Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victoria Care Center during CMS and state inspections, most recent first.
Dietary aide failed to wear a beard net while handling and serving food. The aide was observed in the kitchen with a goatee and facial stubble without a beard net, then later in the tray line scooping food into resident trays with the beard net positioned under the chin instead of covering the facial hair. The RD witnessed and acknowledged both observations, and the facility policy required anyone with a beard in food prep areas to wear a beard net.
Care plans were not accurately updated for two residents. One resident with COPD, hypoxia, and other diagnoses was observed using a suction machine for oral secretions, but the respiratory POC did not address suctioning or coughing. Another resident with MRSA wound infection had orders and signage for both TBP/contact isolation and EBP, and the POC listed both precautions even though staff described the resident as being on strict contact isolation in a single room.
A nurse crushed and administered a resident’s Metoprolol Succinate ER 50 mg despite the physician’s order stating not to crush it. The resident had heart failure, CKD, and HTN, and was unable to swallow whole tablets. The nurse said she did not realize the medication was extended release, and the DON acknowledged ER medications should not be crushed; the facility policy also stated long-acting dosage forms should generally not be crushed.
Improper Storage of Rectal and Oral Medications: Rectal suppositories and oral meds were observed stored together in one med cart, including acetaminophen and bisacodyl suppositories alongside oral dicyclomine, antacid tablets, ibandronate, ondansetron, and sumatriptan. The ADON confirmed the meds were stored next to each other and stated rectal meds and oral meds should not have been stored together.
Improper Handling of Soiled Linen: Staff failed to follow infection control practices when contaminated linen was left in a resident bathroom and a hospice aide was observed placing a pile of soiled linen directly on the floor while providing care to a resident. The facility policy required soiled linen to be handled and transported to minimize microorganism transmission, and the DON acknowledged the practices did not meet required infection control standards.
Burnt Kitchen Electrical Socket: A burnt electrical wall socket was observed in the kitchen, with a juicer plugged into one outlet. The DS and MNTD/AMD stated a food warmer had caused sparks, burn marks, and a tripped breaker, and that the food warmer had not been inspected or approved before use. The MNTD/AMD also said electrical equipment was only inspected yearly, no approval process existed for resident/family-owned electrical items, and no logs were kept for inspected equipment, despite policy requiring monthly inspections and approval before use.
Water Leak Under Medication Room Sink: A medication room sink had an active leak beneath the cabinet, with damaged and discolored cabinet material and wet surfaces observed during inspection. The MDSC confirmed the cabinet base was wet, while the assigned nurse was unaware of the condition. Maintenance staff stated the sink was non-operational, the leak was condensation from the AC system, and the MNTD said the leak appeared longstanding and that medication room sinks were not included in monthly rounds. The ADM acknowledged staff had not been checking the sink and the issue should have been identified.
A resident with symptoms of a UTI did not receive the first dose of a newly ordered antibiotic, Cipro, in a timely manner. The nurse waited for pharmacy delivery instead of using the Emergency Medication Kit, and did not adjust the administration time, resulting in a delay of treatment.
A resident with a history of DVT and PE missed six doses of Lovenox due to unavailability, and staff did not notify the physician as required by facility policy. Interviews confirmed that both pharmacy and physician notification were expected but not completed.
The facility failed to implement care plan interventions for several residents, including not providing necessary equipment for skin maintenance, not completing medication administration, and not documenting IV hydration. Residents were not repositioned regularly, and one resident did not receive a snack during dialysis. These deficiencies were confirmed by staff and led to unmet resident needs.
The facility failed to maintain resident dignity and timely response to call lights, affecting three residents. A resident's confidential medical information was publicly displayed, violating their privacy. Two residents experienced significant delays in call light responses, leading to feelings of embarrassment and frustration. The facility's policy on call light response times was not adhered to, with observed delays far exceeding the expected 10-minute response time.
