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 Vineyard Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple serious diagnoses experienced a change in condition when he developed bleeding from his tongue after self-biting. An LVN documented the event and obtained MD orders to monitor for ongoing bleeding and complications, but also recorded the resident representative as "unknown" despite the RP’s contact information being readily available in the EMR and unchanged throughout the stay. Staff, including the LVN, SSD, DSD, and Administrator, acknowledged that the RP should have been notified of this change in condition, consistent with facility policies requiring prompt notification of the resident and representative for significant clinical changes and the resident’s right to be informed and participate in care decisions.
A resident with HIV, recurrent pneumonia, and moderate cognitive impairment was found in bed with a breakfast tray and a cup containing eight pills on the overbed table, with no nurse present. The resident reported that an LVN had brought the morning medications, was told to leave them so the resident could take them later, and left them at the bedside. Review of the MAR showed multiple 0800 medications, including sulfamethoxazole‑trimethoprim for PCP prophylaxis and several vitamin and mineral supplements. The DSD, nurse consultant, and administrator each stated that medications should not be left unattended and that nurses must observe administration, while regulatory and professional references required medications to be administered as prescribed, within defined time frames, and only to the resident for whom they were ordered.
The facility failed to maintain a safe and sanitary environment in the housekeeping closet on Wing B, with observations of residue on the floor, missing baseboards, and rust-colored debris. Interviews revealed that the janitor was not on duty until the evening shift, and the Administrator acknowledged the need for cleaning and maintenance. The IP/MDSN expressed concerns about safety hazards and infection control issues due to the conditions observed.
The facility failed to properly store and label medications, with 15 blister packs missing expiration dates and an expired narcotic found in a cart for a hospice resident. Additionally, an unlocked cart with loose pills was discovered outside, posing safety risks. The DON and staff acknowledged these issues, emphasizing the importance of proper medication management.
The facility failed to ensure that the Maintenance Director and Dietary Cooks had the necessary competencies to safely carry out food and nutrition services. The Maintenance Director did not follow proper cleaning procedures for the ice machine, while Dietary Cook 1 misused test strips for sanitizing solutions, and Dietary Cook 2 improperly recalibrated thermometers. These deficiencies could lead to contamination and foodborne illness among residents.
A dietary staff member failed to weigh roast turkey before serving it to a resident, contrary to the dietary spreadsheet and meal card instructions. The resident, with a history of type 2 diabetes, atrial flutter, hypertension, and abnormal weight gain, was on a therapeutic diet requiring small portions. This oversight could have led to unplanned weight gain, as confirmed by the Director of Culinary Services and the Registered Dietitian.
The facility failed to maintain food safety and sanitation standards, affecting 50 of 51 residents. Issues included unlabeled and expired food items, contamination risks from black particles and cobwebs, and improper cleaning practices. The DCS, RD, and MAIND acknowledged these deficiencies, which violated the facility's policies on food storage, cleaning, and hair restraints.
A resident with a history of cerebral infarction, Alzheimer's, and other conditions fell from her wheelchair, hit her head, and was unconscious. The incident was not reported to the California Department of Public Health within the required time frame, delaying the investigation. The facility's policy required such incidents to be reported within 24 hours, but the report was submitted late.
A facility failed to implement a behavior monitoring care plan for a resident receiving anti-psychotic medication. The resident, with multiple diagnoses including schizoaffective disorder and dementia, was moderately cognitively impaired. Despite facility policies requiring behavior monitoring for such medications, the care plan lacked this component, as confirmed by staff interviews and policy reviews.
A resident with multiple health conditions was found to be receiving oxygen at 2.5 L/min instead of the prescribed 3 L/min, as observed by an LVN and confirmed by the DON. The facility's policy required adherence to physician orders for oxygen settings, which was not followed, placing the resident at risk of unmet respiratory needs.
A resident with severe cognitive impairment was discharged from a facility without the knowledge or consent of their designated representative. The discharge was signed by another family member, contrary to the facility's policy requiring notification and involvement of the designated representative. Interviews with facility staff confirmed the lack of proper documentation and communication with the representative.
A resident with a history of respiratory issues was receiving continuous oxygen despite having a prn order. The facility's Licensed Nurses did not notify the Attending Physician of this change in condition, which was necessary to update the care plan and physician orders. The resident was cognitively intact and had been using oxygen continuously for over a month without the required notification to the physician.
