Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodcrest Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of lower extremity fracture and osteomyelitis, who had become non‑weight bearing and only able to perform minimal side stepping with moderate assistance, was discharged home when insurance benefits were exhausted. The care plan called for discharge home with family, and case management informed a family member of the discharge date and that 24/7 care would be needed, but did not clearly communicate the resident’s current ADL and ambulation limitations or document any caregiver training or assessment of the family’s ability to provide required care. Staff interviews confirmed that the resident was not ambulating, required assistance for transfers, and that the family was not prepared for the level of care needed, contrary to facility policy requiring evaluation of caregiver availability, capacity, and capability in the post‑discharge plan.
Dumpster Lids Left Open: Surveyors observed two of two dumpster bin lids not fully closed, with the dumpster overloaded with garbage bags and the cover open about a foot and a half. The DSS and RD both stated the lids should be closed, and the facility policy required garbage and trash cans to be inspected daily and lids kept closed.
A resident with stroke-related deficits, AFib, and HTN repeatedly refused ordered meds, but the record did not show consistent assessment of the refusals, reasons, education, interventions, or timely MD notification, despite ongoing elevated BP readings. Another resident with DM had repeated very high blood sugars and an abnormal HgbA1C result that was not documented as addressed promptly or reported to the MD in a timely manner.
Controlled substance records did not match MAR documentation for two residents. An LPN found a discontinued hydrocodone-acetaminophen blister card still stored with active meds, and tablets were removed after the order had been stopped, with no matching MAR entries or progress notes. Another resident’s oxycodone CDR also showed removals that did not reconcile with the MAR, and the DON confirmed the discrepancies.
Medication administration errors exceeded the allowed rate when staff gave the wrong medication and dosage form to one resident and incorrect doses to two other residents during med pass observations. An LVN administered a multivitamin and chewable aspirin instead of the ordered multivitamin-mineral tablet and delayed-release aspirin, gave Vitamin D3 5,000 units and Vitamin B12 500 mcg instead of the ordered doses, and gave 20 mL of lactulose instead of 30 mL. The DON confirmed the ordered medication, dosage form, and doses should have been given as prescribed.
A facility failed to follow infection control practices when an LVN used the same shared BP monitor and cuff for three residents without cleaning or disinfecting it between uses, a housekeeper did not perform hand hygiene after doffing PPE in an EBP room, and a resident’s nasal cannula was not changed weekly as ordered. Staff and the IP confirmed the equipment and hand hygiene practices required disinfection and hand hygiene, and the resident’s oxygen tubing was observed dated past the weekly change schedule.
Failure to provide fingernail care was identified for a resident whose nails were observed to be long, yellowish, and dirty underneath. The resident said nail care had not been provided recently and wanted the nails cut and cleaned. The care plan called for keeping fingernails clean and trimmed, and staff stated CNA nail care includes daily cleaning, trimming, and filing to help prevent infection and injury.
Failure to follow ordered oxygen flow rates for two residents. One resident with COPD and asthma-related respiratory issues was observed on O2 at 5 lpm via NC despite an order for 3 lpm continuously, and another resident with COPD was observed on O2 at 3 lpm despite an order for 2 lpm continuously. An LVN and the ADON both confirmed the observed flow rates did not match the physician orders, and the care plans directed oxygen therapy as ordered.
Dietary staff failed to properly carry out key food safety tasks. A cook could not demonstrate the IDDSI spoon tilt test for minced and moist foods, a second cook gave an incorrect explanation of the cooling process for TCS foods, and a dietary aide did not follow the manufacturer’s required 10-second dip time when testing Quat sanitizer. These failures involved residents receiving minced and moist diets and food from the kitchen, and were linked to choking and foodborne illness concerns.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with multiple complex medical conditions was discharged without a complete post-discharge plan of care, missing critical information such as responsible party contacts, wound care instructions, and follow-up appointment details. Gaps in communication and documentation by the case manager and nursing staff led the resident's family to seek emergency care within 24 hours of discharge.
A deceased resident's body was left in a shared room for 12 hours, causing trauma to two other residents. Despite the death being pronounced in the morning, the body was not removed until the evening, leading to distress and negative psychosocial outcomes for the roommates. Staff interviews revealed a lack of communication and adherence to protocol, and the facility's policies on dignity and resident rights were not followed.
The facility failed to respond promptly to call lights for three residents, resulting in unmet needs. A resident with osteoarthritis reported no response to her call light for restroom assistance. Another resident with a fracture waited over 10 minutes for help, expressing frustration over previous delays. A third resident with cognitive impairment had his call light on for over 15 minutes, needing to be changed. Staff interviews confirmed the policy for prompt responses, but observations showed staff ignoring activated call lights.