A facility failed to ensure consistent documentation of a resident's POLST across paper and electronic records. The paper POLST indicated selective treatment preferences, while the electronic version suggested full treatment, including intubation. Licensed nurses confirmed the discrepancies, which could lead to the resident's end-of-life wishes not being honored.
A resident was not involved in the review and revision of their care plan during an IDT meeting, contrary to facility policy. Staff interviews revealed that the resident was not invited to the meeting, and changes to the care plan were not reviewed with them afterward. This resulted in the resident not participating in deciding their treatment options.
A facility failed to maintain accurate medical records for two residents. One resident was relocated without proper notification or consent, violating facility policy. Another resident's depression and mood were not monitored as ordered, with missing documentation on specific shifts. The DON acknowledged these deficiencies, which could impact care planning and resident rights.
The facility failed to adhere to its Infection Prevention and Control Program, with staff not following Enhanced Barrier Precautions for a resident, improper hand hygiene during feeding, and inadequate labeling and storage of medical equipment. Additionally, a nurse did not change gloves after picking up a dropped item, and another did not perform hand hygiene during wound care, all contrary to facility policies.
The facility failed to ensure a functional environment by not providing pull cords for night lights in several resident rooms, as confirmed by maintenance staff. This deficiency denied residents the use of night lights, potentially increasing fall risk.
A resident experienced an unwitnessed fall and was found confused and forgetful. The facility failed to promptly notify the resident's representative, delaying their involvement in care decisions. The representative was informed hours later, after the physician ordered the resident to be sent to the ER due to anticoagulant therapy, which was deemed a life-threatening situation.
A resident experienced an unwitnessed fall, and the facility failed to ensure a prompt physician response, resulting in a delayed transfer to the ER. The facility's policy requires timely physician advice and treatment, but the physician took three hours to respond to the nursing staff's call. The Director of Nursing confirmed that this delay did not meet the facility's expectations for prompt communication.
A resident transferred to a skilled nursing facility for post-knee replacement care did not receive a scheduled dose of the prescribed antibiotic, sulfamethoxazole-trimethoprim (Bactrim DS), on the day of admission. The Director of Nursing confirmed the oversight, which could have impacted the effectiveness of the treatment.
A resident was discharged without receiving the necessary antibiotic medication for a knee surgical incision infection. The facility's policy required contacting the prescriber if medication delivery was delayed, but the pharmacy did not deliver the medication in time. The Director of Nursing confirmed the medication was unavailable at discharge, acknowledging the pharmacy's failure to meet the resident's needs.
The facility failed to include necessary interventions in the care plans of two residents with pressure ulcers. The care plans lacked measures for offloading heels and did not specify a frequency for turning and repositioning. Additionally, one resident's care plan did not include a specific fluid intake amount despite a physician's order for fluid restriction. These deficiencies were confirmed by the ADON during a review.
A facility failed to accurately document a resident's skin assessment, resulting in an inaccurate care history. The resident, admitted with congestive heart failure, had conflicting records regarding a coccyx pressure ulcer. The Initial Admission Record did not note the ulcer, while subsequent evaluations provided inconsistent onset dates. The Assistant Director of Nursing confirmed an error in the documentation, violating the facility's policy for accurate and chronological record-keeping.
A resident reported being physically abused by a CNA, but the facility delayed reporting the allegation to CDPH beyond the required 24-hour timeframe. The incident was initially reported internally to the Charge Nurse, Nurse Practitioner, DON, and Administrator, but external reporting was not timely, contrary to the facility's policy.
A resident requiring a Kosher diet was not provided with appropriate meals, as the facility failed to include this dietary need in the care plan. Despite informing the RD and DS of his dietary preferences, the resident was served non-Kosher foods. The care plan was only revised to include a Kosher diet after the resident's discharge, contrary to the facility's policy for comprehensive care planning.
