Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 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 Brighton Post Acute during CMS and state inspections, most recent first.
A resident with diabetes had insulin orders that lacked MD-notification parameters for abnormal blood glucose, and another resident had a significant weight gain with delayed and inconsistent 72-hour alert charting after an SBAR. Two residents were observed on O2 at 1.5 L even though both had orders for 2 L, one resident had duplicate PRN O2 orders that could cause confusion, and an LVN placed a resident on BiPap despite scope limits. A resident’s nasal cannula tubing was also not changed per the ordered 7-day schedule.
Food was not palatable or attractive for several residents when surveyors observed regular and puree meal trays with bland, salty, soggy, wet, gelatinous, sticky, and grainy items. A resident stated the coffee, potatoes, and green beans had no taste and that staff kept bringing food she did not like, while another resident said lunch was not enjoyable and he only ate the ham. The ADM, CDM, RDC, and DON all acknowledged that the puree and regular diets should be appetizing and palatable, and the facility policy required nourishing, palatable meals that appear attractive.
Failure to Permit Return After Hospitalization: A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses was sent to the hospital for a change in condition and later had new behaviors and quetiapine added. The ADC, DON, and Administrator decided the facility could not accommodate the resident because of the new medications and behaviors, declined the resident in the referral system, and did not permit the resident to return despite available beds.
MDS assessments for two residents were not accurately completed. One resident with arthritis, muscle weakness, and significant ADL dependence was coded as having no upper or lower extremity impairment despite being dependent for care and reporting constant pain and stiffness. Another resident with anxiety, depression, and hospice/palliative care needs was not coded for anxiety, even though staff confirmed the diagnosis and noted behavioral symptoms such as hitting, kicking, and yelling. The MDS nurse stated the assessments should have been coded differently, and the DON stated she only verified completion, not accuracy.
A resident with anxiety disorder, hemiplegia, hemiparesis, and dementia did not have a completed PASARR Level I screening that accurately reflected her mental health diagnosis. The AC said she reviewed PASARRs for hospital admissions but only completed them for hospice residents admitted from home, while the LVN/ADON said the existing PASARR was invalid and another Level I assessment should have been completed but was not. The DON stated PASARR accuracy and completeness were the AC’s responsibility, and facility policy required a Level I PASRR screen before admission.
A resident prescribed Plavix did not have a care plan to monitor for antiplatelet side effects. The resident had multiple diagnoses, including anemia, type 2 DM, and moderate cognitive deficits, and the MAR showed daily Plavix for clot prophylaxis. During record review, staff confirmed no antiplatelet care plan had been created, even though the LVN and DON stated one was required to guide monitoring for side effects such as bleeding and bruising.
A resident with COPD, chronic respiratory failure with hypoxia, and heart failure had an oxygen order for 2 L/min via NC PRN for SOB, but the care plan still reflected an older revision and was not updated to match the current order. During review, the LVN, ADON, and DON all confirmed the care plan had not been revised, even though the resident was observed using oxygen and the facility’s policy required care plans to be revised as conditions change.
Failure to Provide Scheduled Bathing and Hygiene Assistance: A resident with paraplegia, fecal and urinary incontinence, a PEG tube, and severe cognitive impairment did not receive bathing as scheduled. Staff documented some shower days and marked other days as N/A, which the ADON and DSD confirmed meant the shower did not occur. The resident stated he was not being bathed and felt dirty, while the DON, ADON, DSD, and IP stated staff should have provided a shower or bed bath and documented any refusals.
Nonfunctional Bed Rail Left Unsecured: A resident with hemiplegia, muscle weakness, and vision loss had a left bed rail that would not stay locked and was observed dropping when touched. The resident said the rail had been broken for months and that she had reported it to CNAs, LNs, and maintenance. During repositioning, CNAs did not use the rail, one CNA was unaware it was broken until checked, and the MA confirmed it was not securely locked. The MD stated inspections were quarterly or complaint-based, with no definite schedule for bed rail checks.
Inaccurate Daily Nurse Staffing Posting: The facility posted projected staffing hours instead of actual hours worked, and the daily staffing sheets did not clearly identify RN, LVN, and CNA titles. The ESR, DON, and ADMIN acknowledged the posting combined licensed staff and did not allow residents, visitors, or the public to determine the actual nursing staff providing care.
Two residents had deficiencies related to medication management. One resident with dementia and depression received Namenda for memory loss without written informed consent and without monitoring for side effects or behaviors. Another resident with osteoarthritis and rheumatoid arthritis received PRN oxycodone and acetaminophen daily, but the orders had no pain parameters, and staff described inconsistent methods for deciding which pain medication to give.