The facility failed to ensure accurate PASARR screenings for two residents, leading to deficiencies. One resident was admitted with dementia, schizophrenia, and major depressive disorder, but the screening inaccurately reported no serious mental disorders. Another resident with psychosis and major depressive disorder also had an inaccurate screening. The facility relied on hospitals for accurate screenings and did not verify them upon admission, leading to potential care issues.
A facility failed to notify the state-designated authority after a resident was diagnosed with schizophrenia. The resident, admitted with psychosis and major depressive disorder, received the new diagnosis from a psychiatrist. Staff interviews revealed confusion about the PASARR process, with Social Services and an RN unsure if a new Level I screening was needed for the diagnosis, leading to the oversight.
The facility exceeded the acceptable medication error rate of 5%, with errors affecting two residents. One resident received the wrong iron supplement, while another received incorrect constipation medication. The DON and Administrator expected adherence to physician orders and a medication error rate below 5%.
The facility failed to administer medications on time for three residents, with medications being given beyond the allowed time frame. Residents reported having to seek out nurses for their medications, and records showed multiple instances of late administration without documented reasons. The facility's policy on medication timing was not consistently followed.
A facility failed to provide sufficient nursing staff, leading to inadequate care for residents. Staff reported being consistently short-staffed, with CNAs managing an unmanageable number of residents. A resident expressed dissatisfaction due to delays in personal care and lack of showers. The facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD), resulting in increased workloads and inadequate care.
The facility did not update or post daily staffing information, including actual hours worked by nursing staff, as required. The document 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was not updated with necessary details for multiple dates. The Interim Director of Staff Development was responsible for these calculations but lacked access to payroll data, leading to non-compliance with the facility's policy.
A resident with a history of stroke and aphasia was found unable to reach her call light, as it was placed on her roommate's TV mount. This was confirmed by a CNA, LVN, and the DON, all of whom stated that the call light should be within the resident's reach. The facility's policy also required call lights to be accessible, but it was not followed in this case.
A facility failed to notify a resident's responsible party (RP) when the resident was transferred to a hospital due to chest pain. Despite the facility's policy requiring notification of the RP during a change of condition (COC), there was no documentation of such notification. The resident had a history of supraventricular tachycardia and hypertension and could not make medical decisions independently. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the failure to follow protocol.
A facility failed to communicate a physician's order for physical therapy to a hospice provider for a resident under hospice care, resulting in the resident not receiving the prescribed therapy. The resident, with conditions including supraventricular tachycardia and rheumatoid arthritis, was under hospice care, and the order was not communicated as required by facility policy.
A resident with a full code status was found unresponsive, without a pulse, and not breathing. Despite the resident's condition, LVN 2 and RN 2 did not initiate CPR, citing the resident's body as cold and stiff. Interviews with other staff and the DON confirmed that CPR should have been performed according to the facility's policy and the resident's full code status.
A resident missed multiple doses of prescribed medications, including apixaban and amiodarone, with no documentation or reason provided. Interviews with the DSD and DON confirmed the lack of documentation and administration, contrary to the facility's policy.
A resident fell and broke his hip after the facility failed to repair a loose toilet seat that was reported to staff. The issue was not recorded in the maintenance log or addressed, leading to the resident's fall and subsequent surgery.
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for a resident and her family member. The resident, with a history of multiple medical conditions, expressed a desire to go home, but her family member was not adequately prepared for her discharge. There was no documented evidence of discharge preparations between the issuance of the discharge notice and the planned discharge date, leading to inadequate preparation and orientation.
The facility failed to notify the family member designated as the Power of Attorney (POA) for a resident about a change in the resident's condition. Despite the POA being effective immediately, the Treatment Nurse only informed the resident and the physician, neglecting to notify the POA. This oversight prevented the POA from fulfilling their duties effectively.
Failure to Inform Family of Functional Status and Provide Adequate Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary discharge planning in accordance with its own policy for a resident discharged home after treatment for a right lower leg fracture and left ankle/foot osteomyelitis. The resident had been mostly independent with ADLs and used a rollator for longer distances prior to hospitalization, but during the facility stay he was non‑weight bearing on the left lower extremity, had weakness in the right lower extremity, and was only able to perform a few feet of side stepping with a front‑wheeled walker and moderate assistance. The care plan identified a goal to discharge the resident back to the community with his wife and for the facility to discuss the discharge plan with the resident and family as appropriate. Case management documentation showed that the case manager informed a family member that the resident’s insurance benefits would be exhausted and that he would discharge home, and that the family would assist with care at home. Subsequent documentation noted that during an insurance meeting, the team, including the physician and rehab director, was aware the resident would exhaust benefits and discharge home with 24‑hour family care. However, there was no documentation that the family member was informed of the resident’s current functional limitations, including his limited ambulation status, or that caregiver training was offered or provided, or that the family’s capacity to perform the required care was assessed, as required by the facility’s discharge policy. Interviews further confirmed these gaps. The resident reported he was discharged due to exhaustion of insurance benefits and that he and his wife were now bedridden, with family providing care. A CNA stated she never saw the resident walk and that he required assistance to get into the car at discharge. The case manager acknowledged she did not discuss the resident’s limited ambulation status with the family and could not recall if caregiver training was offered. The family member stated she was told only that the resident would need 24/7 care, did not know he could not walk, was not offered caregiver training, and required assistance from another family member and paramedics to manage the resident at home. The facility’s policy required evaluation of caregiver availability, capacity, and capability to perform required care as part of the individualized post‑discharge plan, which was not documented or demonstrated in this case.
