Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arvin Post Acute during CMS and state inspections, most recent first.
A resident with intact cognition who used a wheelchair reported twisting her left leg, experienced knee pain and swelling, and requested an X-ray after returning from an outing. An RN documented the complaint, noted swelling, administered PRN pain medication, and texted the MD with photos and the resident’s request for imaging; the MD replied with a thumbs up emoji and PRN pain medication orders but did not issue a clearly documented order for hospital transfer at that time. Over the next several days, the resident continued to report high pain levels (7–8) that were recorded on the MAR and in nurse’s notes, yet no timely diagnostic imaging or transfer occurred. When an X-ray was finally obtained days later, it showed an acute nondisplaced distal femur fracture, and the resident was then sent to the hospital, where records indicated knee pain had been present for six days and surgical repair was planned. Interviews with the RN, MD, DON, and the resident revealed miscommunication about the MD’s emoji response, lack of a formal communication policy, and that the resident believed she should have been sent to the hospital the day of the injury.
The facility did not follow its own policies for reporting and investigating abuse and exploitation. In one case, after a resident-to-resident altercation involving a cognitively impaired individual, the required follow-up investigation report was not completed or submitted within the mandated timeframe. In another case, an allegation of financial abuse involving a resident and a power of attorney was not reported to CDPH within 24 hours as required.
A resident with severely impaired cognition experienced a witnessed fall, but the responsible party was not notified as required by facility policy. Review of records and staff interview confirmed the lack of documentation of notification following the incident.
The facility failed to maintain sanitary conditions in the kitchen, resulting in a significant infestation of German cockroaches. Observations revealed live cockroaches in various areas, and the kitchen staff did not clean and sanitize counters prior to food preparation. The pest control program was ineffective, and structural issues provided entry points for pests. This posed a risk to residents' health, as cockroaches carry bacteria and pathogens that can lead to foodborne illnesses.
The facility failed to ensure that advance directives (ADs) were offered and completed for 15 residents. Staff, including the MDSC and SSD, could not provide documentation of ADs in the residents' medical records, despite the facility's policy requiring it. The SSD noted that AD forms were given to families, but none were returned, and the NC also found missing AD documentation during reviews.
The facility failed to follow infection control practices, including improper linen storage, lack of hand hygiene before meals, and inadequate PPE use during wound care. Shared bathrooms were unclean, and PPE supplies were missing for residents on Enhanced Barrier Precautions.
The facility failed to maintain an effective pest control program, resulting in a persistent cockroach infestation in the kitchen and dining areas. Staff reported seeing live and dead cockroaches since the kitchen renovation, despite monthly pest control treatments. The infestation posed a risk of foodborne illnesses to residents.
A facility failed to ensure informed consent was properly obtained and documented for a resident's use of Remeron and Temazepam. The physician did not provide informed consent before verbal consent was obtained, and licensed personnel did not witness or validate the consent. The forms lacked a nurse's signature to verify that the necessary information was provided, contrary to facility policy.
The facility failed to maintain the confidentiality of PHI for two residents, leading to unauthorized access to their medical records. A clinical note for one resident was mistakenly placed in another resident's clinical record, violating the residents' rights to privacy as outlined in their Admission Agreements. The facility's policies on documentation and PHI management, which stress confidentiality and protection against unauthorized disclosure, were not followed.
The facility failed to follow its policy on personal belongings for two residents. One resident's belongings were not inventoried upon readmission, leading to missing underwear. Another resident lost clothing items during a room remodel, which were not found or reported by staff. The facility's policy requires inventory and respect for residents' belongings, which was not upheld.
A facility failed to complete a Baseline Care Plan (BCP) for a resident within 48 hours of admission, as required by policy. The resident, admitted with Diabetes Mellitus and End-Stage Renal Disease, did not receive a BCP Summary, which was confirmed by the MDS Coordinator. This was contrary to the facility's policy that mandates a BCP and summary be provided within 48 hours.
A facility failed to develop a comprehensive care plan for a resident's personal grooming, specifically fingernail care. Observations revealed the resident's nails were long and dirty, with an avulsion on the right thumbnail. Staff acknowledged the need for grooming, but no care plan was documented, contrary to facility policy.
