Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Atterdag Care Center during CMS and state inspections, most recent first.
A resident with dementia, gait abnormalities, and other psychiatric and cognitive diagnoses experienced multiple falls over time. Post Fall Evaluations were completed after each event, documenting existing fall risk factors and interventions such as neuro checks, vital sign monitoring, pain assessment, and MD/POA notification. However, the care plan that had been initiated earlier was not revised to update the focus, goals, or interventions after these repeated falls. The DON confirmed that no changes were made to the care plan despite the additional falls, contrary to facility policies requiring reassessment, IDT review, and updating of the fall care plan and overall care plan when new problems or condition changes are identified.
A resident with dementia-related diagnoses and an order for PRN lorazepam for moderate to severe anxiety received a dose of lorazepam, but staff did not document the reason for administration in the MAR or medical record. The DON acknowledged the absence of this required documentation. Facility policy required that when a PRN medication is given, the nurse must document the reason, route, date, and time, which did not occur in this case.
A resident's personal property inventory list was not updated when new clothing was brought in, despite facility policy requiring staff to label new items and update the inventory. Staff interviews confirmed the expectation to maintain current inventory records, but a review showed the list had not been updated since admission.
The facility failed to ensure food safety standards were met, as the dish machine did not reach required temperatures, and staff did not follow proper glove use protocols. The dish machine consistently showed lower temperatures than required, and there was no mechanism to verify these temperatures. Additionally, an employee used the same gloves to handle raw and cooked meat, violating FDA guidelines. These deficiencies could lead to foodborne illness for the 49 residents consuming food from the kitchen.
A facility failed to ensure proper pharmaceutical services for a resident by not obtaining a physician's order for blood pressure monitoring and medication administration. The resident received Coreg without specific parameters, and a nurse revised the medication record without physician direction. The facility lacked a policy to identify hypotension, leading to multiple hypotensive episodes during medication administration.
The facility failed to monitor the medication refrigerator temperature twice daily, as required by policy, resulting in temperatures falling below the acceptable range. The DON confirmed that influenza vaccines were stored in this refrigerator, and no corrective actions were documented for the out-of-range temperatures.
The facility failed to provide residents with diets that matched their physician-prescribed orders, leading to potential nutritional deficits. Discrepancies were found between the PointClickCare (PCC) diet orders and meal ticket reports for several residents, as confirmed by the Registered Dietitian (RD). The facility's policy required a Dietary Communication form for diet changes, but inconsistencies persisted, indicating a lapse in ensuring accurate dietary information.
The facility failed to adhere to menu portion sizes, resulting in incorrect servings for residents on specific diets. On two occasions, residents received incorrect portion sizes due to staff using the wrong scoops, which was confirmed by the Director of Dietary Services and the RD. This inconsistency in portion sizes could potentially impact residents' nutritional needs.
A facility failed to ensure that a resident's POLST matched the EMR, leading to a potential risk of incorrect life-sustaining treatment administration. The resident, with senile degeneration of the brain, had a POLST indicating DNR, but the EMR showed a CPR order. The MDS Coordinator acknowledged the records did not match, as the EMR was not updated to reflect the resident's current wishes.
A facility failed to develop a care plan for RNA services for a resident with muscle weakness, gait abnormalities, and repeated falls. Despite an order for range of motion exercises, no care plan was documented. The MDS Coordinator confirmed the absence of a care plan, contrary to the facility's policy requiring updates as changes occur.
A resident in the facility had an elevated pulse of 103 beats per minute, flagged by the computer system as tachycardia. The nurse did not recheck the pulse or take any preventative actions, and the issue persisted with a pulse of 106 the next day. The DON confirmed that the elevated pulse was not addressed for two days, failing to meet professional standards of care.
The facility's dishwashing machine failed to reach the required temperatures for sanitization, as observed by the DDS and confirmed by a Vendor Technician. The temperature gauges were not functioning, and the facility's policy for checking gauge accuracy was not effectively implemented.
Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s care plan following multiple falls. The resident, an older male admitted on 8/26/24, had diagnoses including senile degeneration of the brain, Alzheimer’s disease, adjustment disorder with mixed anxiety and depressed mood, and abnormalities of gait and mobility. Record review showed that the comprehensive care plan for this resident was initiated on 9/6/24. Post Fall Evaluations (PFEs) documented that the resident experienced an unwitnessed fall on 2/17/26 at 3:45 p.m., with a care plan focus noting an actual fall and multiple risk factors such as lower body weakness, gait and balance difficulties, cognitive impairment, and other listed conditions. The PFE included goals and interventions such as neuro checks, monitoring vital signs every shift for 72 hours, monitoring for pain, and notifying the MD and POA of changes or complications. Subsequent PFEs dated 3/4/26 and 3/10/26 documented additional falls, including another unwitnessed fall, but indicated that the care plan focus, goals, and interventions remained unchanged from the initial PFE on 2/17/26. During an interview and concurrent record review on 3/20/26 at 12:40 p.m., the DON confirmed that the resident’s care plan, initiated on 9/6/24, had no focus, goals, or interventions revised after the three documented falls. Review of the facility’s “Fall Prevention Program” policy stated that after any fall, the licensed nurse will reassess fall risk, complete a PFE, and the IDT will review the fall within 72 hours and add all interventions to the fall care plan. The “Care Planning” policy further stated that newly identified problems and condition changes are to be care planned, and that licensed staff should update the care plan weekly with new interventions and resident responses. Despite these policies, no revisions were made to the resident’s care plan following the falls on 2/17/26, 3/4/26, and 3/10/26.
Failure to Document Reason for PRN Lorazepam Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical record contained required documentation for the administration of a PRN medication. A male resident with diagnoses including senile degeneration of the brain, Alzheimer’s disease, and adjustment disorder with mixed anxiety and depressed mood had a physician’s order for lorazepam 1 mg by mouth every 2 hours as needed for moderate to severe anxiety manifested by vomiting, shortness of breath, or restlessness. Review of the Medication Administration Record (MAR) for the month showed that a dose of lorazepam was administered on 3/17/26 at 5:57 a.m. However, the MAR and the resident’s medical record did not contain any documentation of the reason the PRN lorazepam was given at that time. During an interview, the DON confirmed that the MAR for this resident lacked documentation of the reason for the PRN medication administration on that date and time. The facility’s Medication Administration policy, revised 10/8/24, required that when a PRN medication is given, the nurse must document the reason given, route of administration, date, and time, which was not done in this instance.
Failure to Update Resident Personal Property Inventory
Penalty
Summary
The facility failed to ensure that a resident's personal property inventory list was updated when new belongings were brought in. The resident reported being unable to locate a pair of pants she had purchased, prompting staff to assist in finding the item, which was eventually located and identified with the resident's name tag. Interviews with social services staff, a licensed nurse, and a certified nursing assistant confirmed that facility protocol requires staff to label new clothing and update the inventory list when new items are added. However, a review of the resident's inventory list revealed it had not been updated since admission, and the Director of Nursing acknowledged the list was outdated and should have been updated when the new pants were labeled. The facility's policy requires recording additional belongings on the clothing list as they are brought in or removed.
Deficiencies in Dishwashing and Glove Use Protocols
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. The high-temperature dish machine was not reaching the required temperatures of 150 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle. The facility lacked a mechanism to verify the plate-level temperature was reached according to their policy and procedure. Observations and interviews revealed that the dish machine consistently showed lower temperatures than required, and the facility did not have a way to verify these temperatures accurately. The Director of Dietary Services and the Maintenance Engineer were unaware of the issue until it was brought to their attention by the surveyor, and the Registered Dietitian was not conducting regular inspections to verify the dish machine's performance. Additionally, the facility's staff failed to follow proper glove use protocols, which is critical in preventing cross-contamination. An employee was observed using the same gloves to handle raw meat and then touching other items, including cooked meat and utensils. This practice is against the FDA Food Code, which requires single-use gloves to be used for only one task and discarded when switching tasks or when they become soiled. The Registered Dietitian acknowledged the expectation for staff to change gloves after handling raw meat but noted that staff might have a false sense of security when wearing gloves. The deficiencies in the dishwashing process and glove use had the potential to result in the growth of microorganisms, which could cause foodborne illness for the 49 residents eating food from the kitchen. The facility's failure to adhere to its policies and procedures for dishwashing and glove use, as well as the lack of regular inspections and monitoring, contributed to these deficiencies.