Dumpster Lids Left Open
Penalty
Summary
F814, Dispose Garbage and Refuse Properly, was cited after surveyors observed that two of two dumpster bin lids were not fully closed. On January 5, 2026, at 10:03 a.m., during concurrent observation and interview with the Dietary Service Supervisor, the dumpster was overloaded with garbage bags and the cover was open about a foot and a half; the DSS stated the dumpster was not fully covered and that dumpsters should be covered to prevent insects and rodents' infestation. On January 8, 2026, at 11:23 a.m., during concurrent observation of a picture of the dumpster and interview with the Registered Dietician, the RD stated there were a lot of bags and the lids were open, and further stated that dumpster lids should be covered and that the main objective is to keep the rodents out. A review of the facility policy titled "Garbage and Trash," dated 2023, indicated that garbage and trash cans must be inspected daily and lids are closed.
Medication Refusals and Delayed Follow-Up on Abnormal Diabetes Lab Result
Penalty
Summary
Resident 83 had a documented pattern of refusing all ordered medications, including amiodarone, amlodipine, apixaban, clonidine patch, and hydralazine, across multiple months. The resident was admitted with diagnoses including hemiparesis and hemiplegia following cerebral infarction, atrial fibrillation, and hypertension, and was documented as having the capacity to understand and make decisions with a BIMS score of 13. The care plan identified refusing medication as a focus, but the record did not show consistent evaluation of the refusals, the reasons for refusal, education provided, interventions attempted, or the resident’s response. The MAR showed repeated refusals of the resident’s medications, and blood pressure readings were documented on several dates with multiple elevated systolic values. The record did not show consistent periodic nursing or physician progress note documentation addressing the refusals, the reasons for refusal, or interventions related to the elevated blood pressure readings when medications were refused. Quarterly IDT care conference notes also did not address the resident’s pattern of medication refusals. Facility staff acknowledged the resident had been refusing medications and vital signs for at least a year, and the DON confirmed the documentation should have included the refusals, physician notification, and the plan of care related to them. Resident 100, who was admitted with diabetes mellitus, had blood sugar monitoring showing repeated readings in the 351 to 400 mg/dl range during August, September, and October 2025. A physician ordered an HgbA1C lab draw, and the result was 9.1%, above the reference range. The record did not show documented evidence that the abnormal HgbA1C result was addressed. Staff interviews indicated the result should have been promptly referred to the physician, and one RN stated it was not referred until 15 days after the lab result date. The DON stated abnormal results should be reported to the physician timely and that the notification should have been documented.
Controlled Substance Documentation and Storage Discrepancies
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for controlled substances when a discontinued hydrocodone-acetaminophen order for one resident remained in active medication storage and tablets continued to be removed from inventory after the physician had discontinued the medication. During inspection of the medication cart, the discontinued blister card was still stored with active medications, and the licensed nurse confirmed it should have been removed and given to the DON for destruction. For that resident, the controlled drug record showed one tablet removed on a date before discontinuation without corresponding MAR documentation of administration or pain assessment, and additional tablets were documented as removed after the order had already been discontinued. The January MAR did not contain an active order for the medication after discontinuation. Nursing staff confirmed that controlled substance administrations were required to be documented on both the CDR and MAR, and there were no progress notes corresponding to the documented removals after discontinuation. The resident stated he received pain medication when he reported pain, but could not recall the specific medication on the dates in question and reported that Norco caused hallucinations and visual disturbances, while Tylenol helped his pain. A second resident had a blister card for oxycodone stored on the medication cart, and the CDR and MAR did not reconcile. The record showed tablets removed from inventory on two occasions, but there was no corresponding documentation of administration or pain assessment on the MAR. The DON confirmed the discrepancies between the CDR and MAR and stated the expectation that controlled substance removal be documented on the CDR and medication administration be documented on the MAR. The residents involved had diagnoses including peripheral vascular disease and osteoarthritis, respectively, and the findings were based on observation, interview, and record review.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and its medication administration policy, resulting in a 20% medication error rate with five errors out of 25 medication administration opportunities observed for three residents. During medication pass observations, errors involved administration of an incorrect medication and dosage form for one resident, incorrect doses for two residents, and the facility’s policy required medications to be given in accordance with prescriber orders and verified for the right medication and right dosage before administration. For one resident, an LVN administered a multivitamin tablet and an aspirin 81 mg chewable tablet instead of the ordered multivitamin-mineral tablet and delayed-release aspirin 81 mg. For a second resident, an LVN administered Vitamin D3 5,000-unit capsules and Vitamin B12 500 mcg tablets instead of the ordered Vitamin D3 1,000-unit tablet and Vitamin B12 1,000 mcg tablet. For a third resident, an LVN administered 20 mL of lactulose oral solution instead of the ordered 30 mL dose. The DON reviewed each order and confirmed the correct medication, dosage form, or dose should have been administered as ordered by the physician.