A resident experienced unrelieved knee pain that limited her participation in physical therapy due to the facility's failure to provide effective pain management. Despite the resident's complaints and a documented care plan, staff did not consistently communicate her therapy refusals due to pain to the appropriate personnel, nor was the physician notified or pre-medication administered. The facility's policies on pain management were not followed, resulting in a deficiency in individualized care.
A resident on a mechanical soft diet was served a regular diet meal, contrary to their prescribed dietary needs. The resident, who was severely cognitively impaired and admitted for hospice care, was at risk of choking due to this oversight. Facility staff confirmed the meal did not match the prescribed diet texture, and procedures to ensure diet orders were followed were not adhered to.
A facility failed to maintain effective infection control practices. An RN did not change gloves or perform hand hygiene during a dressing change for a resident on Enhanced Barrier Precautions, while an LVN did not perform hand hygiene between resident medication administrations. The DON confirmed these lapses, which contradicted the facility's infection control policies.
A facility failed to develop a comprehensive person-centered care plan for a bedbound resident, leading to the resident spending her waking hours picking on her skin, resulting in excoriations. The resident, with multiple diagnoses including Parkinson's disease and paraplegia, expressed boredom, and it was found that an activity care plan was not created at the time of admission. The lack of an activity care plan was acknowledged by the Activity Director, LVN, MDS Nurse, and DON.
The facility failed to maintain a functioning call light system, affecting seven residents who could not request assistance. A resident used a handbell due to a non-working call light, and the Director of Maintenance was unaware of the issue due to a lack of routine checks. The Administrator and Director of Staff Development were also unaware of the extent of the problem, despite the facility's policy requiring operable call lights and routine inspections.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Responsible Party (RP) of a change in condition when the resident experienced bleeding from the mouth. The resident was admitted with multiple diagnoses, including muscle wasting, dementia, malignant neoplasms of the prostate and sigmoid colon, and posthemorrhagic anemia. An MDS assessment showed a BIMS score of 3/15, indicating severe cognitive impairment. On 12/26/25, a Change in Condition Evaluation documented that the resident had bleeding from the right side of the tongue due to self-biting, and new orders were received to monitor the oral cavity for bleeding, swelling, pain, or signs of infection and to report any changes to the MD. In the same note, the nurse documented that the resident representative was “unknown,” while also entering a date and time for family/resident representative notification. During interviews, LVN 2 stated that the mouth bleeding was a change in condition and that the RP should have been notified, noting that the resident had dementia and could not make medical decisions for himself. LVN 2 also confirmed that the RP’s information was easily accessible in the EMR and had remained the same throughout the resident’s stay, and she did not know why the nurse documented the RP as unknown. The Social Services Director stated that the RP was involved in care conferences and should have been notified of any change in condition. The Director of Staff Development stated that RPs must be notified for any change in condition, and if the RP could not be reached, this should be documented and passed to the next shift; she confirmed that the resident’s bleeding in the mouth was a change in condition and that the RP should have been called. The Administrator stated that RPs should be notified right away when there is a change in condition. Facility policies on Notification of Changes and Resident Rights required prompt notification of the resident and resident representative when there is a significant change in condition and affirmed the resident’s right to be informed of and participate in treatment and to be informed in advance of changes to the plan of care.
Medications Left Unattended at Bedside and Not Administered as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff administered medications in accordance with professional standards of practice for one sampled resident. On 4/1/26 at 11:10 a.m., surveyors observed Resident 2 lying in bed with eyes closed, with a breakfast tray and a small medicine cup containing eight pills on the overbed table, and no licensed nursing staff present. Resident 2 reported that the nurse had brought his medications earlier that morning, he told her to leave them and that he would take them later, and the nurse left the medications at the bedside. Resident 2 did not know what the medications were for. Resident 2’s admission record showed diagnoses including muscle wasting, muscle weakness, abnormalities of gait and mobility, recurrent pneumonia, and HIV disease. The MDS assessment indicated a BIMS score of 10/15, reflecting moderate cognitive impairment. Review of the MAR for April 2026 showed that the morning (0800) medications included ascorbic acid, ferrous sulfate, folic acid, a multivitamin, sulfamethoxazole‑trimethoprim for PCP prophylaxis, vitamin A, vitamin B‑12, and zinc. LVN 1 stated she had prepared Resident 2’s 8:00 a.m. medications and left them on the overbed table at approximately 9:00 a.m. because the resident said he would take them later, and acknowledged she should have followed up to ensure the medications were taken. At 11:15 a.m., the Director of Staff Development observed and handled the same medicine cup at the bedside, confirming the presence of eight pills and stating that medications should never be left unattended at the bedside and should be removed if a resident declines them. The Nurse Consultant and the Administrator both stated that medications should not be left unattended, that the nurse must observe the resident taking medications, and that medications left at the bedside could be taken by another resident. Professional references and the California Code of Regulations reviewed by surveyors indicated that medications must be administered as prescribed, within specified time frames after preparation and around the prescribed time, and that no medication shall be used for any patient other than the one for whom it was prescribed. The facility’s LVN job description required delivery of medications in accordance with physician orders and in compliance with federal and state laws and regulations.