A facility failed to update a resident's care plan after they were discharged from hospice care due to an extended prognosis. Despite the discharge, the care plan continued to indicate the need for hospice services. Interviews with staff confirmed the oversight, which contradicted the facility's policy requiring care plan updates following significant changes in a resident's condition.
A facility failed to provide necessary oral care for a resident with hemiplegia and hemiparesis following a stroke. The resident reported that staff did not brush his teeth before or after meals, and an LVN confirmed the absence of a toothbrush in the resident's bedside table, although an unused toothpaste tube was found. The facility's policy requires that residents unable to perform ADLs independently receive necessary services to maintain oral hygiene, which was not followed.
A resident with a contracted left hand did not receive person-centered care as their care plan was not implemented. Observations revealed long, thick fingernails curling into the palm and no hand splint applied. Staff were unaware of the need for a splint, and a surgical consult order was not processed, delaying care. The facility's policies for nail care and care plans were not followed, resulting in potential adverse outcomes.
A resident's feet and toenails were left untreated due to the facility's failure to provide adequate foot care and a podiatry referral. The resident's toenails were observed to be deformed, thick, and discolored, with no documentation of a podiatry referral found. The facility's policy required such referrals for foot disorders, but it was not followed in this case.
A resident with diabetic neuropathy and pressure-related injuries reported unaddressed pain, despite having physician's orders for pain management. The facility failed to document pain levels consistently and administered medication without appropriate orders, highlighting a deficiency in pain management practices.
The Dietary Manager (DM) failed to manage a multi-generational cockroach infestation in the kitchen, compromising the food and nutrition service. Nine dead cockroaches were observed in a food preparation area, and the DM admitted to noticing various pests since renovations began. The Registered Dietitian (RD) was not informed of the issue, highlighting a lack of communication. The DM's job description requires ensuring quality food and nutrition, which was not achieved.
The facility failed to ensure the Admissions Coordinator understood and explained the Binding Arbitration Agreement (BAA) to residents and their representatives. The AC did not explain the agreement's articles and was unaware of the facility's policy on BAAs. Instances were found where the BAA was not properly acknowledged, including a resident with severe cognitive impairment signing the agreement herself. The facility's policy requires verbal acknowledgment of understanding, which was not documented.
The facility failed to maintain a safe and sanitary shower area, with a vinyl cover left off, broken tiles, and suspected mold, as observed by a CNA and housekeeping manager. Maintenance personnel were aware of the issue but it was not reported or logged. Facility policies require hazardous areas to be addressed and bathrooms cleaned daily, which was not adhered to.
The facility failed to protect two residents from verbal abuse by an Activity Assistant, who yelled, cursed, and threw popcorn at them during activities. Both residents were cognitively intact and reported emotional distress. The incident was confirmed by the Administrator and witnessed by the Receptionist.
A resident reported verbal abuse by a CNA, and the facility failed to complete the investigation within the required five working days. The Administrator and DON acknowledged the delay, which was against the facility's policy on abuse prevention.
Delayed Hospital Evaluation and Imaging After Resident’s Reported Leg Injury and Persistent Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to promptly send a resident for hospital evaluation and treatment after the resident reported a left leg injury and requested an X-ray. The resident had intact cognition with a BIMS score of 15, used a wheelchair, and required assistance with ADLs. On the day of the incident, the resident returned from a family outing around 5 p.m., with nursing documentation initially indicating normal vital signs and no pain or discomfort. Approximately three hours later, an SBAR documented that the resident reported left leg pain, stated her leg had twisted while in a wheelchair with family, and that mild swelling of the left knee was noted. The nurse administered PRN pain medication, recorded normal vital signs, and notified the physician and responsible party. The physician ordered a lidocaine patch and Norco PRN for pain, but there was no documented physician order to send the resident to the hospital at that time. Over the following days, the resident continued to experience significant pain that was repeatedly documented but not acted upon with timely diagnostic evaluation. The MAR showed ongoing high pain scores, including levels of 7 and 8, documented daily from the day after the injury through several subsequent days, with PRN hydrocodone-acetaminophen administered. A nurse’s note several days later again documented the resident’s complaint of left knee pain. Despite these persistent high pain scores and ongoing complaints, there was no documentation that the resident was sent promptly for imaging or hospital evaluation. The facility’s pain care plan and standing order to monitor and record pain every shift were in place, but the underlying cause of the pain was not promptly investigated. When imaging was finally obtained several days after the initial injury, a radiology report of the left knee showed an acute nondisplaced distal femur fracture. An SBAR then documented that the X-ray results were