Failure to Ensure Proper Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident by not obtaining a physician's order for blood pressure monitoring and medication administration. The resident was prescribed Coreg, a blood pressure medication, without specific parameters for blood pressure or pulse monitoring. Despite the absence of these parameters, the resident continued to receive the medication from September 12, 2024, to October 13, 2024, without the nursing staff consulting the resident's physician for clarification. On October 13, 2024, a nurse independently revised the resident's medication administration record to include daily blood pressure and pulse recordings without physician direction. The facility also lacked a policy and procedure to identify hypotension, which contributed to the oversight. The resident experienced multiple hypotensive episodes from October 13, 2024, to January 23, 2025, during which the blood pressure medication was administered despite low blood pressure readings. This oversight had the potential to cause severe hypotension, risking the resident's health by potentially leading to organ failure and shock.
Failure to Monitor Medication Refrigerator Temperature
Penalty
Summary
The facility failed to adequately monitor and maintain the medication refrigerator temperature within the acceptable range, as required by their policy. The Director of Nursing (DON) confirmed that the temperatures of the refrigerator in the medication storage room were only monitored once a day, contrary to the facility's policy which mandates twice-daily monitoring. During the review of the Medical Room Refrigerator Temperature Monitoring Log (MRRTML) for October, November, and December 2024, it was found that several recorded temperatures were below the accepted range of 36-46 degrees Fahrenheit. Specifically, temperatures as low as 30 degrees Fahrenheit were recorded, and there was no documented evidence of corrective action taken when these out-of-range temperatures were noted. The DON acknowledged that influenza vaccines were stored in the medication room refrigerator, which further emphasizes the importance of maintaining proper storage conditions. The facility's Policy and Procedure on Medication Storage clearly states that medications requiring refrigeration should be kept at temperatures between 36 and 46 degrees Fahrenheit, and the temperature should be monitored and recorded twice daily. The failure to adhere to these guidelines had the potential to result in residents receiving ineffective medications due to improper storage conditions.
Dietary Discrepancies in Resident Meal Orders
Penalty
Summary
The facility failed to ensure that residents were provided with a well-balanced, physician-prescribed diet that met their nutritional needs. This deficiency was identified through observations, record reviews, and interviews, revealing discrepancies between the meal tickets and the diet orders for seven residents. For instance, during a lunch meal service, a resident's meal ticket indicated a puree small portion diet with a #6 scoop of lamb, which did not align with the facility's practice of using half portions for small portion diets. Additionally, the Registered Dietitian (RD) confirmed discrepancies between the PointClickCare (PCC) diet orders and the meal ticket reports, indicating inconsistencies in the dietary information provided to the kitchen staff. The facility's policy and procedure for the transmission of diet orders, dated 09/04/2018, required a Dietary Communication form to be completed, dated, signed by a Licensed Nurse, and sent to Dietary upon admission or change of diet order. However, the review of facility documents showed that the diet orders in the PCC system did not match the meal ticket reports for several residents, leading to potential nutritional deficits. The RD acknowledged that diet discrepancies existed between the PCC and the meal ticket reports, which were only reviewed every couple of months, further contributing to the issue.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed correctly, leading to incorrect portion sizes being served to residents on specific diets. On January 22, 2025, during the lunch meal, four residents on puree diets received incorrect portion sizes of meat, potatoes, and zucchini. The facility's Daily Spreadsheet specified that a #6 scoop should be used for meat and a #10 scoop for vegetables, but a #8 scoop was used instead. This discrepancy was confirmed by both the staff member responsible for serving the meals and the Director of Dietary Services. Additionally, on January 21, 2025, a resident on a regular diet received incorrect portion sizes of cod, polenta, and spinach, as the staff used a #12 scoop instead of the required #8 scoop for regular portions. The Registered Dietitian (RD) was not aware that the staff was not following the menu portion sizes and acknowledged that portion sizes were inconsistent from day to day. The RD stated that while they occasionally observe tray accuracy or conduct test trays, these checks are primarily for temperature rather than portion size accuracy. The RD confirmed that the expectation is for kitchen staff to follow the menu daily spreadsheet and adhere to the specified portion sizes. This failure to follow the menu and portion sizes has the potential to result in residents not having their nutritional needs met.
