Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 California Care Center during CMS and state inspections, most recent first.
Care plans were not reviewed and revised for three residents when their conditions changed. One resident with stroke-related impairments had prostheses and poorly fitting dentures that were not care planned, another resident with an ICD and weight-monitoring orders had no related care plan interventions, and a third resident with severe cognitive impairment and hemiplegia had a contracted hand without care plan interventions. The Care Plan Coordinator, DON, and administrator stated these abnormal conditions should have been included and that the MDS and care plan should match.
A resident with CHF, anemia, CAD, and debility had a cardiology order for daily weights and for reporting rapid weight gain, but the order was not transcribed onto the POS. The cardiology NP said the facility was expected to record the resident’s weight as ordered and had no communication or weight records, while an LPN, the DON, and the administrator described the charge nurse’s responsibility for transcribing and clarifying new orders.
A resident was given another resident's medication, leading to hospitalization. The RN monitored the resident instead of notifying the physician immediately, delaying notification until after adverse effects were observed. The DON and physician expected immediate notification of such errors.
A medication error occurred when a resident received another resident's medication due to a mix-up at the dining table. The error was not caught until the resident showed adverse reactions, leading to hospitalization. Staff interviews revealed a lack of communication and verification in the medication administration process.
Care plans not updated for changed resident conditions
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for three of 14 sampled residents within the required timeframe and when changes in condition occurred. The facility policy stated that each resident’s assessment is ongoing and the care plan is to be revised as changes occur, with the interdisciplinary team responsible for reviewing and updating care plans when a significant change occurs. Surveyors found that the care plans for Residents #3, #13, and #21 did not reflect current conditions or interventions documented in the record. Resident #3’s comprehensive admission MDS dated 05/07/26 showed cognitive status, no behavioral symptoms, no rejection of care, and diagnoses including stroke with upper extremity impairment on one side and lower extremity impairment on both sides, with high fall risk. The care plan dated 11/12/25 did not address interventions for prostheses on both lower extremities or the resident’s improper denture fit. A nurse note dated 04/30/26 documented therapy to assist with proper placement and use of prosthetics. During interview, the resident stated the dentures did not fit properly since the strokes and said not having teeth affected self-image and worsened depression. The Care Plan Coordinator, DON, and administrator each stated dentures and other abnormal conditions should be care planned and that the MDS and care plan should match. Resident #13’s MDS showed cognitive status and debility related to cardiorespiratory conditions, heart failure, anemia, and coronary artery disease. A nurse note dated 02/27/26 documented receipt of an ICD, and a cardiology note dated 03/26/26 showed the resident received a dual chamber ICD on 02/27/26 with an order to report a weight gain of two to three pounds in 24 hours and five pounds in a week. The care plan updated on 04/15/26 did not address reporting daily and weekly weight monitoring and was not updated within 14 days of the ICD placement. Resident #21’s quarterly MDS showed severe cognitive impairment, no behavioral symptoms, no rejection of care, and hemiplegia or hemiparesis with upper and lower extremity impairment on one side. The care plan last updated 02/25/26 did not include interventions for contracture, and observations on 05/05/26, 05/06/26, and 05/07/26 showed the resident seated in a wheelchair with a contracted left hand and no interventions in place. The Care Plan Coordinator, DON, and administrator stated that contractures, limitations, and other abnormal conditions should be included in the care plan.
Failure to Transcribe Daily Weight Order for Resident With CHF
Penalty
Summary
Facility staff failed to maintain professional standards of practice when a treatment order for daily weights was not transcribed for Resident #13, who had congestive heart failure, anemia, coronary artery disease, and debility related to cardiorespiratory conditions. The resident’s cardiology visit note included an order to report a weight gain of two to three pounds in 24 hours and five pounds in a week, but review of the Physician Order Sheet on 03/31/26 and again on 04/30/26 showed that the order for daily weights and the related reporting parameters were not entered into the resident’s record. During interviews, the cardiology nurse practitioner stated the facility was expected to record the resident’s weight as ordered and to seek clarification if the order was not understood, and said there were no communication or records of the resident’s weights. An LPN stated the charge nurse was responsible for reviewing new orders and transcribing them, including daily and weekly weights. The DON stated the charge nurse was responsible for transcribing new orders and acknowledged responsibility for ensuring physician orders were followed, while the administrator stated the order error should have been identified and clarified and that the resident was not responsible for monitoring his or her own weights.
Failure to Notify Physician of Medication Error
Penalty
Summary
Facility staff failed to notify a resident's physician immediately after a medication error occurred, which resulted in the resident being given another resident's medication. The resident, who was cognitively intact and had active diagnoses of cancer and renal failure, was initially assessed with no changes in condition or behavior. However, later observations noted the resident was lethargic, hypotensive, and bradycardic, leading to an emergency room visit and subsequent hospital admission. The physician was not notified until after the resident was sent to the hospital. Interviews with facility staff revealed that the Registered Nurse (RN) who discovered the error chose to monitor the resident instead of contacting the physician immediately. The Certified Medication Technician (CMT) was not instructed to notify the physician, and the Director of Nursing (DON) stated that staff are expected to contact the physician immediately in such cases. The physician expressed an expectation to be informed of medication errors as soon as they occur, questioning the delay in notification until after the resident experienced adverse effects.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility staff failed to ensure residents were free from significant medication errors when a medication intended for one resident was mistakenly administered to another. This incident occurred when a Certified Medication Technician (CMT) gave a resident their medication at the dining table but did not verify that the medication was taken before leaving. A dietary aide later found the medication cup with pills at the table and mistakenly assumed it belonged to the resident who usually sat there, not realizing the residents had switched seats. The dietary aide handed the medication cup to a Registered Nurse (RN), who then administered the medication to the wrong resident. The resident who received the incorrect medication was cognitively intact and had diagnoses of cancer and renal failure. After receiving the wrong medication, the resident initially showed no changes in condition or behavior. However, later in the day, the resident became lethargic and exhibited hypotension and bradycardia, prompting the RN to call emergency medical services. The resident was subsequently transported to the hospital for further evaluation and treatment. Interviews with the facility staff revealed a breakdown in communication and verification processes. The CMT had already administered the correct medication to the resident earlier in the hallway, but this information was not communicated effectively to the RN. The RN, acting on the assumption that the medication cup contained the resident's missed dose, administered it without verifying the resident's medication history for that day. This series of actions and inactions led to the resident experiencing an adverse reaction and requiring hospitalization.
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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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Nursing homes near California
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tipton Oak Manor | 12.4 mi | ★★★★★ | 6 | 0 |
| Stonebridge Oak Tree | 18.1 mi | ★★★★★ | 4 | 0 |
| River City Living Community | 18.1 mi | ★★★★★ | 8 | 0 |
| Eldon Nursing & Rehab | 18.8 mi | ★★★★★ | 15 | 0 |
| Jefferson City Manor Care Center | 19.8 mi | ★★★★★ | 8 | 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.