventions specific to the new symptoms, contrary to facility policy.
Surveyors found that staff failed to follow physician orders for oxygen therapy for three residents with respiratory conditions. In each case, staff administered oxygen at higher flow rates or more frequently than ordered, did not document clinical justification or notify the physician, and did not clarify conflicting or incomplete orders. Nursing and administrative staff confirmed that the orders were not followed as required.
Staff failed to consistently use enhanced barrier precautions and follow infection control protocols for two residents with wounds and indwelling devices, including not wearing gowns and gloves during high-contact care and not performing proper hand hygiene. Additionally, a nurse was observed handling oral medications with bare hands, contrary to policy. Staff interviews revealed a lack of training and awareness regarding these requirements.
A resident with intact cognition and significant visual impairment was physically abused by a roommate with moderate cognitive impairment and psychiatric diagnoses. The incident, witnessed by a CNA, involved the roommate slapping the resident on the face in their shared room. Facility records indicated no prior aggression between the two residents, and the event was documented as isolated.
A resident with a documented diagnosis of depression was admitted, but the Level I PASARR screening incorrectly indicated no serious mental disorder, resulting in the absence of a required Level II evaluation. The MDS Coordinator acknowledged the inaccuracy, and the facility's policy for accurate PASARR completion was not followed.
A resident with severe physical and cognitive impairments, including quadriplegia and hand contractures, was observed to have excessively long fingernails over several days. Staff interviews confirmed that CNAs were responsible for nail care for non-diabetic residents and acknowledged the resident's nails should have been trimmed according to facility policy, but this was not done.
A resident with an indwelling urinary catheter did not receive care in accordance with facility policy and infection control standards. Staff failed to keep the catheter drainage bag below bladder level and did not use proper technique during catheter care, including not using a clean part of the cloth for each stroke and cleaning in the wrong direction. The resident was fully dependent on staff for care due to significant medical conditions.
Two residents with documented food allergies and dietary preferences were served meals that did not accommodate their needs, despite facility policies requiring identification and communication of such restrictions. In both cases, staff failed to provide appropriate substitutions or prevent the delivery of allergen-containing or unwanted food items, and the established double-check procedures were not consistently followed.
A resident was inappropriately prescribed and administered Divalproex sodium for seizure prevention without a seizure disorder diagnosis, contrary to facility policies. The resident had severe cognitive impairment and a history of vascular dementia, anxiety disorder, and other conditions, but no history of seizures. The medication was discontinued after the resident's responsible party intervened.
Two residents experienced significant changes in their health conditions, but the LTC facility failed to complete required Change of Condition (COC) assessments. One resident had an unwitnessed fall resulting in a fracture, and another showed changes in urine patterns and blood in urine. The facility's policy mandates documentation of such changes, but this was not followed, leading to incomplete records and potential risks.
A resident with a fracture of the left arm did not have a comprehensive care plan developed as required by facility policy. Despite being cognitively intact and having a history of syncope and falls, the facility failed to create a care plan following an unwitnessed fall that resulted in the fracture. Interviews with the RN and DON confirmed the absence of a care plan, which was necessary to monitor potential complications.