A resident with a history of bipolar and anxiety disorders became agitated and wanted to leave the facility after a CNA was rude and used foul language. The incident was confirmed by the DON and documented in the resident's progress notes, highlighting a failure to uphold the facility's policy on Residents' Rights.
Dietary Aide Failed to Wear Beard Net During Food Handling
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices when a dietary aide did not wear a beard net while handling and serving food. During an observation in the kitchen at 9 a.m., the dietary aide was seen with a goatee measuring approximately 1 to 2 inches in length, along with stubble on both cheeks and the upper lip, and was not wearing a beard net. When asked why, the dietary aide stated, "I forgot." The registered dietician witnessed the observation and acknowledged the deficient practice. During tray line observation at 12:20 p.m., the same dietary aide was observed in the tray line and food preparation area standing over steam table pans and trays while scooping food into individual resident trays. At that time, the beard net was positioned under the dietary aide's chin, leaving the facial hair unsecured. When asked why the beard net was under the chin and not covering the beard, the dietary aide again stated, "I forgot." The registered dietician was present and acknowledged the observation and interview. The facility policy titled, "Workplace Hygiene: Who Needs a Hair Restraint?" stated that all employees entering the kitchen or food preparation area must wear a hair restraint, including anyone with a beard who must wear a beard net.
Care Plans Not Updated for Respiratory Needs and Infection Precautions
Penalty
Summary
The facility failed to ensure the comprehensive care plan was accurate and complete for two residents. For one resident with respiratory needs, the clinical record showed diagnoses including UTI, hypoxia, COPD, and AKI, and the resident was observed coughing while resting in bed with an oxygen concentrator, suction machine, and tube feeding machine present in the room. The resident’s caregiver stated that nursing staff used the suction machine to remove phlegm and oral secretions, but the respiratory plan of care did not address the need for suctioning or the coughing episodes. For another resident with a wound infection related to MRSA, the record showed physician orders for transmission-based precautions, contact isolation, and enhanced barrier precautions. Facility observations showed both EBP signage and contact isolation signage posted at the resident’s room. The plan of care for the wound infection also listed both TBP and EBP. During interview, the Infection Preventionist explained the differences between contact isolation and EBP, and the MDS coordinators were unable to explain why both precautions were listed in the plan of care when the resident was reportedly on strict contact isolation in a single room with services provided in the room. The DON acknowledged that the care plan was not updated and did not reflect the interventions being used for the resident with respiratory needs or the resident on contact isolation precautions. The DON also stated that between EBP and TBP, the resident would be placed on the stricter precaution, which was contact isolation. The facility policy stated that the interdisciplinary team is responsible for developing a comprehensive person-centered care plan with measurable objectives and timeframes based on the comprehensive assessment.
Crushed Extended-Release Metoprolol Given Contrary to Order
Penalty
Summary
The facility failed to ensure that an extended-release medication was administered in accordance with the attending physician’s written order for one resident. The resident was admitted with diagnoses including heart failure, chronic kidney disease, and essential hypertension, and the admission record noted the resident was unable to swallow whole tablets. During a concurrent observation and interview, a nurse was observed preparing the resident’s morning medications and crushed Metoprolol Succinate ER, then mixed the crushed medication in applesauce and administered it to the resident. A later review of the resident’s order summary showed a physician’s order for Metoprolol Succinate ER 50 mg by mouth once daily for hypertension, with instructions that it was not to be crushed. The nurse stated she was unaware the medication was extended release and confirmed that extended-release tablets should not be crushed and that she should not have crushed it. The DON also acknowledged that extended-release medications should not be crushed. The facility policy stated that long-acting dosage forms should generally not be crushed and an alternative should be sought.