Infection Control Lapses With Shared Equipment, Hand Hygiene, and Oxygen Tubing
Penalty
Summary
Infection control practices were not followed for shared medical equipment when a wrist BP monitor with an attached cuff was used for three residents without being cleaned or disinfected between uses. On January 5, 2026, LVN 3 used the same wrist BP monitor to obtain blood pressure readings for Resident 111, Resident 61, and Resident 110, and after each use the monitor was placed back on the medication cart without cleaning or disinfecting it. During interview, LVN 3 acknowledged the equipment was shared and should have been cleaned and disinfected after each use with facility-approved wipes kept in the medication cart. The facility also failed to ensure hand hygiene was performed after PPE was removed while a housekeeper entered an Enhanced Based Precaution room. HK 1 was observed entering the room and, after doffing PPE, did not perform hand hygiene. During interview, HK 1 stated hand hygiene should have been done immediately after PPE was removed and acknowledged the potential for cross-contamination. The IP stated hand hygiene is required in multiple situations, including after doffing PPE, and the facility policy directed use of alcohol-based hand rub after removing gloves and before and after entering an isolation precaution room. The facility further failed to follow its standards of practice for oxygen equipment for Resident 14. The resident, who had diagnoses including shortness of breath and fluctuating capacity to understand and make decisions, was observed using oxygen via nasal cannula at 2 L/min, and the tubing was dated 12/29/25 even though the physician order directed the nasal cannula to be changed every Sunday. LVN 2 and the ADON both stated the tubing should be changed weekly on Sundays, and the ADON stated the licensed nurse should have changed the nasal cannula in accordance with facility practice. The facility policy stated the nasal cannula should be changed once a week and as needed.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to provide fingernail care for one resident who was unable to perform the task independently. During an observation and interview, the resident was found with long, yellowish fingernails on both hands and black residue under three fingernails on the left hand. The resident stated that fingernail care had not been provided recently and requested that the fingernails be cut and cleaned. The resident’s record indicated a diagnosis of heart failure, and the history and physical noted that the resident had the capacity to understand and make decisions. The resident’s care plan identified a risk for skin breakdown and skin tears or injury related to scratching, with an intervention to keep fingernails clean and trimmed. A CNA stated that CNAs are responsible for daily fingernail care, including cutting, cleaning the surface and underneath the nails, and filing. The DSD and ADON both stated the resident’s fingernails should have been cleaned and trimmed, and the facility policy stated nail care includes daily cleaning and regular trimming to keep the nail bed clean and prevent infections.
Failure to Follow Ordered Oxygen Flow Rates
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for two residents reviewed for oxygen use. One resident with COPD and asthma-related respiratory issues was observed using oxygen at 5 lpm via nasal cannula, although the physician order directed oxygen at 3 lpm continuously. The resident’s record also showed a care plan directing oxygen therapy as ordered. During interview, the LVN stated the resident’s oxygen flow rate should have been 3 lpm according to the physician’s orders, and the ADON confirmed the ordered rate was 3 lpm. A second resident with COPD was observed using oxygen at 3 lpm via nasal cannula, while the physician order directed oxygen at 2 lpm continuously. The resident’s care plan directed oxygen to be administered as ordered. During interview, the LVN stated the resident’s oxygen flow rate should have been 2 lpm according to the physician’s orders, and the ADON confirmed the ordered rate was 2 lpm. The facility policy stated orders shall be implemented, and the charge nurse job description included preparing and administering medications as ordered by the physician.