Sanitation and Safety Deficiencies in Housekeeping Closet
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the housekeeping closet on Wing B. Observations revealed brown/gray and white residue on the floor, missing plastic baseboards exposing multiple layered holes near the base of the left wall, and a metal drain with rust-colored debris and an uneven untiled surface. The sink piping had peeling paint and brown-colored staining. These conditions were observed during a concurrent observation and interview with the housekeeper, who indicated that the janitor was responsible for cleaning the closet. Interviews with the Administrator and the Infection Preventionist/Minimum Data Set Nurse (IP/MDSN) revealed that there was no janitor on duty until the evening shift, and the janitor was scheduled for the evening shift. The Administrator acknowledged the need for the closet drywall to be swept, the floors stripped and waxed, and the area under the sink to be cleaned. The IP/MDSN expressed concerns about the rust on the pipes and the uneven surfaces, which could pose safety hazards and infection control issues. Further observations with the Maintenance Director and the IP/MDSN showed that the floor was in the process of being wax stripped, revealing brown liquid, debris, and missing tiles. The Maintenance Director explained that the wall damage was due to the vacuum hitting against the wall without the baseboard protector. The IP/MDSN reiterated concerns about the uneven drain surface and the potential for cross-contamination. The Administrator later stated that maintaining a safe, clean, and sanitary environment was part of her role, but the facility faced challenges such as budgeting, scheduling, and provider availability.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles. During observations, it was found that 15 out of 383 sampled medication blister packs lacked visible expiration dates. This issue was acknowledged by the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1, who both confirmed that medications should have expiration labels. The Pharmacy Consultant (PC) also emphasized the importance of visible expiration dates, noting that medications without them could be expired, potentially affecting their effectiveness. Additionally, an expired liquid narcotic medication was discovered in a medication cart for a resident on hospice care. The narcotic had an expiration date of 8/30/24, and the LVN responsible stated that expired medications should be logged and stored in a double-locked area until disposal by the pharmacy. The PC confirmed that expired medications could lose potency, posing a risk to residents if administered. Furthermore, an unlocked medication cart containing 10 unidentified loose pills was found on the back patio. The Maintenance Director and Director of Staff Development acknowledged that the cart should have been emptied and cleaned before being taken outside. The DON expressed concern about the potential for overdose or allergic reactions due to the unidentified pills. The PC reiterated that medications should not be loose and should be properly documented and stored to ensure resident safety.
Inadequate Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the Maintenance Director (MAIND) and Dietary Cooks (DC) 1 and 2 had the appropriate competencies to safely and effectively carry out the functions of the food and nutrition services for 50 of 51 residents. The MAIND did not demonstrate or verbalize the proper cleaning procedure for the ice machine according to the manufacturer's guidelines. This was observed during an interview where the MAIND used an incorrect solution mixture and cleaning method, admitting to using personal experience rather than formal training. The Director of Culinary Services (DCS) and Registered Dietitian (RD) confirmed that the MAIND lacked competency in cleaning the ice machine, which could lead to contamination and foodborne illness. DC 1 failed to demonstrate the proper use of a test strip for the sanitizing bucket, which is crucial for ensuring the correct concentration of quaternary ammonium compounds. During an observation, DC 1 incorrectly used the test strip and misinterpreted the acceptable concentration range. The DCS and RD confirmed that DC 1 did not follow the correct procedure, which could result in improper disinfection and increased risk of pathogen transmission. DC 2 did not demonstrate competency in recalibrating a thermometer according to the facility's policy. During an observation, DC 2 incorrectly placed the thermometer in a cup of ice water, allowing it to touch the bottom, which could lead to inaccurate temperature readings. The DCS and RD confirmed that DC 2 did not follow the correct recalibration procedure, which could result in food being prepared at unsafe temperatures, posing a risk of foodborne illness to residents.