communicated to the physician and responsible party, and the resident was sent to the hospital. The hospital H&P recorded that the resident arrived by EMS with left knee pain for six days, with imaging confirming a new nondisplaced distal femur fracture that had occurred six days earlier, and orthopedic surgical repair was planned. Interviews revealed that the RN had texted the physician on the night of the injury, including photos of the swollen knee and a statement that the resident was requesting an X-ray. The physician responded with a thumbs up emoji and pain medication orders, later stating that the thumbs up signified approval for an X-ray and an expectation that the resident would be sent to the ER that night or the next morning. The DON acknowledged miscommunication between the RN and physician, stated that emojis were not a professional communication method and could cause confusion, noted the resident’s Spanish-only language as a possible contributor to misunderstanding about how the injury occurred, and confirmed there was no facility policy on proper nurse-physician communication. Facility policies on quality of care, pain assessment and management, and change in condition required accommodation of needs, addressing underlying causes of pain, and physician notification and transfer when needed, but the resident was not promptly transferred for evaluation of the leg injury. The deficiency is further supported by the resident’s own account of the events. In interview, the resident, who was alert and oriented, stated that she broke her left leg in the facility when she twisted her leg while going to the bathroom in her wheelchair and felt her left knee pop. She reported sharp, constant, moderate-intensity pain in her left knee daily from the time of injury until she was taken to the hospital six days later. She questioned why it took so long for her to be sent to the hospital and stated she believed she should have been taken the same day she injured her leg. These statements, combined with the documented persistent high pain scores, the delayed imaging and diagnosis of an acute femur fracture, and the lack of timely transfer despite physician contact and clear reports of pain and swelling, form the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Timely Report and Investigate Abuse and Financial Exploitation Allegations
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of abuse, neglect, exploitation, or misappropriation in two separate incidents. In the first incident, following a resident-to-resident altercation where one resident with severe cognitive impairment struck another cognitively intact resident with a pillow and threatened further harm, the facility did not complete or submit a follow-up investigation report (FIR) within five business days as required by their policy. The administrator acknowledged that the FIR was not completed or sent to the California Department of Public Health (CDPH) within the specified timeframe. In the second incident, the facility did not report an allegation of financial abuse within 24 hours as required by policy. A family member raised concerns about another individual obtaining power of attorney over a resident, who was cognitively intact but unsure about the paperwork she had signed. The facility's records confirmed that the concern was communicated to staff, but the administrator did not notify CDPH of the allegation within the required period. Both incidents demonstrate failures to follow established procedures for timely reporting and investigation of abuse allegations.
Failure to Notify Responsible Party of Resident's Change in Condition After Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify the responsible party (RP) of a resident's change in condition following a witnessed fall. During a review of the resident's records, it was found that although the resident had a severely impaired cognition as indicated by a BIMS score of 6, there was no documentation that the RP had been informed of the incident. The facility's policy requires prompt notification of the resident's representative in the event of an accident or incident resulting in injury, with notifications to be made within 24 hours unless otherwise instructed. The Licensed Vocational Nurse confirmed that the RP should have been notified and that no such documentation existed in the progress notes.
Cockroach Infestation in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to a significant infestation of German cockroaches. Observations on multiple occasions revealed live cockroaches in various areas of the kitchen, including the floor drain, walls, and food preparation counters. The presence of these pests was confirmed by a pest control service technician. The kitchen staff did not clean and sanitize the kitchen counters prior to food preparation, despite the known cockroach infestation, which increased the risk of contamination of food contact surfaces. The facility's pest control program was ineffective, as evidenced by the continued presence of cockroaches despite regular pest control visits. The Dietary Manager and other staff members reported seeing cockroaches and other pests since the renovation of the kitchen. Structural issues, such as holes in the walls and ceiling, were identified as potential entry points for the pests. These issues were known to the facility's administration and maintenance department, but had not been prioritized for repair. The infestation posed a significant risk to the health of the residents, as cockroaches are known to carry numerous bacteria and pathogens that can lead to foodborne illnesses. The facility's failure to address the infestation and maintain a clean and sanitary kitchen environment placed 70 of 72 highly susceptible residents at risk. The lack of a designated kitchen sanitation schedule or log further contributed to the unsanitary conditions and the potential for harm to the residents.