Dietary Staff Failed to Follow IDDSI, Cooling, and Sanitizer Testing Procedures
Penalty
Summary
The facility failed to ensure dietary staff could safely and effectively carry out food and nutrition services when Cook 1 did not know how to fully test minced and moist texture foods using the spoon tilt test. During a concurrent interview and demonstration, Cook 1 could not show how the spoon tilt test was done and stated she did not know what it was. The Registered Dietician stated the cook should have known how to prepare and check thickened liquids using the spoon tilt test for IDDSI diets, and the facility’s Minced and Moist IDDSI document identified the spoon tilt test as a critical test. This failure had the potential for risk of choking for six residents who had dysphagia and received minced and moist diets from the kitchen during the lunch meal. The facility also failed to ensure dietary staff followed required procedures for cooling ambient food and testing sanitizer concentration. Cook 2 stated that cooling down tuna salad meant cooling room-temperature food to 40 F in two hours, while the RD stated the correct process was cooling from 140 F to 70 F in two hours and then from 70 F to 40 F in the next four hours, as outlined in the facility’s cooling procedures. In addition, a Dietary Aide tested the red bucket Quat sanitizer but dipped the test strip for 6.9 seconds instead of the manufacturer’s required 10 seconds. The Dietary Services Supervisor stated the test strip should have been dipped for 10 seconds and that failing to do so could result in the wrong sanitizer concentration and ineffective sanitization of food contact surfaces. These failures had the potential to cause foodborne illnesses for 111 residents who received food from the kitchen.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Provide Complete Post-Discharge Plan of Care
Penalty
Summary
The facility failed to ensure that a resident received a comprehensive post-discharge plan of care containing all necessary information for the continuation of care after discharge. The resident, who had a complex medical history including a left above-the-knee amputation, COPD, and cirrhosis with ascites, was discharged without complete documentation regarding responsible party contact information, activity levels, equipment and supplies, home health agency details, wound care instructions, ombudsman information, follow-up appointments, and pharmacy information. The discharge summary also lacked documentation of discharge diagnosis and prognosis. Interviews with facility staff revealed that while the case manager and social service staff attempted to coordinate discharge planning, there were gaps in communication and follow-through. The case manager did not make follow-up appointments as ordered, nor did she discuss the possibility of applying for additional services through Medi-Cal. The home health agency and insurance care coordinator were notified of the resident's needs, but no appointments were scheduled prior to discharge. The resident's family was left without clear instructions, leading them to contact the facility for advice when the resident experienced swelling in his leg after discharge. As a result of the incomplete discharge planning and lack of necessary information, the resident's family sent him to the emergency room within 24 hours of discharge. Facility policy and job descriptions indicated that nursing services and case management were responsible for preparing and communicating the post-discharge plan, but these requirements were not met in this instance, resulting in a breakdown in the continuity of care.
Failure to Remove Deceased Resident Promptly
Penalty
Summary
The facility failed to treat residents with respect and dignity when a deceased resident's body was left in the room with two other residents for approximately 12 hours. This incident involved Residents A and B, who shared a room with Resident C, who passed away early in the morning. Despite the death being pronounced at 8:57 a.m., Resident C's body was not removed until 7:30 p.m. that evening. During this time, Residents A and B experienced negative psychosocial outcomes, including trauma and distress, as they were forced to remain in the room with the deceased. Interviews with Resident B revealed that the presence of the deceased body was traumatic and disrespectful, as staff entered the room without acknowledging the living residents. Resident B's family requested that meals be served elsewhere due to the smell, but this was not accommodated. Resident A also expressed anger and distress over the situation, stating that the staff did not offer a room change. Medical records and social service notes confirmed the residents' distress and the offer of psychological support and room changes after the incident. Staff interviews indicated a lack of communication and adherence to protocol. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) acknowledged the inappropriate delay in removing the body and the failure to offer room changes to the living residents. The Director of Nursing (DON) admitted that the situation was not handled efficiently and that staff expectations were not met. The facility's policies on dignity and resident self-determination were not followed, as staff failed to promote a dignified environment and respect the residents' rights.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights within a reasonable time for three residents, leading to unmet needs. Resident 5, who has osteoarthritis, muscle wasting, and a history of falling, reported to her family that she activated her call light for restroom assistance, but no one responded. Resident 6, with a fracture, hypertension, and difficulty walking, was observed with an activated call light for over 10 minutes without response. He expressed frustration over waiting more than an hour for assistance earlier in the day. Resident 7, with metabolic encephalopathy, osteoarthritis, and moderate cognitive impairment, had his call light on for over 15 minutes without response, needing to be changed. Staff interviews revealed that the facility's policy is to answer call lights promptly, and all staff are responsible for responding, regardless of resident assignment. However, observations showed staff walking past activated call lights without checking on residents. The Director of Nursing confirmed the expectation for timely responses and that call lights should be within residents' reach. The facility's policy, dated March 2021, emphasizes the importance of timely responses to residents' requests and needs.