Improper Storage of Rectal and Oral Medications
Penalty
Summary
The facility failed to ensure medications were properly stored when rectal and oral medications were observed stored together in one medication cart. During a review of the facility's undated policy and procedure titled "Storage of Medications," the policy stated that orally administered medications are to be kept separate from externally used medications such as suppositories, liquids, and lotions. During a concurrent observation and interview with the ADON, two packages of acetaminophen suppositories, one package of bisacodyl suppositories, one bottle of dicyclomine oral medication, one bottle of antacid tablets, and one package of ibandronate were observed stored next to each other in one compartment of the top drawer of the [NAME] Hall East medication cart. In the third drawer of the same cart, two packages of bisacodyl suppositories, two packages of ondansetron oral tablets, and one package of sumatriptan oral tablets were also observed stored next to each other. The ADON confirmed the medications were stored next to each other and stated rectal medications and oral medications should not have been stored together.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to follow its infection prevention and control practices for handling soiled linen. Staff were observed handling contaminated linen for one resident, and soiled linen was also observed left in the bathroom occupied by two other residents. During the observation and interview, the Infection Preventionist and the ADON acknowledged that used soiled linens should never remain in the resident environment and should be disposed of properly. The facility policy stated that soiled linen should be handled, collected, transported, processed, and stored in a manner that minimizes transmission of microorganisms, and that soiled linen should not come into contact with the floor or furniture. A hospice aide was observed providing care to a resident while a pile of contaminated soiled linen was directly in contact with the floor. The aide stated that the soiled linen should have been in a plastic bag. The resident receiving hospice services had diagnoses including malignant neoplasm of the bronchus and lung, bone involvement, surgical aftercare following nervous system surgery, and anemia. The Infection Preventionist explained that soiled linens must not be placed on the floor and should be placed in a plastic bag and transported to the soiled linen room, and the DON acknowledged that the current practices did not meet the required standards for infection control.
Burnt Kitchen Electrical Socket
Penalty
Summary
The facility failed to ensure routine inspection and maintenance of electrical equipment in the kitchen. During observation, a burnt electrical wall socket was noted in the kitchen, and a juicer machine was plugged into the fourth outlet of the multi-plug socket while the other three outlets were unused. The dietary supervisor stated the burnt socket was caused by a food warmer that had previously been plugged into that location. The maintenance director and assistant maintenance director acknowledged that the kitchen electrical socket was burnt and said the food warmer had caused sparks, burn marks, and tripped the circuit breaker. They stated the food warmer had not been inspected or approved by maintenance before use, kitchen staff had not notified them of it, and the maintenance department inspected electrical appliances in the kitchen once a year. They also stated the department did not inspect, certify, or approve electrical and electronic appliances brought in by residents or family members before use and did not keep logs to track inspected or approved equipment or preventive maintenance. The facility policy required monthly inspection of electrical equipment and required personal electrical items to be inspected and approved before use.
Water Leak Under Medication Room Sink
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment when a water leak was observed underneath the sink in one medication storage room. During observation, the cabinet beneath the sink was noted to have a damaged base with broken and lifted surface material and dark discoloration, and water was actively leaking from the drain assembly beneath the sink. A dry paper towel used to wipe the cabinet base became wet, and the MDSC confirmed the base of the cabinet was wet and that there was an active water leak. Staff interviews showed the sink in the medication room was not being used and the nurse assigned to the nursing station was not aware of the leak or the condition of the cabinet. Maintenance staff stated the sink was non-operational and the water supply had been cut off, and one maintenance leader said the water leaking from the pipe was condensation from the air conditioning system and acknowledged it was not clean. The MNTD confirmed there was a water leak under the sink and said it appeared to have been there a long time, while also stating medication room sinks were not included in monthly maintenance rounds even though they should be. The ADM stated staff were not checking the sink because it had not been used in a long time and acknowledged the issue should have been identified.