Failure to Follow Portion Control for Resident's Meal
Penalty
Summary
The facility failed to ensure proper portion control for a resident's meal, specifically regarding the serving of roast turkey. During an observation, a dietary staff member did not weigh the roast turkey before cutting and serving it, contrary to the dietary spreadsheet and meal card instructions, which specified a 2 oz portion. The dietary staff member acknowledged the importance of weighing the meat to ensure the resident received the correct portion size, as per the dietary requirements. The resident involved had a medical history that included type 2 diabetes mellitus, atrial flutter, hypertension, and abnormal weight gain. The resident was on a therapeutic diet requiring small portions and chopped meat texture. The failure to weigh the roast turkey could have led to the resident consuming more than the prescribed amount, potentially affecting their health condition. Interviews with the Director of Culinary Services and the Registered Dietitian confirmed that the dietary staff did not follow the established procedures, which could have resulted in unplanned weight gain for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 50 of 51 residents. An open box of green tea was found without a label indicating the open and received date, which is crucial to prevent serving expired tea. The Director of Culinary Services (DCS) and the Registered Dietitian (RD) acknowledged the importance of labeling to avoid potential foodborne illness. Additionally, an expired bottle of ground rosemary seasoning was discovered on the kitchen shelf, which should have been discarded according to the facility's policy. Further observations revealed black particles on a red wine vinegar bottle, which the DCS attributed to dust and acknowledged as a contamination risk. Spider cobwebs and brown and black particles were found behind the ice machine, which the Dietary Aide (DA) and DCS recognized as a potential source of contamination. The Maintenance Director (MAIND) was observed cleaning the ice machine without a beard net, contrary to the facility's policy, posing a risk of cross-contamination. The ice machine itself had black substances inside, indicating a lack of proper cleaning and maintenance. The RD confirmed that the black substance could be from dust, bacteria, mold, or other pathogens, posing a risk of foodborne illness. The facility's policies on food storage, cleaning, and hair restraints were not followed, leading to these deficiencies in food safety and sanitation practices.
Failure to Timely Report Resident Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury to the California Department of Public Health within the required time frame for a resident who fell from her wheelchair, hit her head, and was unconscious. This incident occurred on January 8, 2025, and the resident was subsequently transferred to a General Acute Care Hospital for further evaluation. The failure to report the incident in a timely manner resulted in the fall not being investigated within the required time frame, potentially compromising the resident's safety needs. The resident involved in the incident had a history of cerebral infarction, Alzheimer's disease, schizophrenia, major depressive disorder, and a history of falling. At the time of the incident, the resident was unable to complete a cognitive assessment, as indicated by a Brief Interview for Mental Status score of 99. The fall was initially witnessed by a Licensed Nurse who observed the resident lean forward and fall out of her wheelchair, resulting in a head injury and loss of consciousness. Interviews with facility staff revealed that the necessary forms for notifying the state or authorities were not included in the investigation packet. The Director of Nursing acknowledged that the incident was reportable due to the resident's loss of consciousness. However, the report to the state office was submitted late, as confirmed by the Administrator. The facility's policy required unusual occurrences, such as falls with major injury, to be reported to appropriate agencies within 24 hours, which was not adhered to in this case.
Failure to Implement Behavior Monitoring for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 25, who was receiving anti-psychotic medication. The deficiency was identified when it was observed that Resident 25 did not have a care plan for behavior monitoring, which is essential for residents on such medication. This oversight was noted during a concurrent observation and interview with Resident 25, who was found in her room, unable to recall how long she had been at the facility and expressing a lack of desire to answer questions. Resident 25 was admitted to the facility with multiple diagnoses, including Parkinson's disease, respiratory failure, heart failure, schizoaffective disorder, dementia, and major depressive disorder. A review of her Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. Despite these conditions, the care plan lacked a behavior monitoring component, which was confirmed during an interview with a Licensed Vocational Nurse (LVN) who acknowledged the necessity of such a plan to ensure the medication's effectiveness and minimize side effects. Interviews with facility staff, including a Certified Nursing Assistant (CNA), a Pharmacy Consultant (PC), and the Administrator (ADM), revealed that behavior monitoring was expected for residents on anti-psychotic or psychotropic medications. The facility's policies and procedures also emphasized the importance of behavior monitoring and updating care plans accordingly. However, these protocols were not followed for Resident 25, leading to the deficiency noted in the report.