Inaccurate PASARR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for two residents, leading to deficiencies in the screening process. Resident #3 was admitted with a medical history of dementia, schizophrenia, and major depressive disorder, yet the PASARR Level I screening inaccurately indicated that the resident did not have any serious diagnosed mental disorders. Interviews with facility staff, including Social Services, a Registered Nurse, the Director of Nursing, and the Administrator, confirmed the inaccuracy of the screening. Similarly, Resident #59 was admitted with diagnoses of psychosis and major depressive disorder. The PASARR Level I screening for this resident also inaccurately reported no serious diagnosed mental disorders. Interviews revealed that the facility relied on the hospital to complete the screenings accurately and did not review them for accuracy upon admission. The Director of Nursing and the Administrator acknowledged the inaccuracies in the screenings and the potential for misleading the facility about the residents' needs. The deficiency arose from the facility's reliance on hospitals to conduct accurate PASARR screenings without verifying the information upon admission. This oversight led to inaccurate screenings for both residents, potentially affecting the care and services they required. The facility's policy required all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but the lack of verification contributed to the deficiency.
Failure to Notify State Authority of New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness, specifically schizophrenia. The resident, who was admitted on December 15, 2023, had a medical history that included psychosis and major depressive disorder, both diagnosed on the day of admission. On December 29, 2023, the resident received a new diagnosis of schizophrenia from a psychiatrist. Despite this new diagnosis, there was no evidence in the resident's medical record that a referral was made to the state-designated authority as required by the preadmission screening and resident review (PASARR) requirements. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. Social Services (SS) #7 indicated that Level I screenings were typically completed at the hospital before admission and that a new screening would only be necessary if there was a change in the resident's condition. SS #7 believed that the resident's mental status had not changed, and therefore, a new Level I screening was not required. Registered Nurse (RN) #8 also expressed uncertainty, stating that a new Level I screening would be completed for a new order of psychotropic medication, but not necessarily for a new diagnosis. This confusion and lack of action led to the failure to notify the appropriate authority about the resident's new diagnosis of schizophrenia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by two medication errors out of 33 opportunities, resulting in a 6.06% error rate. This affected two residents during medication administration. Resident #10, who was admitted with a diagnosis of unspecified anemia, was prescribed ferrous fumarate 324 mg to be taken three times a day. However, during an observation, LVN #6 administered ferrous sulfate 325 mg instead of the prescribed medication. Resident #39, admitted with diagnoses including adult failure to thrive and unspecified dementia, was prescribed Senna-S for chronic constipation. The order specified two tablets of Senna-S to be given twice daily. During medication administration, LVN #6 gave one Geri-kot 8.6 mg tablet and one docusate sodium 100 mg capsule instead of the prescribed combination. Interviews with the DON and the Administrator revealed expectations for nurses to administer medications as per physician orders and maintain a medication error rate below 5%.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure medications were administered on time as prescribed by the physician and according to the facility's policy for three residents. During an unannounced visit, it was observed that medications due at 9:00 a.m. were still being administered by an LVN at 11:42 a.m., well beyond the two-hour window allowed by the facility's policy. Interviews with the LVNs revealed inconsistencies in understanding the time frame for medication administration, with some stating a two-hour window and others a one-hour window. Resident 1, who was alert and conversant, reported having to look for the nurse when it was time for his pain medication. A review of Resident 1's medication administration record showed multiple instances of late administration, including critical medications such as Imatinib and Aspirin. Similarly, Resident 2, who also had the capacity to understand and make decisions, received medications like Metformin and Hydralazine late, with no documentation explaining the delays. Resident 3, who had been discharged, also experienced late medication administration, including Aspirin and Atenolol, with no documented reasons for the delays. The facility's policy required documentation for early, late, or omitted medications, but this was not adhered to. The Director of Nursing acknowledged the difficulty in predicting outcomes from late medication administration, depending on the medication type and frequency.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as observed during an unannounced visit on July 23, 2024. Interviews with staff, including CNAs and LVNs, revealed ongoing staffing issues, with reports of being consistently short-staffed across all shifts. CNAs reported being assigned an unmanageable number of residents, with one CNA stating they had 26-27 residents to care for. This shortage was corroborated by the staffing coordinator, who noted that the facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD) on several occasions, leading to increased workloads and inadequate care. Resident 4, who was interviewed during the visit, expressed dissatisfaction with the care received due to staffing shortages. The resident reported that staff were often too busy to respond promptly to call buttons and that there were significant delays in receiving personal care, such as being changed or showered. The resident had not received a shower since May 28, 2024, despite preferring showers over bed baths. A review of the resident's medical records confirmed the lack of showers and no documented evidence of refusal or preference for bed baths. The facility's staffing coordinator and Director of Nursing acknowledged the staffing deficiencies, noting that the required DHPPD was not consistently met, and CNAs were often overburdened with too many residents. The facility's policy, which mandates sufficient staffing to meet residents' needs, was not adhered to, resulting in inadequate care and potential resident dissatisfaction. The facility was actively recruiting more staff and asking current staff to work additional hours to address the staffing shortfall.