Failure to Serve Menu Item at Lunch: A cook plated lunch trays with ham, beans, and steamed cabbage, but cornbread listed on the menu was not served to three residents. Each resident stated they did not receive the cornbread, and the cook said he missed adding it when plating began. The CDM, RD, and DON all stated residents were expected to receive all menu items unless otherwise ordered or refused, and the facility policy required staff to ensure the correct meal was provided.
A resident with right-sided hemiplegia, MDD, and CKD was served cabbage even though his care plan listed cabbage as a dislike. During observation, he said he did not enjoy lunch and only ate the ham. The CDM confirmed he should not have been served cabbage, and the RD and DON stated residents should receive foods aligned with documented preferences.
Improper Air Gaps at Ice Machine and Food Prep Sink: The facility failed to maintain proper air gaps for the ice machine drain and the food prep sink. The CDM and MD observed plumbing at the sink and ice machine, and the MD stated the ice machine drain did not have an air gap. The MD also stated he installed an inline air gap under the food prep sink after searching online and did not review regulations or food code before doing so.
Kitchen Pest Control Failure: The facility failed to keep the kitchen free of flies while food was being prepared for residents. Staff observed flies in the dishwashing area and later near the food processor and cornbread, with one fly landing on tongs used with food. The CDM stated the kitchen should have no flies, and the maintenance log documented flies in the building.
The facility's fire protection system was nonfunctional for several days, during which a fire watch was implemented and all fire exit doors were closed. Despite documented procedures requiring notification, the facility did not inform CDPH or HCAI of the system outage, as confirmed by the Administrator and Maintenance Supervisor.
A resident with a history of stroke, moderate cognitive impairment, and high fall risk experienced three falls in three days, including one resulting in a hip fracture, due to the facility's failure to provide adequate supervision and implement individualized interventions. Staff and documentation confirmed that the resident was known to be impulsive, non-compliant with safety instructions, and did not use the call light or assistive devices, yet care plans remained generic and ineffective, lacking timely updates and specific supervision measures.
A resident with a history of stroke, hemiplegia, and moderate cognitive impairment experienced multiple falls resulting in a hip fracture after the facility failed to develop and implement an individualized care plan. Despite staff awareness of the resident's poor safety awareness, impulsiveness, and refusal to use assistive devices or call for help, the care plan remained generic and did not specify the necessary level of supervision or assistance, leading to repeated unwitnessed falls and injury.
A resident was served an uncut country-fried steak instead of the prescribed No Added Salt (NAS) diet with Mechanical Soft texture. The resident had difficulty cutting the meat and only ate half. An LVN and the CDM confirmed the error, acknowledging the risk of choking. The DON stated that dietary staff should verify diet orders during meal plating, and licensed nurses should check meal trays before serving, but this was not done.
A resident reported being hurt by an aide during care to a CNA, who failed to report the allegation to the charge nurse or administrator as required by facility policy. The resident, who had intact cognition and required assistance with daily activities, later stated they felt safe. The administrator was unaware of the incident until informed by surveyors.
The facility exceeded the acceptable medication error rate, reaching 7.41%, due to errors in administering multivitamins with minerals instead of the prescribed multivitamins to two residents. The errors were attributed to the failure of LVNs to verify medication labels against physician orders before administration.
The facility did not meet the required room size of 80 sq. ft. per resident in 26 rooms, with sizes ranging from 66.8 to 78.8 sq. ft. per resident. Despite this, no residents expressed concerns, and the facility had a waiver for non-compliant rooms. The DON and Administrator reported no issues with care provision due to room size.
The facility failed to notify the LTC-Ombudsman of a resident's transfer to the hospital, resulting in the Ombudsman being unaware of the discharge circumstances. The resident had multiple diagnoses, including Metabolic Encephalopathy and End Stage Renal Disease. The Social Services Director admitted to not knowing the requirement to notify the Ombudsman for hospital transfers.