Delay in Administration of Antibiotic for UTI
Penalty
Summary
A deficiency occurred when a resident exhibiting signs of a urinary tract infection (foul smelling urine) did not receive the first dose of a newly ordered antibiotic, Cipro, within a reasonable timeframe. The physician's order for Cipro was placed in the late afternoon, with instructions for same-day delivery from the pharmacy. However, the medication was not administered as scheduled, and the nurse did not adjust the administration time for the first dose. The Medication Administration Record showed that the initial dose was not given at the intended time, and there was no documentation of an adjusted administration time. The Assistant Director of Nursing confirmed that the nurse did not utilize the Emergency Medication Kit to obtain the Cipro, instead waiting for the pharmacy delivery. Facility policy states that if a medication is not immediately available and is needed urgently, it should be obtained from the Emergency Medication Supply. The failure to follow this policy resulted in a delay in administering the antibiotic to the resident.
Failure to Administer Anticoagulant as Ordered and Notify Physician
Penalty
Summary
The facility failed to follow physician's orders for the administration of Lovenox (Enoxaparin Sodium Injection) for a resident who was admitted with a post-operative diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). The hospital discharge summary included orders for Lovenox 100 mg to be administered subcutaneously every 12 hours. Review of the electronic medication administration record and physician orders revealed that the resident missed six doses of Lovenox over a four-day period, and there was no documentation that the physician was notified about the unavailability or delay of the medication. Interviews with the nurse supervisor and the director of nursing confirmed that nursing staff are expected to notify the pharmacy and the physician if a medication is unavailable, and acknowledged that the physician should have been contacted. Facility policy also requires the prescriber to be contacted when medication delivery is delayed or unavailable.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to unmet needs and potential harm. Resident 61 did not receive a foot cradle and alternate pressure mattress as ordered for skin maintenance. Resident 123's care plan interventions, including oxygen therapy and monitoring for insomnia and pain, were not completed on multiple occasions. Similarly, Resident 138's interventions, such as being up to a chair for meals and monitoring for signs of bleeding, were not implemented as required. Resident 682, who was transferred to the facility after a hip fracture repair, did not have proper documentation for IV hydration, which was crucial for managing elevated BUN levels. The lack of documentation and administration of IV fluids as per the care plan was confirmed by the nursing staff. Additionally, Resident 5, who has multiple sclerosis, reported not being regularly turned and repositioned, which was a necessary intervention to prevent further decline in physical mobility and skin breakdown. Furthermore, Resident 36, who requires dialysis, was not provided with a snack during treatment as ordered, leading to potential nutritional deficiencies. Resident 121, who needed pillows to offload pressure from heels, did not have this intervention documented or implemented, despite a physician's order. The facility's failure to adhere to care plans and document interventions as required was acknowledged by the Director of Nursing and other staff members during interviews.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. Resident 110's confidential medical information was publicly displayed in their room, violating their right to privacy and dignity. An orange Swallow Guide containing specific treatment details was posted at the head of their bed, which should have been covered to protect their confidentiality. Two residents, Resident 240 and Resident 66, experienced significant delays in call light responses, leading to feelings of embarrassment, frustration, and anger. Resident 240 reported waiting up to an hour for staff to respond, resulting in instances where they had to void in their bed. The Nurse Call Activity Report (NCAR) for Resident 240 showed multiple instances of prolonged call durations, some exceeding 30 minutes. Similarly, Resident 66 expressed dissatisfaction with the night shift's response times, stating they often waited an hour or more for assistance. This delay caused Resident 66 to feel angry, frustrated, and embarrassed, as they were left in pain, hungry, and thirsty. The NCAR for Resident 66 also indicated numerous instances of extended call durations, with some exceeding 40 minutes. The facility's policy on call light response times was not adhered to, as the Director of Nursing acknowledged that a reasonable expectation for response time was 10 minutes, and the observed delays were unacceptable.