Removal Plan
- Implemented an acceptable written plan of correction
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were offered and completed for 15 out of 27 sampled residents. During interviews and record reviews, it was found that several residents, including Residents 6, 7, 10, 11, 12, 21, 25, 26, 28, 30, 33, 41, 49, 59, and 64, did not have documentation of an AD in their medical records. The Minimum Data Set Coordinator (MDSC) and Social Services Director (SSD) were unable to provide evidence that these residents were offered or had completed ADs. The facility's policy and procedure on advance directives, dated September 2022, requires that residents or their representatives be provided with written information about their rights to accept or refuse medical treatment and to formulate an AD. Despite the facility's policy, the staff failed to document the offer of assistance in establishing ADs or the residents' decisions to accept or decline such assistance. The SSD mentioned that AD forms were distributed to resident families, but none were returned. Additionally, the Nurse Consultant (NC) was unable to find documentation of ADs for several residents during record reviews. This lack of documentation and follow-through on the facility's policy potentially jeopardizes the residents' ability to have their healthcare wishes honored.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control practices for seven residents, leading to multiple deficiencies. Linens were improperly stored on bedside tables in the rooms of two residents, contrary to the facility's policy that linens should only be in rooms when changing or making beds. Additionally, two residents did not have their hands cleansed before eating lunch, as observed by the staff, which is a basic infection control measure. A treatment nurse did not follow proper infection control protocols during wound care for a resident on Enhanced Barrier Precautions (EBP). The nurse failed to perform hand hygiene before and after glove use and did not wear the required personal protective equipment (PPE) such as gowns and masks during the procedure. This oversight occurred despite the facility's policy requiring PPE for high-contact activities like wound care. The facility also failed to maintain cleanliness in shared bathrooms, with feces observed under the toilet and on the sink. Furthermore, there was a lack of PPE supplies for two residents on EBP, with one resident going three days without the necessary precautions. The facility's policies clearly state the need for PPE supplies to be available both inside and outside residents' rooms, especially for those with a history of multidrug-resistant organisms or indwelling medical devices.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the repeated presence of live cockroaches in the kitchen. Observations and interviews revealed that cockroaches were found in various locations, including the floor drain, walls, and food preparation areas. The Dietary Manager and other staff members reported seeing cockroaches, ants, and pincher bugs since the kitchen renovation in March 2024. Despite monthly visits from a pest control company, the infestation persisted, with both live and dead cockroaches observed in the kitchen and dining areas. Interviews with staff, including the Dietary Manager, Dietary Aides, and the Administrator, confirmed awareness of the pest issue. The Administrator acknowledged the presence of holes in the kitchen that could serve as entry points for pests. Staff members reported seeing cockroaches in the kitchen, dishwashing area, and janitorial closet, with some noting an increase in sightings following the facility's renovation. The Environmental Specialist identified a multi-generational infestation of cockroaches, indicating a significant and ongoing problem. The Pest Control Company Owner confirmed the presence of German cockroaches in the kitchen, which are known to spread various bacteria and diseases. The facility's pest control invoices indicated recent inspections and treatments for roaches, but the problem remained unresolved. The facility's policy and procedure on pest control, dated May 2008, stated that the building should be kept free of insects and rodents, highlighting a failure to adhere to this policy. The presence of cockroaches in food preparation and dining areas placed residents at risk for foodborne illnesses.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained and documented for the use of antipsychotic medications for a resident. Specifically, the physician did not provide informed consent to the resident's representative before verbal consent was obtained for the administration of Remeron and Temazepam. The Minimum Data Set Coordinator (MDSC) confirmed that the physician signed the informed consent forms after verbal consent was obtained, indicating that the resident's representative did not receive the necessary information about the medications, including their risks, benefits, and alternatives, at the time of consent. Additionally, the facility did not ensure that licensed personnel witnessed and validated the verbal consent received from the resident's representative. The informed consent forms for both Remeron and Temazepam lacked the signature of a licensed nurse to verify that informed consent was obtained and that the required material information was provided. This oversight was contrary to the facility's policy, which mandates that a licensed nurse must verify and sign the consent form before administering psychotropic medication.