Incomplete orders and improper respiratory and monitoring documentation
Penalty
Summary
Physician orders for insulin administration for two residents did not include parameters for when the MD should be notified for low or high blood glucose levels. One resident had an active order for insulin lispro per sliding scale, and the other had an active order for insulin aspart 5 units before meals. Both residents had diabetes, and one was admitted with type 2 diabetes with ketoacidosis while the other was admitted with type 2 diabetes and morbid obesity. The ADON stated there should be parameters for MD notification related to abnormal blood glucose levels, and the DON confirmed residents receiving insulin should have defined parameters for MD notification. The residents’ care plans did not include parameters for MD notification related to abnormal blood glucose levels. Resident 124 experienced a significant weight gain and an SBAR was completed because of a 25-pound gain within one month. The MD ordered additional diuretics, including spironolactone, and the resident was educated on elevating his feet. The ADON stated the expectation after the change in condition was to complete the COC, notify the MD, refer to the RD, and initiate 72-hour alert charting. The ADON stated alert charting should have started on the night shift after the SBAR and been completed every shift for 72 hours, but it was initiated later and documented only twice. The charting was not completed consistently each shift and did not include consistent documentation of edema or fluid overload assessments. The TAR also did not contain documentation of monitoring for edema or fluid overload. Resident 101 had two active O2 orders with the same PRN indication for shortness of breath, one for 2 L and one for 3 L, which the ADON and DON stated could cause confusion and should have been clarified into one clear order or distinct parameters. During observation, Resident 101’s oxygen concentrator was set at 1.5 L, and Resident 87’s oxygen concentrator was also set at 1.5 L even though the physician order for each resident was 2 L via nasal cannula. LVN 1 confirmed both residents were receiving oxygen below the ordered flow rate. Resident 122 was placed on BiPap by LVN 1, although the current LVN scope of practice indicated LVNs are not allowed to manipulate non-invasive ventilation. Resident 122 also had a physician order to change nasal cannula tubing every seven days, but the tubing observed was dated 3/30/26 and had not been replaced when it should have been.
Food Not Palatable or Attractive
Penalty
Summary
The facility failed to provide food that was palatable and attractive for three sampled residents, including Residents 33, 83, and 119, after residents reported that meals lacked flavor, tasted bad, or were refused. Resident 119 was observed in bed with a regular diet tray containing chopped chicken, potatoes, green beans, and hot chocolate, and stated she did not like the food, that the coffee did not taste good, that the potatoes had no taste, and that the green beans did not taste good. She also stated she told staff she did not like the food but continued to receive it, and said she would prefer a peanut butter and jelly sandwich. Surveyors observed and tasted test trays for both regular and puree diets. The regular diet tray included ham, beans, cabbage, and cornbread; the beans and cabbage were served in residual cooking liquid that made the cornbread and ham wet, and the ham tasted salty while the cabbage and beans had no flavor or seasoning. The puree tray contained formed food items with brown liquid on top, but the cabbage was gelatinous, the beans had no flavor or seasoning, and the cornbread was thick, sticky, grainy, and tasted like plain cornbread. The Administrator sampled both trays and stated the puree tray did not taste as good as the regular tray, and that the puree and regular diets should taste the same. Resident 33 stated he did not enjoy lunch, describing the cabbage as soggy and the beans as having no flavor, and said he only ate the ham and was ready to eat again. The CDM stated puree foods should be colorful, taste good, and have a mashed potato consistency, and the RDC stated the puree tray did not look appetizing and that too much water or thickener could affect taste and reduce palatability. The DON stated food should have nice portions, different food types should not run together, and food should appear presentable and be palatable, and that residents could refuse to eat if food was not presentable or palatable. The facility policy stated residents are to receive a nourishing, palatable, well-balanced diet and that food service staff will inspect trays to ensure meals taste and appear palatable and attractive.
Failure to Permit Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return to the facility following hospitalization after the resident was not re-admitted back on [DATE]. The resident had been admitted to the facility with diagnoses including epilepsy, sequelae of nontraumatic intracerebral hemorrhage, paroxysmal atrial fibrillation, nontraumatic intracranial hemorrhage, cognitive communication deficit, and major depressive disorder. The resident’s MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment. The admission coordinator stated the resident was sent to the hospital for a change in condition and that the hospital provided clinical updates while the resident was followed for return to the facility. The admission coordinator stated the hospital sent discharge orders and transfer information, and that the resident would normally be processed for readmission. The admission coordinator also stated the resident had a significant change in condition, was on restraints, and had been started on quetiapine for agitation. A meeting with the DON and Administrator resulted in the decision that the facility could not accommodate the resident because of the new behaviors and medications, and the resident was declined in the electronic referral system. The DON stated the resident had been sent out for a change in condition and later returned from the hospital with multiple medications and agitation. The DON stated the resident was not permitted to return because of the diagnosis and because the facility considered the new medications to be chemical restraints. The DON and Administrator stated the facility had available beds but decided not to re-admit the resident. The facility policy stated that the requirement to permit return following hospitalization applies to all residents regardless of payer source, and that if the facility determines a resident cannot return, it must comply with facility-initiated discharge requirements.