Inconsistent POLST Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident had the most current Physician Orders for Life-Sustaining Treatment (POLST) documented consistently across both paper and electronic records. The POLST is a critical document that outlines a resident's treatment preferences in the event of a medical emergency. In this case, discrepancies were found between the paper POLST and the electronic health record (eHR) for the resident. The paper POLST indicated a preference for selective treatment, avoiding burdensome measures, and not intubating, while the electronic POLST indicated a trial period of full treatment, including intubation and mechanical ventilation. During interviews and record reviews, it was confirmed by licensed nurses that the paper and electronic POLST documents did not match, which they acknowledged should not be the case. This inconsistency in documentation had the potential to result in the resident's end-of-life wishes not being honored, as emergency personnel might follow incorrect or outdated instructions during a medical emergency.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to ensure that Resident 106 was involved in the review and revision of their care plan during the interdisciplinary team (IDT) meeting. The facility's policy and procedure indicated that residents, along with their families or responsible parties, should participate in the development of the care plan. However, Resident 106 was not invited to the IDT meeting, and the changes made to the care plan were not reviewed with them afterward. This lack of involvement resulted in Resident 106 not being given the opportunity to participate in deciding their treatment options. Interviews with facility staff, including a social services designee (SSD), a minimum data set nurse assessment coordinator (MDS2), and the Director of Nursing (DON), confirmed that Resident 106 was not present at the care plan meeting. The SSD acknowledged speaking with Resident 106 before the meeting but did not review the care plan changes with them afterward. MDS2 admitted that residents are never present at these meetings and that the revisions are not reviewed with them, which was acknowledged as a deviation from the expected practice. The DON confirmed that all residents should be present at care plan meetings if they are able to attend, highlighting a systemic issue in the facility's process.
Deficiencies in Documentation and Resident Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care and resident rights. For one resident, the facility did not maintain a complete, accurately documented, and systematically organized room transfer form during their relocation. The resident was moved without prior notification or consent, as required by the facility's policy. The Director of Nursing (DON) confirmed that the resident was verbally informed, but no written notification or consent was obtained, and the form used was incorrectly titled 'STATUS CHANGE' instead of 'Notification of Room or Roommate Change.' This discrepancy in documentation and lack of proper notification violated the facility's policy and the resident's rights. For another resident, the facility failed to monitor the resident's depression and mood as ordered by the physician. The resident was on medication for mood disorders and depression, with specific orders to monitor episodes of depression and mood disorder using hashmarks every shift. However, there was no documentation of monitoring on two specific PM shifts. The DON acknowledged the lack of documentation, which was contrary to the facility's policy requiring a complete account of the resident's care and treatment in an accurate and chronological order. This failure to document monitoring could impact the resident's care planning and the provision of appropriate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program (IPCP) in several instances. Staff did not follow Enhanced Barrier Precautions (EBP) for a resident who required such measures. During an observation, an occupational therapist and a physical therapist provided direct care to the resident without wearing gowns, despite signage indicating the need for EBP. The facility's policy required the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. In another instance, a certified nurse assistant (CNA) was observed feeding two residents simultaneously, using the same hand and utensil without proper hand hygiene between feedings. The facility's policy allowed one staff member to feed two residents but required adherence to infection control guidelines to prevent cross-contamination. The CNA did not follow the hand hygiene policy, which mandates handwashing before and after direct contact with residents and before and after assisting with meals. Additionally, the facility failed to label and properly store oxygen and nebulizer equipment for two residents, and a medication nurse did not change gloves after picking up a dropped item before administering a patch to a resident. Furthermore, a treatment nurse did not perform hand hygiene between glove changes during wound care for another resident. These actions were contrary to the facility's policies, which required weekly changes and labeling of equipment and emphasized the importance of handwashing in infection control.
Missing Night Light Pull Cords in Resident Rooms
Penalty
Summary
The facility failed to provide a functional and comfortable environment for residents by not ensuring the availability of pull cords for overhead night lights in several resident rooms. During an initial tour observation, it was noted that rooms 109A, 110A, 113A, 113B, 114A, 114B, 115A, 116A, 116B, 118A, 118B, 119B, 120A, 121A, 124A, and 125A were missing night light pull cords. This deficiency was confirmed during an interview with the Director of Maintenance and the Assistant Maintenance, who acknowledged the absence of pull cords in the identified rooms. The lack of pull cords denied residents the use of night lights, potentially increasing the risk of falls during nighttime hours.