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that updated staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff, was posted in a prominent place readily available to residents and visitors. During an observation, it was noted that the document titled 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was posted in the facility lobby but was not updated with the necessary information. The forms lacked details such as the actual total direct care service hours, actual total CNA direct care service hours, the average patient census, the actual DHPPD, and the actual CNA DHPPD for multiple dates. Interviews with the Staffing Coordinator and the Interim Director of Staff Development (IDSD) revealed that the IDSD was responsible for calculating and posting the actual direct care service hours and DHPPD. However, the IDSD stated that these calculations were done weekly based on data from payroll, to which she did not have access. Consequently, the documents from July 1 to July 14 were not updated. The facility's policy required daily posting of staffing numbers within two hours of each shift's start, but this was not adhered to, as confirmed by the Administrator.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, had her call light within reach, which is a violation of her rights to a dignified existence and self-determination. During unannounced visits, it was observed that Resident 2, who was alert but had unclear speech due to aphasia, was unable to reach her call light as it was hanging on the TV mount of her roommate. This was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the call light was not within Resident 2's reach, which would prevent her from calling for help. Resident 2's medical record indicated she was admitted with a diagnosis of stroke, resulting in right-sided weakness and aphasia, and her care plan specified that the call light should be within her reach due to her self-care deficit. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) all confirmed that the call light should always be accessible to Resident 2. The facility's policy on answering call lights, dated March 2021, also stated that call lights should be within easy reach of residents when they are in bed. The DON acknowledged that the policy was not followed in this instance.
Failure to Notify Responsible Party of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a change of condition (COC) and the resident was transferred to a general acute care hospital (GACH). This deficiency was identified during unannounced visits conducted on June 24 and 25, 2024. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the facility's protocol required notifying the doctor and RP when a resident experienced a COC or was sent to the hospital. However, a review of the resident's records showed no documentation that the RP was informed of the transfer to the hospital for chest pain on July 15, 2023. The resident in question had a history of supraventricular tachycardia and hypertension and was unable to make medical decisions independently. Despite this, there was no evidence in the resident's chart that the RP was notified of the hospital transfer. The facility's policy, dated December 2023, clearly stated that a nurse should notify the resident's representative in such cases and document the information in the medical record. The DON acknowledged that the facility did not adhere to its policy, resulting in the RP being unaware of the resident's health condition.
Failure to Communicate PT Order to Hospice
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy was communicated to the hospice provider for a resident under hospice care. This oversight resulted in the resident not receiving the prescribed physical therapy. The resident, who was admitted with diagnoses including supraventricular tachycardia and rheumatoid arthritis, was under hospice care since November 29, 2023. A physician's order for physical therapy was issued on December 5, 2023, following an orthopedic appointment, but there was no documented evidence that this order was communicated to the hospice provider. During interviews, the Director of Rehabilitation (DOR) confirmed that the order for physical therapy was not communicated to him, which was against the facility's protocol. The Director of Nursing (DON) stated that hospice managed all care for residents under hospice, implying that the hospice provider might have declined the therapy. However, the facility's policy required communication with the hospice provider to ensure resident needs were met. The failure to communicate the physician's order for physical therapy to the hospice provider was a deficiency identified during the survey.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive, despite being designated as a full code. The resident, who had a medical history including atrial fibrillation and hypertension, was admitted to the facility and had the capacity to understand and make decisions. The resident's Minimum Data Set indicated a full code status, meaning CPR should have been initiated if the resident was found without a heartbeat or not breathing. On the day of the incident, the resident was found unresponsive, without a pulse, and not breathing by LVN 2, who was the charge nurse at the time. Despite the resident's body being cold and stiff, LVN 2 acknowledged that CPR should have been initiated but did not proceed with it. RN 2, the supervisor, was informed of the situation and also decided against performing CPR, citing the resident's condition as cold and lifeless. Both LVN 2 and RN 2 failed to initiate CPR, contrary to the facility's policy and the resident's full code status. Interviews with other staff members, including RN 3 and the Director of Nursing (DON), confirmed that CPR should have been initiated for a full code resident found unresponsive. The facility lacked a written policy for CPR, relying instead on the POLST forms in residents' charts. The DON stated that the staff should have assessed the situation, checked the POLST, and initiated CPR if the resident was a full code. The failure to perform CPR resulted in the resident not receiving necessary life-saving measures.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of the residents when four medications were not administered during the scheduled time with no documentation for one resident. Resident 1, who was alert and oriented, reported missing doses of apixaban and amiodarone. A review of Resident 1's medical record revealed that the 9 pm dose of amiodarone was not given on three occasions, the 5 pm dose of apixaban was not given once, the 5 pm dose of ascorbic acid was not given once, and the 9 pm dose of atorvastatin was not given on three occasions. There was no documentation for these missed doses, and no reason was provided for not administering the medications as ordered by the physician. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the lack of documentation and administration for the missed doses. Both the DSD and DON acknowledged that the medications should have been administered as ordered and that any missed doses should have been documented with a reason. The facility's policy on medication administration documentation, which requires documentation of all administered medications and reasons for any missed doses, was not followed in this instance.