Discrepancy in POLST and EMR for Resident
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) matched the electronic medical record (EMR) for a resident, which could potentially lead to a delay or incorrect administration of life-sustaining treatments. The discrepancy was identified during a review of the resident's records, where the POLST indicated a 'do not attempt resuscitation' (DNR) status, while the EMR contained a physician order for cardiopulmonary resuscitation (CPR). This inconsistency was acknowledged by the Minimum Data Set Coordinator (MDS 1), who noted that the order in the EMR had not been updated to reflect the resident's current wishes as documented in the POLST. The resident involved was an elderly female with a diagnosis of senile degeneration of the brain, a condition characterized by a progressive decline in cognitive function. The facility's policy and procedure on life-sustaining measures and advanced health care directives required that if a resident desired a DNR status, the physician should review the request with the resident or their surrogate and document the DNR order on the physician's order sheet. However, this procedure was not followed, leading to the mismatch between the POLST and the EMR.
Failure to Develop RNA Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan to address Restorative Nursing Assistant (RNA) services for a resident, identified as Resident 27. This resident was admitted with diagnoses including generalized muscle weakness, abnormalities of gait and mobility, and a history of repeated falls. Despite an order for RNA services, specifically active and passive range of motion exercises for the right upper extremity, there was no documented care plan addressing these RNA services. During an interview and record review, the Minimum Data Set Coordinator confirmed the absence of a care plan for RNA services. The facility's policy and procedure on care plans, dated November 1, 2011, requires all disciplines to have input on the care plan and to update it as changes occur.
Failure to Address Tachycardia in Resident
Penalty
Summary
The facility failed to ensure that standards of practice regarding tachycardic pulses were addressed for a resident, leading to a deficiency. The resident's medical record showed an elevated pulse of 103 beats per minute, which was flagged by the facility's computer system. According to the Fundamentals of Nursing, a pulse above 100 beats per minute in adults is considered tachycardia. Despite this, the elevated pulse was not rechecked by the nurse responsible for the resident's care on the same day, and no interventions were documented to address the elevated pulse. The following day, the resident's pulse was recorded at 106 beats per minute, indicating that the issue persisted. Interviews with the nurse and the Director of Nursing (DON) confirmed that no preventative actions were taken to address the resident's tachycardia over the two-day period. The DON acknowledged that the elevated pulse should have been addressed immediately upon identification, but it was not, resulting in a failure to meet professional standards of quality care.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwashing machine was functioning properly and in safe operating condition, as the temperatures of the wash and rinse cycles did not reach the manufacturer's specified levels. During an observation in the main kitchen, the rinse temperature gauge read 124°F and the wash temperature gauge read 128°F, both below the required temperature for effective sanitization. The Director of Dietary Services (DDS) confirmed that staff relied solely on the display gauges to verify machine temperatures and had no alternative method for temperature validation. Further investigation revealed that the temperature test strips, which should change color at 180°F, did not change when cycled through the dishwashing machine, indicating inadequate temperature levels. However, when submerged in 187°F water, the test strips changed color as expected. A review of the facility's policy indicated that the Director of Food and Nutrition Services should periodically check the accuracy of the gauges using thermal strips and report any discrepancies. A Vendor Technician later confirmed that the temperature gauges were not functioning and recommended their replacement.
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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 Solvang
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lompoc Valley Medical Center Comprehensive Care Ce | 17.9 mi | — | 5 | 0 |
| Lompoc Skilled Nursing & Rehabilitation Center | 19.1 mi | — | 0 | 0 |
| Buena Vista Care Center | 21.9 mi | — | 14 | 1 |
| Channel Islands Post Acute | 24.7 mi | — | 1 | 0 |
| Valle Verde Health Facility | 25.3 mi | — | 7 | 0 |
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