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to promptly notify the resident representative of a fall experienced by a resident, which was a deviation from the facility's policy and procedure on Fall Management System. The policy, dated January 2022, required that the resident representative be informed of any fall and the resident's status. On January 23, 2025, at 3:18 a.m., a progress note documented that the resident had an unwitnessed fall, was confused, and forgetful. However, the resident's representative was not informed of the incident until 6:08 a.m., resulting in a delay in their involvement in decision-making regarding the resident's care. The facility's policy on Change of Condition Reporting/Documentation, dated 2023, also required that the responsible party be notified of any change in the resident's condition. During an interview and record review, the Director of Nursing acknowledged that the resident's representative should have been notified at the time of the fall. The delay in notification meant that the resident's representative was not immediately involved in critical decisions, such as the physician's order to send the resident to the emergency room due to anticoagulant therapy, which was considered a life-threatening situation by the representative.
Delayed Physician Response After Resident Fall
Penalty
Summary
The facility failed to ensure prompt physician response following a resident's fall, leading to a delayed transfer to the emergency room. According to the facility's policy and procedure on physician services, physicians are expected to provide advice, treatment, and determine the appropriate level of care needed for each resident. On January 23, 2025, at 3:18 a.m., a progress note indicated that a resident had an unwitnessed fall, and the nursing staff communicated with the physician, awaiting a response. However, the physician did not respond until 6:08 a.m., approximately three hours later, at which point the order was given to send the resident to the hospital for further evaluation and treatment. During an interview and record review with the Director of Nursing, it was confirmed that the physician's delayed response did not meet the facility's expectations for prompt communication.
Antibiotic Administration Failure Post-Transfer
Penalty
Summary
The facility failed to ensure that a resident received their prescribed antibiotic treatment without interruption following a transfer from an acute care facility to the skilled nursing facility. The resident, a female admitted for aftercare following knee replacement surgery, was prescribed sulfamethoxazole-trimethoprim (Bactrim DS) to be taken twice daily for five days. The discharge instructions from the hospital indicated that the last dose was administered at 10 AM on the day of transfer. Upon review of the resident's records, it was found that the second dose of the antibiotic was not administered as scheduled at 5 PM on the day of admission to the nursing facility. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the dose should have been given. The failure to administer the antibiotic as prescribed had the potential to reduce the effectiveness of the treatment and/or prolong the resident's recovery process.
Failure to Provide Antibiotic Medication on Discharge
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary antibiotic medication upon discharge. The facility's policy and procedure required contacting the prescriber if there was a delay in medication delivery. The resident had an order for Bactrim DS to treat a right knee surgical incision infection. On the day of discharge, the facility sent a fax to the pharmacy requesting the medication, but it was not delivered in time. The Medication Administration Record indicated that the resident was discharged to home without the medication. A progress note documented concerns about how the resident would obtain the medication since it had not been delivered. The Director of Nursing confirmed that the medication was not available to send home with the resident, acknowledging that the pharmacy did not meet the resident's medication needs.
Deficiencies in Care Plans for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plans for two residents with pressure ulcers included necessary interventions. For both residents, the care plans did not specify the offloading of heels from pressure surfaces, which is a critical measure to prevent the worsening of pressure ulcers. Additionally, the care plans lacked a defined frequency for turning and repositioning the residents, which is essential for pressure ulcer prevention. These omissions were identified during a review of the care plans and confirmed by the Assistant Director of Nursing, who acknowledged that the interventions should have been included. Furthermore, the care plan for one of the residents did not specify the amount of fluid intake, despite a physician's order for a fluid restriction. The care plan merely encouraged fluid intake without detailing the specific amount, which could lead to fluid overload. This oversight was also confirmed during the review with the Assistant Director of Nursing, who noted that the intervention was not resident-specific as it lacked the necessary details regarding fluid intake.