Confidentiality Breach of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of Private Health Information (PHI) for two residents, resulting in unauthorized access to their medical records. During a review of Resident 25's Clinical Record (CR), it was discovered that it contained a clinical note for Resident 58, specifically a Skilled Nursing Progress Note (SNPN) dated 10/18/24. This error was confirmed during an interview and record review with the Medical Records Clerk, who acknowledged that Resident 58's SNPN was incorrectly placed in Resident 25's CR. Additionally, Resident 58's Admission Agreement highlighted the resident's right to privacy and confidentiality of personal and clinical records, which was violated in this instance. The facility's policies on Charting and Documentation, as well as Protected Health Information (PHI) management, emphasize the confidentiality of resident information and the responsibility of personnel to prevent unauthorized disclosure, which was not adhered to in this case.
Failure to Inventory and Protect Residents' Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the inventory and documentation of residents' personal belongings, affecting two residents. Resident 30's belongings were not inventoried and documented upon readmission, as confirmed by the Social Services Director who could not provide a personal belonging inventory for the readmission date. Resident 30 reported missing underwear to a CNA, who searched the laundry but could not locate them. The facility's policy requires that personal belongings be inventoried and documented upon admission and updated as necessary, which was not followed in this case. Similarly, Resident 21 experienced a loss of clothing items following a room remodel. The resident reported missing two flannel shirts and two pairs of jeans, which were not found in the closet. The Treatment Nurse was unaware of the missing items, and a review of Resident 21's personal belonging inventory sheet confirmed the ownership of these items. The facility's policy emphasizes the importance of treating residents' belongings with respect and maintaining a homelike environment, which was not upheld in this instance.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a Baseline Care Plan (BCP) for a resident within 48 hours of admission, as required by their policy. The resident, identified as Resident 12, was admitted with diagnoses including Diabetes Mellitus with diabetic neuropathy and End-Stage Renal Disease. During a review, it was found that the BCP Summary for Resident 12, dated August 16, 2024, was incomplete and had not been provided to the resident or their representative. The Minimum Data Set Coordinator confirmed that the BCP Summary was not delivered, which was contrary to the facility's policy that mandates a baseline care plan be developed and a summary provided to the resident or representative within 48 hours of admission.
Failure to Develop Comprehensive Care Plan for Resident's Grooming Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident's personal grooming, specifically regarding the care of fingernails. During observations and interviews, it was noted that the resident's fingernails were long, with a blackish substance inside the nailbeds, indicating a lack of proper grooming. The Licensed Vocational Nurse (LVN) and Treatment Nurse (TN) both acknowledged the need for trimming and cleaning of the resident's fingernails. Additionally, the resident had an avulsion on the right thumbnail, which was a concern that required attention. Upon review, the Minimum Data Set Coordinator (MDSC) was unable to find any documentation of a care plan addressing the resident's personal grooming needs, including fingernail care. The facility's policy and procedure for fingernail care emphasized the importance of regular cleaning and trimming to prevent infections and skin problems. However, the absence of a documented care plan for the resident's grooming needs indicated a failure to adhere to these guidelines, potentially leading to unmet care needs.
Failure to Revise Care Plan After Change in Hospice Status
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 25, after a change in their hospice care status. Initially, Resident 25 was under hospice care, but was discharged from hospice services on November 15, 2024, due to an extended prognosis. Despite this change, the resident's care plan continued to indicate that they required hospice care and were at risk for various health issues related to terminal illness. This discrepancy was noted during a review of the resident's records, which included an Order Summary Report and a Nursing-Weekly Summary, both of which contained conflicting information about the resident's hospice status. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and a Nursing Consultant (NC), confirmed that the care plan should have been updated to reflect the resident's current status of no longer receiving hospice care. The facility's policy and procedure on care plans emphasized the need for ongoing assessments and revisions when there is a significant change in a resident's condition. However, this protocol was not followed, leading to the potential for Resident 25 to receive unnecessary hospice services.