Failure to Revise Care Plans and Document IDT Actions After Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to timely review and revise comprehensive, person-centered care plans and to document IDT involvement after significant resident-to-resident aggression incidents. The facility’s own policy required ongoing assessment and care plan revision when residents’ conditions or behaviors changed, and when there was a significant change in status. Despite this, after an initial incident in which one male resident with dementia and a history of depression and recurrent subdural hematoma entered another male resident’s room via a shared bathroom, threw items, and grabbed the resident by the ankles, there was no documented update to the aggressor’s care plan. The DON acknowledged that the first incident on 2/20/26 was not reflected in the care plan or IDT notes, even though interventions were reportedly discussed verbally. The second incident occurred the following day, when the same aggressive resident became verbally and physically aggressive toward his new roommate, the roommate’s visiting daughter, and staff, including spitting and throwing objects in the hallway and at others. Nursing notes documented the behaviors and notifications to the MD, responsible party, and law enforcement. The DON confirmed that only the second incident was discussed in IDT notes and that the care plan was reviewed and updated after this second event, not after the first. The facility’s Behavioral Assessment, Intervention and Monitoring policy required that new onset or changes in behavior be documented and that the IDT thoroughly evaluate new or changing behavioral symptoms to identify causes and develop a plan of care, but the first incident was not addressed in this manner. The facility also failed to document IDT review and care plan revisions for the residents who were victims or witnesses to the aggression. For the resident who was grabbed by the ankles, nursing notes documented the event and notifications, and social services later documented that the resident described the assault, expressed feeling safe only if the aggressive resident stayed out of his room, and reported using a wheelchair to block the shared bathroom door. The social services note stated that the IDT was to discuss room changes or other safety measures, but the DON and DMR were unable to find any IDT documentation or follow-up on these recommendations. Another roommate, who witnessed the incident and reported concerns for his roommate’s safety and for other residents, had no nursing assessments, IDT notes, or care plan updates documented related to the event, despite social services noting his concerns. A fourth resident, who was the aggressor’s roommate during the second incident and whose daughter intervened to protect him from the aggressive behavior, also had no documented care plan updates related to the incident, even though he was moved to a different room afterward. These omissions occurred despite facility policies requiring ongoing assessment and care plan revision when residents’ conditions or circumstances changed.
Unclear PRN Lorazepam Orders Lead to Nurse-Selected Dosing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs by maintaining clear, physician-directed parameters for PRN psychotropic medication. A male resident with a history of hypertension, hyperlipemia, prostate cancer, depression, dementia, and obstructive sleep apnea had been admitted after hospitalization for altered mental status and a recurrent right subdural hematoma. Review of his electronic medical record showed that, as of a specific date, he had two active PRN orders for lorazepam, both written for anxiety manifested by aggressive behavior, but with different dosages and frequencies: 0.5 mg every 12 hours PRN and 1 mg every 24 hours PRN. Both orders carried the same indication and lacked distinct administration criteria to differentiate when each dose should be used. During interviews and record reviews with the DON, Medical Records Director, and nursing staff, it was confirmed that both lorazepam orders were active simultaneously and that the orders did not specify clear parameters for choosing between the 0.5 mg and 1 mg doses. The DON acknowledged that the orders were confusing and that the administration instructions did not differentiate the two doses. LVN 1 and LVN 2 both stated that nurses were using their own nursing judgment to decide whether to administer 0.5 mg every 12 hours or 1 mg every 24 hours for aggressive behavior, based on their experience, comfort level with the resident, and assessment of the resident’s agitation. LVN 2 confirmed that she had administered the 1 mg dose twice and that her rationale for choosing the higher dose was her judgment that the resident was very agitated and yelling in the hallway, and that the family wanted the resident comfortable. The consultant pharmacist, upon review of the medication orders and MAR, stated that at the time of the monthly review the resident had only one lorazepam order and that the 1 mg order was added later. The pharmacist noted that, with both orders active, the resident could potentially receive a total of 2 mg of lorazepam in 24 hours if both orders were carried out, and that the physician should have discontinued one order or clarified the administration instructions. The pharmacist and DON both indicated that medication orders should not rely on nurses’ judgment alone to determine dose selection and that PRN orders should have clear, defined parameters, including the expectation to use the lowest safe dosage for psychotropic medications. Facility policies on Medication Therapy and Administering Medications required that each resident’s medication regimen include only necessary medications, that orders be supported by appropriate care processes, and that there be a clear indication, appropriate dosage, and appropriate frequency and duration, which were not met in this case due to the duplicative and non-specific PRN lorazepam orders.