Failure to Repair Loose Toilet Seat Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident (Resident 3) by not repairing a loose toilet seat that was reported as needing repair. This failure led to Resident 3 falling off the loose toilet seat and sustaining a broken hip, which required surgical repair. The incident occurred after Resident 3 had informed the Social Service Assistant (SSA) about the loose toilet seat the day before the fall, but the issue was not recorded in the maintenance log or addressed in a timely manner. Resident 3, who was alert and conversant, reported the loose toilet seat to the SSA on April 2, 2024. Despite this, the SSA did not record the issue in the maintenance log or verbally alert the maintenance staff. On April 3, 2024, Resident 3 fell while attempting to use the toilet, resulting in a broken hip. The resident was assessed by nursing staff and subsequently transferred to the hospital for surgical repair. The resident's medical history included hypertension, end-stage renal disease, and a stroke, and he was previously independent with toilet transfers and walking. Interviews with staff revealed that the maintenance logs were not utilized properly, and the SSA was not initially aware of their existence. The Director of Nursing (DON) confirmed that the maintenance department was notified of the loose toilet seat only after the fall occurred. The facility's policy on safety and supervision emphasized the importance of identifying and reporting accident hazards, but this protocol was not followed in this instance.
Inadequate Discharge Preparation and Orientation
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for Resident 2 and her family member. Resident 2, who had a history of encephalopathy, cerebrovascular accident with left-sided weakness, type 2 diabetes, and chronic kidney disease, expressed a desire to go home by the end of February 2024. However, her family member was not adequately prepared for her discharge, and there was no documented evidence that the family member was notified of the discharge notice issued on February 9, 2024, due to non-payment. The notice was effective on March 10, 2024, but Resident 2's family member was not informed until February 27, 2024, and requested more time to make arrangements at home. Despite this, the facility did not provide sufficient discharge preparations between February 9 and February 27, 2024. Interviews with the Certified Nurse Assistant (CNA) and the Social Services Director (SSD) revealed that Resident 2 required assistance with personal hygiene, had poor balance, and would benefit from assistance if discharged home. The SSD stated that Resident 2 was self-responsible and had been provided with personalized resources on March 8, 2024, including home health, transportation, and pharmacy referrals. However, the SSD also mentioned that some services required private pay, and Resident 2 needed to agree to the expenses. The SSD believed that the three-day period between March 8 and March 10, 2024, was sufficient for Resident 2 to arrange private caregivers and other options, but Resident 2's family member filed an appeal on March 9, 2024, delaying the discharge. Further review of Resident 2's records indicated that she required supervision and assistance with various activities of daily living, as documented in her Minimum Data Set (MDS) dated February 14, 2024. The facility's policy on preparing residents for discharge, dated December 2023, stated that residents should be prepared in advance for discharge and that a post-discharge plan should be developed. However, the facility did not adhere to this policy, as there was no documented evidence of discharge preparations with Resident 2 and her family member between February 9 and February 27, 2024, leading to inadequate preparation and orientation for a safe and orderly discharge.
Failure to Notify POA of Resident's Condition Change
Penalty
Summary
The facility failed to ensure that the family member (FM) designated as the Power of Attorney (POA) for Resident 2 was notified about a change in the resident's condition. Resident 2, who had diagnoses including type 2 diabetes mellitus with a right foot ulcer, end-stage renal disease on dialysis, and Alzheimer's disease, experienced a deterioration of a diabetic ulcer on February 6, 2024. Despite the POA being effective immediately as of September 16, 2022, the Treatment Nurse (TN) only notified Resident 2 and the physician about the condition change, failing to inform the FM who was the designated POA. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) both stated that the responsible party should be notified of any changes in condition, but this protocol was not followed in this instance. Interviews with the Director of Staff Development (DSD) and a review of Resident 2's records confirmed that the FM should have been notified of the change in condition. The facility's policy indicated that a resident representative, including a POA, should be notified to support the resident in decision-making. However, the TN was unaware of the POA status and did not notify the FM. The DON acknowledged that the POA should have been notified and could not explain why the TN failed to do so. This oversight resulted in the FM being unable to fulfill their POA duties effectively, as they were not informed of the resident's deteriorating condition.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Extended Care Hospital Of Riverside | 0 mi | ★★★★★ | 15 | 0 |
| Mission Care Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Alta Vista Healthcare & Wellness Centre | 1.2 mi | ★★★★★ | 1 | 0 |
| Villa Health Care Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Valencia Gardens Health Care Center | 1.6 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.