Failure to Provide Oral Care for Resident
Penalty
Summary
The facility failed to ensure proper oral care for a resident, identified as Resident 33, who was admitted with hemiplegia and hemiparesis following a stroke. During an observation and interview, it was noted that the resident had a dry mouth and yellowish teeth, indicating a lack of oral hygiene. The resident reported that staff did not brush his teeth before or after meals and could not recall the last time oral care was provided. A Licensed Vocational Nurse (LVN) confirmed the absence of a toothbrush in the resident's bedside table, although an unused tube of toothpaste was found. The facility's policy on Activities of Daily Living (ADL) requires that residents unable to perform ADLs independently receive necessary services to maintain oral hygiene, which was not adhered to in this case.
Failure to Implement Care Plan for Resident's Hand Contracture
Penalty
Summary
The facility failed to provide person-centered quality care for a resident, identified as Resident 10, by not implementing the care plan interventions as ordered. During observations, it was noted that Resident 10's left hand was contracted, with long, thick fingernails curling into the palm, and no hand splint was applied. Interviews with staff, including an LVN and a Treatment Nurse, revealed a lack of awareness regarding the necessity of a hand splint and the inadequate trimming of the resident's fingernails. The Director of Nursing confirmed that the care plan, which included keeping the fingernails short and applying a hand splint, was not followed. Additionally, a physician's order for a surgical consult with a hand specialist, dated October 2023, was not processed, further delaying necessary care. The facility's policies and procedures for nail care and comprehensive person-centered care plans were not adhered to, as evidenced by the failure to maintain the resident's fingernails and implement the care plan interventions. The care plan specifically required short fingernails to prevent skin injury and the application of a hand splint to prevent the fingers from rubbing against each other. The oversight in processing the surgical consult order and the lack of implementation of the care plan interventions resulted in delayed care for Resident 10, with the potential for adverse outcomes due to the contracted state of the resident's hand and the risk of skin injury.
Failure to Provide Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to provide adequate foot care and a podiatry referral for a resident, identified as Resident 33, resulting in untreated feet and toenails. During an observation and interview, the Treatment Nurse noted that Resident 33's right big toenail was deformed, with abnormal growth, yellowish, and had a fungus-like appearance. The other toenails on both feet were long, thick, yellowish, and some had blackish discoloration. The skin on the top of the right foot was dry and flaky. The Treatment Nurse acknowledged the need for trimming and a podiatry referral, but confirmed that Resident 33 had not been referred to a podiatrist. Further interviews and record reviews with the Director of Nursing and the Minimum Data Set Coordinator revealed that there was no documentation of a podiatry referral for Resident 33. The facility's policy and procedure on foot care, dated October 2022, indicated that residents should receive appropriate care and treatment to maintain foot health and that those with foot disorders should be referred to qualified professionals. However, this policy was not followed in the case of Resident 33, leading to the deficiency.
Inadequate Pain Management and Documentation for a Resident
Penalty
Summary
The facility failed to manage and document pain accurately for a resident, identified as Resident 12, who was admitted with multiple diagnoses including Diabetes Mellitus with diabetic neuropathy and End-Stage Renal Disease. The resident had several pressure-related deep tissue injuries, some of which were acquired in-house, and reported experiencing significant pain from these sores. Despite having physician's orders for pain management, the resident stated that staff ignored their pain complaints and did not administer pain medication as needed. The review of the resident's Medication Administration Record (MAR) revealed inconsistencies in pain monitoring and medication administration. The MAR indicated that pain levels were to be monitored every shift, but there were instances where no monitoring was documented. Additionally, the resident received Hydrocodone-Acetaminophen for a pain level of 5, which was not covered by the existing physician's orders for pain scales 1-3 and 7-10. The Minimum Data Set Coordinator confirmed these discrepancies and noted the absence of a policy and procedure for pain management, which contributed to the deficiency in providing appropriate pain management for the resident.
Dietary Manager Fails to Address Cockroach Infestation
Penalty
Summary
The Dietary Manager (DM) at the facility failed to demonstrate competency in managing the food and nutrition service, as evidenced by a multi-generational cockroach infestation in the kitchen. During an observation, nine dead cockroaches were found in a drain above a sink where food is prepared. The DM acknowledged the presence of ants, pincher bugs, and cockroaches, which she noticed since the facility began renovations in March 2024. Despite this, no action plan was implemented to address the infestation and ensure the health and safety of the residents. The Registered Dietitian (RD) was not informed about the live cockroaches, indicating a communication breakdown within the facility. The DM's job description emphasizes the responsibility to ensure quality food and nutrition in compliance with federal, state, and local standards, which was not met in this instance.