Failure to Implement and Document Post-Fall, Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three residents following unwitnessed falls and changes in condition. For one resident with COPD, peripheral vascular disease, anal canal cancer with colostomy, and dementia, the resident experienced an unwitnessed fall after slipping on spilled water in her room, resulting in a left hip fracture and subsequent hip hemiarthroplasty. Although the resident returned from the hospital with a new post-operative condition and reported ongoing hip pain, there was no care plan developed or implemented to address her post-surgical needs. The Director of Nursing and the admitting RN both stated that a care plan should have been implemented upon readmission and after the change in condition, but it was not. For a second resident with COPD, schizophrenia, orthostatic hypotension, and unsteadiness on feet, the facility failed to follow the existing care plan interventions after an unwitnessed fall. The resident’s post-fall evaluation documented a high fall risk, and the care plan called for neuro checks for 72 hours after the fall. However, only the initial neuro check entry was found in the electronic medical record, and the remaining neuro checks from subsequent days could not be located in either paper or electronic form. The DON confirmed that if the documentation could not be located, the neuro checks were not completed. Additionally, although the IDT met to discuss the fall, there was no IDT note documented in the record to show that the team had met and addressed the incident. For a third resident with COPD, schizophrenia, muscle weakness, lung cancer, cervical disc disorder with radiculopathy, and unsteadiness on feet, the facility did not document implementation of care plan interventions following an unwitnessed fall. The resident’s post-fall evaluation showed a high fall risk, and the IDT note described an unwitnessed fall where the resident was found sitting on the floor by the bed with no observed skin injuries and decreased urine output, leading to further assessment and transfer to the ER. The care plan specified frequent rounding every two hours to check for pain, placement, position, and toileting needs. However, the facility could not produce documentation that staff checked on the resident every two hours as required. The DON, CNAs, and Medical Records Director all acknowledged that such checks should be documented in the EMR, but they were unable to locate any record of when the resident was last checked, indicating that the care plan interventions were not documented as carried out. The facility’s own policies on fall risk assessment, care plan goals and objectives, interdisciplinary care planning, and charting and documentation require resident-centered fall prevention plans, measurable care plan goals with timetables, IDT-developed comprehensive care plans, and complete and accurate documentation of services and changes in condition. Despite these policies, the facility did not complete required fall risk scoring for one resident’s post-fall evaluation, did not implement a new care plan after a significant surgical event, did not complete or retain required neuro check documentation for another resident after an unwitnessed fall, and did not document two-hourly monitoring for a third resident as specified in the care plan. These actions and omissions led to the cited deficiency for failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for the affected residents.
Failure to Investigate and Replace Missing Resident Belongings
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a resident reported a missing pair of shoes and a hinged knee brace. The resident, who had diagnoses including type 2 diabetes mellitus, unsteadiness on feet, hypertension, and difficulty walking, was cognitively intact as indicated by a BIMS score of 15. Upon discharge, the resident reported the missing items to the Social Services Director (SSD), but staff did not follow the facility's policy to investigate, document, or offer replacement or reimbursement for the lost belongings. Interviews with facility staff revealed that the standard procedure for missing items included searching for the item, checking the resident's Inventory of Personal Effects (IPE), and completing a Theft and Loss Monitoring (TLM) form. In this case, the SSD acknowledged that no TLM form was completed at the time the items were reported missing, and the process for resolving the missing belongings was not initiated within the required timeframe. The IPE did note the missing items, but there was no evidence of a timely investigation or follow-up as required by facility policy. Further review of facility policy confirmed that all reported losses, especially those valued at $25 or more, must be documented and reported, with a written inventory established upon admission. Despite these requirements, the missing items were not properly investigated or replaced, and the resident was not reimbursed for the value of the lost possessions. This resulted in the resident losing personal items without appropriate action from the facility.
Failure to Secure Resident and Staff Protected Information After Shed Break-In
Penalty
Summary
The facility failed to protect and secure protected health information (PHI) for residents and private information for staff when two of seven storage sheds were broken into and remained unsecured for several days. During an observation, it was found that one shed was missing a door and was covered only by a wooden board, while the other had a door but no lock. Inside the first shed, there were filing cabinets containing over 200 files with resident medical records, including names, dates of birth, social security numbers, and medical diagnoses, as well as employee files with personal and employment information. The filing cabinets themselves were also not locked. Interviews with facility staff, including the Environmental Service Director (ESD), Medical Records Director (MRD), Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), revealed that several were unaware that the sheds contained PHI and staff private information. The ESD stated he did not know the contents of the sheds and that the sheds had remained unlocked since the break-in. The MRD, ADON, and DON all acknowledged that PHI and private information should be kept confidential and secure, and that it was unacceptable to store such information in an unsecured location. The ADM stated he had been informed by a previous Human Resources Manager that the sheds did not contain PHI or private information, and that staff should have inspected the filing cabinets to ensure the information was protected. A review of the facility's policy and procedure confirmed that all personnel are responsible for managing and protecting resident and facility information to prevent unauthorized release or disclosure. The HIPAA Privacy Rule was also referenced, which requires appropriate safeguards to protect the privacy of PHI. The failure to secure the sheds and filing cabinets containing sensitive information was directly observed and confirmed by multiple staff members.