Failure to Adhere to Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who was receiving oxygen therapy. The resident, who had been at the facility for two to three years, was observed receiving oxygen at a flow rate of 2.5 L/min instead of the physician-prescribed 3 L/min. This discrepancy was noted during an observation and interview with the resident, who had a history of congestive heart failure, type 2 diabetes mellitus, morbid obesity, shortness of breath, end-stage renal disease, chronic gout, anxiety disorder, and depression. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged the incorrect oxygen setting and confirmed that the oxygen rate should have been set to 3 L/min as per the physician's order. The Director of Nursing (DON) also stated that licensed nurses should follow physician orders for oxygen settings to ensure residents receive the proper dose of oxygen. The facility's policy on oxygen administration emphasized the importance of verifying physician orders and adjusting the oxygen delivery device to administer the correct flow of oxygen. The failure to adhere to these standards placed the resident at risk of unmet respiratory needs.
Failure to Notify Designated Representative of Resident Discharge
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident, identified as Resident 60, who was discharged without the knowledge or consent of their designated representative, RP 2. The resident, who had a history of dementia and a BIMS score indicating severe cognitive impairment, was discharged against medical advice (AMA) with the paperwork signed by another family member, OF 1. The facility's records indicated that RP 2 was the designated representative, yet there was no documentation of communication with RP 2 regarding the discharge. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the facility did not follow proper procedures in notifying the designated representative. The SSD acknowledged the lack of documentation and the importance of contacting the representative, while the DON stated that the documentation was insufficient and emphasized the need to involve the representative in such decisions. The facility's policy required that the resident or their representative sign a release of responsibility form when discharged without a physician's approval, which was not properly adhered to in this case.
Failure to Notify Physician of Continuous Oxygen Use
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive person-centered care plan for a resident who had an order for prn oxygen but was receiving it continuously due to episodes of increasing shortness of breath. The Licensed Nurses did not notify the Attending Physician of this change in condition, which was necessary to update the care plan and physician orders to reflect the resident's continuous use of oxygen. The resident, who was cognitively intact with a BIMS score of 14, had a medical history of shortness of breath, acute respiratory failure with hypoxia, heart failure, hypertension, obstructive sleep apnea, and muscle weakness. Despite the resident's continuous use of oxygen for over a month, the Licensed Nurses failed to notify the Attending Physician, which was a requirement according to the facility's policy and procedure for changes in a resident's condition or status.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in frequent complaints of knee pain that went unrelieved. The resident, who had been at the facility for two to three years, was observed experiencing knee pain that limited her ability to participate in physical therapy sessions. Despite the resident's complaints and the presence of a surgical scar on her right knee, the facility did not adequately address her pain management needs, which were documented in her care plan. The resident's care plan indicated that she had pain in her right knee and required monitoring and reporting of changes to her physician. However, the facility's staff, including CNAs and LVNs, failed to consistently communicate the resident's refusal of therapy due to pain to the appropriate personnel. The RNA reported the resident's refusal of therapy to the licensed nurse, but there was no evidence that the physician was notified or that pre-medication was administered to manage the resident's pain before therapy sessions. Interviews with facility staff, including the DON and IP, revealed that the licensed nurse should have notified the physician immediately upon the resident's refusal of therapy due to pain. The facility's policy on pain assessment and management emphasized the importance of recognizing and addressing pain, but the staff did not adhere to these guidelines. The lack of communication and failure to update the resident's care plan contributed to the deficiency in providing individualized care for the resident.
Failure to Provide Appropriate Diet Texture for Resident
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for a resident on a mechanical soft diet. During an observation, the resident was served a regular diet meal, which included chunks of cooked meat, rice, a whole flour tortilla, and fresh tomato pieces, despite being prescribed a mechanical soft diet. This discrepancy was noted on the resident's meal ticket, which clearly indicated the need for a mechanical soft diet. The resident, who was admitted for hospice care with diagnoses including Alzheimer's disease, depression, anxiety, and Type 2 Diabetes Mellitus, was severely cognitively impaired with a BIMS score of 3. The dietary staff, including the Dietary Aide, Director of Culinary Services, and Registered Dietician, confirmed that the meal served did not match the prescribed diet texture. They acknowledged the increased risk of choking for residents on a mechanical soft diet who are served regular diet texture foods. Interviews with facility staff, including the Activities Assistant and Director of Nurses, revealed that there were procedures in place to ensure meal trays matched diet orders. However, these procedures were not followed, resulting in the resident receiving an inappropriate meal. The facility's policy and procedure on food preparation guidelines emphasized the importance of providing food in a form that meets each resident's individual needs, which was not adhered to in this instance.