Inaccurate Documentation of Resident's Skin Assessment
Penalty
Summary
The facility failed to ensure accurate documentation of a skin assessment for a resident, leading to an inaccurate resident care history. The resident, who was admitted with a primary diagnosis of congestive heart failure, had discrepancies in the documentation of a pressure ulcer on the coccyx. The Initial Admission Record (IAR) did not indicate the presence of a coccyx pressure ulcer upon admission, while the Change in Condition Evaluation (CiCE) noted the ulcer started on a later date. However, the Skin Pressure Ulcer Weekly (SPUW) report inaccurately documented the ulcer as present on admission with an onset date prior to the CiCE's noted start date. During a review with the Assistant Director of Nursing (ADON), it was confirmed that the SPUW contained an error regarding the onset date of the pressure ulcer. The facility's policy on documentation and charting requires a complete and accurate account of the resident's care in a chronological manner, which was not adhered to in this instance. This discrepancy in documentation highlights a failure in maintaining accurate medical records for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in a timely manner for one of the sampled residents. On July 17, 2024, at 6:35 p.m., a resident reported to the Charge Nurse that her assigned Certified Nursing Assistant (CNA) had physically abused her by pinching and pulling her hair. The Charge Nurse immediately informed the Nurse Practitioner, Director of Nursing (DON), and Administrator about the allegation. However, the facility did not report the incident to CDPH until July 19, 2024, at 3:30 p.m., which was beyond the required 24-hour reporting timeframe. The facility's policy and procedure on abuse prevention and prohibition mandates that such allegations be reported to the appropriate state or federal agencies within the applicable timeframes. The DON acknowledged the delay in reporting during an interview, admitting that the report should have been made within 24 hours.
Failure to Implement Kosher Diet in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required a Kosher diet, resulting in the resident receiving non-Kosher foods. The resident, who was discharged from the facility, reported that despite informing the Registered Dietician and Dietary Supervisor of his dietary needs upon admission, he was served ham and cheese sandwiches, which are not Kosher. The resident's dietary assessment, completed by the RD, indicated a preference for a Kosher diet and listed specific food dislikes, including ham and pork. The Nutritional Care Plan for the resident, initiated on the same date as the dietary assessment, identified an increased risk for malnutrition but did not include specific interventions for a Kosher diet until after the resident's discharge. The Director of Nursing acknowledged that the care plan was revised to include the Kosher diet only after the resident had left the facility. The facility's policy requires the interdisciplinary team, including the Dietary Supervisor/Dietician, to develop a comprehensive, person-centered care plan based on the resident's needs, which was not adhered to in this case.
Resident Rights Violation Due to CNA's Rude Behavior
Penalty
Summary
The facility failed to protect the rights of a resident when a Certified Nursing Assistant (CNA) was rude to them, resulting in the resident becoming agitated and wanting to leave the facility. The resident, who was admitted for rehabilitation therapy after gallbladder surgery and has a history of bipolar disorder and anxiety disorder, experienced emotional distress due to an argument with the CNA. During an interview, the Director of Nursing (DON) confirmed that the CNA used foul language and made inappropriate comments to the resident. The Nursing Progress Note indicated the resident was restless and emotionally distressed following the incident, and the Psychiatric Progress Note confirmed the resident's account of the CNA's rude behavior. The facility's policy on Residents' Rights emphasizes the right to be treated with respect and dignity, which was not upheld in this instance.
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What surveyors actually found near you
We read the 197 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ventura
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal View Healthcare Center | 1.3 mi | ★★★★★ | 11 | 0 |
| Ventura Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Oxnard Manor Healthcare Center | 3.2 mi | ★★★★★ | 14 | 0 |
| Glenwood Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Shoreline Care Center | 6.1 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.