Failure to Administer PRN Medication at Prescribed Time and Incomplete Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to administer lorazepam to a resident according to the physician's prescribed time frame. The resident, who had diagnoses including type 2 diabetes mellitus, unspecified dementia with anxiety, depression, and post-traumatic stress disorder, was admitted for respite care. The medication order specified lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety. However, the medication was administered earlier than ordered, as the nurse did not verify the timing of the previous dose. The error was identified when the nurse, after administering the medication, realized during documentation that the dose had been given too soon. The nurse acknowledged not checking the five rights of medication administration, specifically the right time, due to being distracted by other duties, such as redirecting the resident's behavior. The nurse also failed to document the administration on the Medication Administration Record (MAR) as required by facility policy, although it was recorded on the Controlled Substance Accountability Sheet. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the medication was given too early and that proper procedures, including checking the last administration time and documenting on the MAR, were not followed. Facility policy requires medications to be administered within 60 minutes of the scheduled time and for all administrations to be recorded on the MAR immediately after administration. The failure to follow these procedures resulted in the resident receiving lorazepam earlier than prescribed.
Failure to Accurately Document Medication Administration and Error
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia with anxiety, depression, and PTSD, was administered lorazepam 0.5 mg earlier than prescribed. The registered nurse (RN) responsible for the medication pass did not verify the timing of the last dose before administering the medication, as required by the physician's orders. The RN realized the error after administration and notified the physician, who instructed monitoring for any reactions. However, the RN failed to document the call to the physician and did not complete an incident report regarding the medication error. Further review revealed that the administration of lorazepam was not documented on the resident's Medication Administration Record (MAR) as required by facility policy, although it was recorded on the Controlled Substance Accountability Sheet (CSAS). The facility's policies and procedures specify that all medications administered must be documented immediately on the MAR, including the date, time, dosage, and the nurse's signature or initials. The lack of documentation on the MAR meant that the medication administration was not accurately reflected in the resident's clinical record. Additionally, the incident was not fully documented in the resident's progress notes or clinical record. The progress note only briefly mentioned the medication error and ongoing monitoring, without providing a complete account of the error, notifications made, or subsequent physician orders. The facility's policy requires that medication errors be documented in both an incident report and the resident's clinical record, including all relevant details and notifications. The failure to follow these documentation standards resulted in incomplete and inaccurate medical records for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident in accordance with both its own policy and state regulations. The resident, who had a history of transient cerebral ischemia attack, hypertension, muscle weakness, and required assistance with personal care, reported pain in the right shoulder. Upon assessment by an LVN, a lump was found on the right shoulder, and further examination revealed a lump and deep purple bruising on the right side of the chest, with the bruising spreading to the right breast, chest, left breast, and upper abdomen. The resident and staff were unable to explain the cause of the injury, and the incident met the facility's definition of an injury of unknown origin. Despite the facility's policy and state law requiring immediate reporting—no later than two hours after identification—to the California Department of Public Health (CDPH) and the ombudsman, this injury was not reported within the required timeframe. Interviews with the LVN, Director of Staff Development, and Director of Nursing confirmed that staff were aware of the reporting requirements and the seriousness of such incidents. Documentation showed that the injury was assessed, and medical interventions were initiated, including imaging and specialist consultation, but the mandated external reporting was not completed as required. The facility's own abuse reporting policy clearly outlines the definition of injuries of unknown origin and the necessity for prompt reporting to regulatory authorities. In this case, the failure to report the injury in a timely manner resulted in a delayed investigation and placed the resident at risk for physical harm and delayed care, as directly stated in the report.