Infection Control Lapses in Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN 1 and LVN 1. RN 1 did not change her gloves after cleansing a wound and before applying medication and a clean dressing to a resident who was on Enhanced Barrier Precautions (EBP). Additionally, RN 1 did not perform hand hygiene after removing her gown and exiting the resident's room. This resident had a history of hemiplegia, hemiparesis, dysphagia, Parkinson's disease, respiratory failure, and dementia, making them particularly vulnerable to infections. During the dressing change, RN 1 wore gloves to handle supplies but did not sanitize the bedside table before placing the supplies. After assisting with the resident's wound dressing change, RN 1 applied a new dressing without changing gloves, discarded her supplies and gloves, and performed hand washing. However, she failed to perform hand hygiene after removing her gown and before exiting the room. The Director of Nursing (DON) confirmed that RN 1 should have performed hand hygiene before starting the dressing change, after removing soiled gloves, and after leaving the resident's room. Similarly, LVN 1 did not perform hand hygiene before entering and exiting resident rooms and between residents during medication administration. LVN 1 acknowledged the importance of hand hygiene to prevent contamination and transfer of germs. The DON stated that the licensed nurse should have performed hand hygiene before entering and after exiting resident rooms and between each resident's medication pass. The facility's policy emphasized hand hygiene as the primary means to prevent the spread of infections, which was not adhered to by the staff involved.
Failure to Implement Activity Care Plan for Bedbound Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was bedbound for eight months and did not have an activity care plan. This oversight led to the resident spending her waking hours picking on her skin, resulting in excoriations on various body parts, including the abdomen, left hip, and right hip. The resident was readmitted to the facility with multiple diagnoses, including Parkinson's disease, congestive heart failure, major depressive disorder, contracture of muscles in the lower legs, and paraplegia. Her Minimum Data Set indicated moderate cognitive impairment. Observations and interviews revealed that the resident was often bored, as evidenced by her staring at the ceiling and expressing boredom. The Activity Director admitted that an activity care plan should have been created at the time of admission but was not. The lack of an activity care plan was acknowledged by the Licensed Vocational Nurse, Minimum Data Set Nurse, and Director of Nursing, who all noted that the resident's behavior of picking on her skin could have been avoided with appropriate activities. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not done in this case.
Non-Functioning Call Light System in Facility
Penalty
Summary
The facility failed to maintain a functioning call light system, which is essential for residents to request assistance. During observations and interviews, it was found that seven out of 56 resident call lights were not functioning properly. Residents in rooms 14 A, 14 B, 14 C, 13 A, 18 B, 19 B, and 20 A were affected. For instance, a resident in room 14 A had been using a handbell for several weeks because the call light was not working. The Certified Nursing Assistant (CNA) confirmed that the call lights in rooms 14 B and 14 C were also non-functional, which was previously unknown to her. The Director of Maintenance (DOM) admitted that routine checks of the call lights were not conducted, and he relied on staff to report any issues. The DOM was unaware of the non-functioning call lights until the survey, and he acknowledged that the call buttons were faulty and needed replacement. The Administrator (ADM) and the Director of Staff Development (DSD) were also interviewed. The ADM was unaware of the multiple call light failures, although she acknowledged the importance of a functioning call system. The DSD, who conducted daily rounds, was aware of the malfunctioning call light in room 14 A and noted that the resident used a handbell as an alternative. The facility's policy and procedure documents indicated that the call light system should be operable and routinely inspected by maintenance staff, and any non-operable call lights should be reported. However, these procedures were not followed, leading to the deficiency.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Reedley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Homes | 0.5 mi | ★★★★★ | 18 | 0 |
| Palm Village Retirement Comm. | 0.8 mi | ★★★★★ | 1 | 0 |
| Dinuba Healthcare | 4.9 mi | ★★★★★ | 17 | 0 |
| Kingsburg Center | 8 mi | ★★★★★ | 3 | 0 |
| Bethel Lutheran Home | 9 mi | ★★★★★ | 19 | 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.