Failure to Properly Explain Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Admissions Coordinator (AC) had a full understanding of the Binding Arbitration Agreement (BAA) to adequately explain its content to residents and their representatives. This deficiency was identified for three residents, where the AC did not explain the 'Articles' in the BAA and was unaware of their meanings. The AC informed residents and their representatives that arbitration was a cheaper and quicker alternative to court but did not discuss the specific terms and conditions of the agreement. Additionally, the AC was not aware of the facility's policy and procedure on Binding Arbitration Agreements and had no method to confirm if the residents or their representatives fully understood the agreement. The report highlights specific instances where the BAA was not properly explained or acknowledged. For Resident 7 and Resident 64, the section indicating that the agreement was explained in a manner understood by the resident or representative was not signed. Resident 8, who had a severe cognitive impairment, signed the BAA herself, raising concerns about her ability to understand the agreement. The AC admitted to guiding residents' hands to sign electronically, which further questions the validity of the consent. The facility's policy requires verbal acknowledgment of understanding, which was not documented in these cases.
Deficiency in Shower Area Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain a safe and sanitary shower area for residents, as observed during a survey. In the south shower room, a vinyl cover had fallen off over the weekend and was left to the side, as reported by a CNA. Additionally, there were broken and missing tiles, and a tan substance was noted on the pony wall of the shower stall. The housekeeping manager indicated that the area could not be properly cleaned due to the missing tiles, and a black substance, suspected to be mold, was observed on the grout line. The maintenance personnel acknowledged awareness of the issue with the vinyl cover but stated it was not reported to him nor logged in the maintenance records. He also mentioned that the tiles had fallen off about a year ago, and a vinyl cover was placed over them as a temporary measure. The facility's policies and procedures require that hazardous areas be identified and addressed to ensure resident safety, and that bathrooms, including showers, be cleaned and disinfected daily. However, these procedures were not followed, leading to the deficiency.
Verbal Abuse by Activity Assistant
Penalty
Summary
The facility failed to ensure that two residents were free from verbal abuse by an Activity Assistant (AA). On 4/7/24, during activities, the AA yelled and cursed at Resident 1 and Resident 2, causing emotional distress. Resident 1 reported being in shock, while Resident 2 was terrified and had popcorn thrown at her by the AA. Both residents were cognitively intact and able to verbalize their needs, as confirmed by their medical records and assessments. The incident was observed and reported by the Receptionist, who witnessed the AA's abusive behavior and documented it in a written incident statement. The Administrator, who is also the facility's abuse coordinator, was informed of the incident and confirmed that the AA's actions constituted verbal abuse. The AA admitted to losing his temper, yelling, and using curse words towards the residents. The facility's policy on abuse prevention clearly states that residents have the right to be free from verbal abuse by staff. Despite this policy, the AA's actions on 4/7/24 violated the residents' rights and the facility's standards of care.
Failure to Timely Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to complete an investigation of a verbal abuse allegation within five working days for one of the residents. During an interview, the resident reported that a Certified Nursing Assistant (CNA) was rude to her, making dismissive and hurtful comments. The resident expressed concern that the verbal abuse might continue. The incident was documented in the resident's Progress Notes, indicating that the resident was very upset and wanted to leave because of the CNA's behavior. The facility's Administrator acknowledged that the investigation report was not submitted within the required five working days, as the incident occurred on February 26, 2024, and the investigation was still not finalized by March 7, 2024. The Director of Nursing (DON) also confirmed that the investigation was not completed within the required timeframe. The facility's policy and procedure on abuse prevention mandates that any allegations be investigated and reported within the timeframes required by federal requirements, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 154 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arvin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Julian Healthcare Center | 13.2 mi | — | 15 | 0 |
| The Rehabilitation Center Of Bakersfield | 14.5 mi | — | 23 | 0 |
| Height Street Skilled Care | 14.9 mi | — | 20 | 0 |
| Valley Healthcare Center | 15.1 mi | — | 26 | 0 |
| Bakersfield Post Acute | 15.1 mi | — | 7 | 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.