Failure to Develop Comprehensive Care Plan for New Lump and Bruising
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who developed a new lump on the right shoulder and a lump with bruising on the right side of the chest. The care plan that was in place was generic and did not include individualized objectives, measurable goals, specific timeframes, or detailed interventions tailored to the resident's new condition. Interviews with facility staff, including the ADON, LVN, and DON, confirmed that while the change in condition was documented and communicated to the physician, the care plan was not updated to reflect the resident's specific needs related to the new symptoms. The resident had a medical history including transient cerebral ischemia attack, hypertension, muscle weakness, and required assistance with personal care. The resident was cognitively intact, as indicated by a BIMS score of 15. Upon reporting right shoulder pain, the resident was assessed by an LVN, who identified a lump and notified the nurse practitioner. Orders were received for pain medication, x-rays, and an ultrasound, and the change in condition was documented. However, the care plan only included general interventions such as encouraging nutrition and hydration and identifying potential causative factors, without addressing the specific needs arising from the new lumps and bruising. Further review of progress notes and provider documentation showed ongoing monitoring of the resident's condition, with worsening bruising and additional medical interventions ordered, including a sling and holding blood thinners. Despite these developments, the care plan was not revised to include detailed, resident-specific interventions or goals related to the new findings. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timeframes, which was not followed in this case.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Surveyors identified that the facility failed to administer oxygen therapy according to physician orders for three residents requiring respiratory care. For one resident with a history of stroke, heart failure, and morbid obesity, staff administered supplemental oxygen at higher flow rates (2.5 to 3.5 L/min) than the physician-ordered maximum of 2 L/min, without documentation of a clinical need or physician notification. Staff did not consistently check or follow the physician's orders, and the resident's medical record did not reflect the increased oxygen administration. Interviews with nursing staff and the DON confirmed that the orders were not followed and that clarification of conflicting orders was not sought. Another resident with acute respiratory failure, sleep apnea, and oxygen dependence received supplemental oxygen at 8-9 L/min via face mask and nasal cannula, despite physician orders specifying 5 L/min. Nursing staff increased the oxygen flow without a physician's order, citing the resident's condition after dialysis, but did not notify the physician or document a change in condition. The resident's oxygen saturation remained within normal limits, and both the DON and the attending physician confirmed that staff should have followed the prescribed orders and obtained physician approval before making changes. A third resident with polymyositis, chronic respiratory failure, and other pulmonary conditions received supplemental oxygen via nasal cannula at 2 L/min continuously, even though the physician's order specified oxygen only if saturation dropped below 92%. Observations and interviews revealed that staff routinely provided oxygen regardless of the resident's oxygen saturation, and the order did not specify the amount to be administered. Staff and the DON acknowledged that orders were not followed as written, and that clarification should have been obtained when orders were incomplete.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
Facility staff failed to implement and follow enhanced barrier precautions (EBPs) and infection control practices as required by facility policy. For two residents with indwelling medical devices and wounds, staff did not consistently use gowns and gloves during high-contact care activities such as medication administration via gastrostomy tube, wound care, transferring, and linen changes. Observations revealed that staff, including a nurse and certified nursing assistants, either were unaware of EBP requirements or did not adhere to them, despite the presence of EBP signage in some cases. Staff interviews confirmed a lack of training and understanding regarding when and how to use EBPs, and the Infection Preventionist acknowledged that staff had not received education on the topic. In addition to failures with EBPs, staff did not consistently follow hand hygiene protocols during resident care. During wound care and personal hygiene activities, staff were observed not changing gloves between clean and dirty tasks, not using hand sanitizer or washing hands after glove removal, and handling clean items after contact with contaminated areas. These lapses occurred even though facility policy required hand hygiene before and after glove use, and after contact with potentially contaminated surfaces or body fluids. Staff interviews indicated that some lapses were due to nervousness or lack of awareness, and the Director of Nursing confirmed that best practices were not followed in these instances. Further, a nurse was observed preparing and administering oral medications by handling tablets with bare hands, contrary to facility infection control policy. The nurse stated he had not received education indicating that medications should not be touched with bare hands, but acknowledged he tried to avoid doing so. The Director of Nursing confirmed that staff were not expected to touch medications with bare hands due to contamination risks. These findings collectively demonstrate a failure to ensure staff were trained and compliant with infection prevention and control practices as outlined in facility policies.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
A deficiency occurred when a resident with a history of depression, major depressive disorder with severe psychotic symptoms, and legal blindness was physically abused by their roommate, who had diagnoses including anoxic brain damage, schizophrenia, depression, and anxiety disorder. The incident took place in the residents' shared room, where the roommate approached and suddenly slapped the resident on the right side of the face while the resident was seated in a wheelchair. This event was directly witnessed by a CNA, who reported the incident to the nursing station. Facility documentation and staff interviews confirmed that neither resident had prior reports of aggression or similar incidents. The facility's investigation concluded that this was an isolated occurrence, and the facility's policy affirms residents' rights to be free from abuse, neglect, and exploitation. The incident was documented in progress notes and supported by a written statement from the CNA who witnessed the event.
Failure to Accurately Complete PASARR for Resident with Depression
Penalty
Summary
The facility failed to ensure that the Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed serious mental illness for one resident. Upon admission, the resident had a documented diagnosis of depression, as indicated in the admission record and confirmed by the Minimum Data Set (MDS) assessment, which also showed moderate cognitive impairment. However, the Level I PASARR completed at admission incorrectly indicated that the resident did not have a serious diagnosed mental disorder, resulting in a negative PASARR outcome and no Level II evaluation being required. Interviews with facility staff revealed that the MDS Coordinator was responsible for ensuring the accuracy of PASARR documentation and acknowledged that the PASARR for this resident was inaccurate. The facility's policy required accurate identification of mental illness or intellectual disabilities to ensure appropriate care and services, but this process was not followed in this instance, as confirmed by the Administrator.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene. The resident, who had a history of quadriplegia, hemiplegia, and hemiparesis following a stroke, was non-verbal, unable to ambulate, and had severe cognitive impairment. Observations over several days revealed that the resident's fingernails were long and close to touching the inner palm of both hands, despite the resident having bilateral hand contractures and being fully dependent on staff for care. Multiple staff interviews confirmed that CNAs were responsible for trimming fingernails for non-diabetic residents and that nail care should be performed regularly, including during scheduled showers or baths and daily checks. Staff acknowledged that the resident's fingernails were too long and should have been trimmed, and the facility's policy required staff to provide grooming and personal hygiene services for residents unable to perform these tasks independently. The deficiency was identified through direct observation, staff interviews, and review of facility policy and resident records.
Failure to Provide Proper Catheter Care and Maintain Drainage Bag Position
Penalty
Summary
The facility failed to provide proper indwelling urinary catheter care according to its own policy and accepted infection control standards for one resident with a catheter. The policy required that the catheter drainage bag be kept below the level of the bladder at all times to prevent backflow of urine, and that catheter care be performed using a clean washcloth for each stroke, cleaning from the insertion site outward. However, during observation, the resident's catheter drainage bag was found hanging on the footboard of the bed above the level of the bladder. The assigned CNA admitted to placing the bag there during room cleaning and forgetting to move it back, and was aware the bag should be below the bladder but did not know the reason. The LVN and DON both confirmed that improper positioning could lead to harm or infection. Further observations of catheter care revealed that the CNA did not follow proper technique as outlined in the facility's policy. The CNA used the same part of a disposable cloth for multiple cleansing strokes and washed back and forth across the catheter entry site, rather than using a clean part of the cloth for each stroke and cleaning from the insertion site outward. Additionally, the CNA cleaned the catheter tubing from the distal end toward the entry site, contrary to policy instructions. The CNA stated he was unaware of the correct direction for cleaning. The resident involved had a history of hemiplegia and hemiparesis following a stroke, generalized muscle weakness, and colon cancer, and was dependent on staff for all activities of daily living, including toileting and hygiene. The care plan and physician orders specified the need for proper catheter care and positioning of the drainage bag, but these were not followed during the survey observations.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies and preferences of two residents, as required by their own policies and procedures. For one resident with documented allergies to bell pepper, broccoli, cauliflower, and eggs, the facility served a lunch meal that included broccoli salad. The resident identified the error and requested the item be removed, which staff did, but no alternative food was offered. The resident reported that staff did not provide substitutes when mistakes occurred with their meals. Staff interviews confirmed that allergies and preferences were listed on tray cards and kitchen lists, and that staff were expected to double-check these before serving meals. However, the process failed to prevent the delivery of an allergen-containing item to the resident. Another resident, with allergies to mushrooms and eggs and a stated preference to avoid all vegetables, was served a meal that included stir fry vegetables. The resident did not eat the vegetables and confirmed that their preferences and allergies had been communicated to the facility. The tray card for this resident clearly indicated 'no vegetables,' yet the meal was not adjusted accordingly. Staff interviews revealed that dietary aides and CNAs were aware of the need to check tray cards and kitchen lists for allergies and dislikes, but the system did not prevent the error in this case. Facility policies required that food allergies and preferences be identified, documented, and communicated to dietary staff, with appropriate substitutions provided as needed. Despite these policies, both residents received meals that did not accommodate their documented allergies or preferences, and in one case, no substitute was offered when the error was identified. Staff interviews indicated an expectation to double-check tray cards and provide alternatives, but these procedures were not consistently followed, resulting in the deficiencies observed.
Inappropriate Administration of Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the safe and appropriate prescribing and administering of psychotropic medication for a resident. Divalproex sodium was prescribed and administered to the resident without determining the appropriate indication for its use. This medication was given for seizure prevention, despite the resident not having a diagnosis of a seizure disorder. The administration of this medication without a valid reason increased the resident's risk of experiencing serious side effects. The resident had a medical history that included vascular dementia, anxiety disorder, cerebral infarction, aphasia, and a history of transient ischemic attack. The resident's Minimum Data Set indicated severe cognitive impairment. Despite these conditions, there was no documented history of seizures, which was the stated reason for prescribing Divalproex sodium. The medication was administered multiple times before being discontinued at the request of the resident's responsible party. Interviews with nursing staff revealed that the medication orders were followed based on the Inter-Facility Transfer Report provided by the hospital. However, the Director of Nursing acknowledged the importance of having the correct indication for medication use to avoid unnecessary administration. The facility's policy required that medications not clinically indicated for a specific condition should not be administered, highlighting a failure in the medication management process.
Incomplete Documentation of Resident Conditions
Penalty
Summary
The facility failed to meet professional standards of quality for two residents due to incomplete documentation of changes in their conditions. Resident 1 experienced an unwitnessed fall in the bathroom, resulting in a fracture to the olecranon process/proximal ulna and radial neck. Despite the severity of the injury, the facility staff did not complete a Change of Condition (COC) assessment, which is crucial for documenting the circumstances and notifying relevant personnel. The facility's policy requires the charge nurse to complete a COC for any changes in a resident's health, but this was not adhered to in Resident 1's case. Resident 2 exhibited a change in urine patterns and later had blood in the urine, yet the facility also failed to complete a COC for these instances. The resident was admitted with several diagnoses, including orthopedic aftercare following surgical amputation and end-stage renal disease. Despite these significant health changes, the necessary documentation to inform other staff and ensure timely care was not completed. The facility's policy mandates documentation of all changes in a resident's condition, but this was not followed for Resident 2. The lack of proper documentation for both residents resulted in incomplete records, which could potentially delay care and put residents at risk. The facility's policy and professional standards emphasize the importance of documenting changes in a resident's condition to maintain quality care and ensure all staff are informed of any health changes. The failure to complete COC assessments for both residents highlights a deviation from these standards, as confirmed by interviews with the facility's RN and DON.
Failure to Develop Care Plan for Resident's Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who sustained a fracture of the left arm. Despite the facility's policy requiring a care plan to be developed within seven days of a comprehensive assessment, no care plan was created for the resident's fractured arm following an unwitnessed fall. This oversight was identified during an observation and record review, where it was noted that the resident was walking with a four-wheeled walker and had an arm brace and bandage on the right arm, resembling a cast. The resident was admitted with diagnoses of syncope, fall, and unsteadiness on feet, and was cognitively intact with a BIMS score of 15 out of 15. The facility's policy mandates that an interdisciplinary team, including the resident's attending physician, registered nurse, and other relevant staff, develop care plans based on resident assessments. However, interviews with the RN and DON confirmed that no care plan was created for the resident's fracture, which was crucial for monitoring potential complications such as changes in color and sensation of the affected arm.
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What surveyors actually found near you
We read the 274 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Modesto Post Acute Center | 0 mi | ★★★★★ | 17 | 0 |
| Golden Modesto Care Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Garden City Healthcare Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Crestwood Manor | 1.2 mi | ★★★★★ | 11 | 0 |
| River View Post Acute | 1.4 mi | ★★★★★ | 35 | 0 |
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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.