MDS Assessments Did Not Accurately Reflect Residents’ Functional Status and Diagnoses
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the health and functional status of two residents. For one resident, the admission record showed diagnoses including osteoarthritis of the left hip and right knee, rheumatoid arthritis, and muscle weakness. During observation, the resident was lying in bed with legs flexed and crossed and stated she was uncomfortable, needed repositioning, and had leg pain all the time because of arthritis. The MDS nurse reviewed the resident’s MDS and stated the resident was dependent with toileting, showering/bathing, and was not attempted to walk due to medical condition or safety concern, but the nurse coded the resident as not having impairment of the upper and lower extremities and acknowledged that this should have been coded differently. Staff interviews supported that the resident required extensive assistance with daily care. A CNA stated the resident was dependent with ADLs and required assistance because she complained of pain all the time and became stiff. An LVN stated the resident was dependent on staff to do all ADL needs and was always complaining of pain and did not want to do anything for herself. The MDS nurse stated he did not perform a bedside assessment and based the coding on the therapy evaluation, while also stating it was his responsibility to ensure assessments were accurate. For the second resident, the admission record showed diagnoses including anxiety, palliative care, and depression. During observation, the resident was lying in bed with eyes closed and did not respond when spoken to. The MDS nurse reviewed the resident’s MDS and stated the resident had been diagnosed with anxiety and should have been coded as such, but was not. A CNA stated the resident could understand simple questions and answer simple words and had behaviors such as hitting, kicking, and yelling at staff. An LVN confirmed the resident had a diagnosis of anxiety and had been started on lorazepam when admitted under hospice care. The DON stated she only verified completion in the MDS and expected the assessments to be accurate, and the facility policy stated that the information captured on the assessment reflects the resident’s status.
PASARR Screening Not Completed or Corrected for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to complete a PASARR Level I screening for one sampled resident, Resident 100, and the PASARR Level I screening dated 6/3/24 did not indicate the resident’s diagnosis of anxiety disorder. Resident 100’s admission record dated 4/8/26 showed diagnoses that included anxiety disorder, hemiplegia, hemiparesis, and dementia. During an initial tour on 4/7/26, Resident 100 was observed lying in bed and biting her fingernails, and she stated she did not remember how long she had been in the facility. During interviews, the AC stated she reviewed PASARR when residents were admitted from the hospital, but only completed PASARR assessments for hospice residents admitted from home and for residents with new psychotropic medication orders. The LVN/ADON stated she was responsible for PASARR assessments for significant changes and hospice admissions or discharges, and that the AC was responsible for reviewing PASARR for accuracy, diagnoses, and medications. The LVN/ADON reviewed Resident 100’s PASARR and stated it was invalid and should not have been done, and that another PASARR Level I assessment should have been completed to correct the issue but was not. The DON stated the AC was responsible for reviewing PASARR for accuracy and completeness and that another assessment should be completed if there was a discrepancy or error. The facility policy stated a Level I PASRR screen must be completed for all applicants before admission unless state process provides otherwise, and admission staff must review PASRR documents prior to admission.
Missing Care Plan for Antiplatelet Monitoring
Penalty
Summary
A comprehensive, person-centered care plan was not developed and implemented for Resident 44 to address monitoring for side effects of Plavix. During observation, Resident 44 was found in bed sleeping with a tray table across the bed. The resident’s admission record showed diagnoses including monoplegia of the right lower limb, major depressive disorder, anemia, and type 2 DM. The MDS assessment indicated a BIMS score of 9 out of 15, showing moderate cognitive deficits. The MAR showed Resident 44 was prescribed Plavix 75 mg by mouth daily for clot prophylaxis. During record review with LVN 3, the resident’s care plans were reviewed and no care plan for antiplatelets had been created. LVN 3 stated that a care plan was required for all residents taking an antiplatelet and should include side effects to monitor for such as bleeding or bruising. The DON also stated that when residents are taking antiplatelets, a care plan is required to inform staff what side effects to monitor for, and that the care plan is in place for resident safety. The facility policy on comprehensive person-centered care plans stated that care plans include measurable objectives and timetables and are developed and implemented for each resident.
Care Plan Not Updated to Match Oxygen Order
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for one resident when the resident’s oxygen care plan was not updated to match the physician’s order. During an initial tour, the resident was observed sitting in a wheelchair with a nasal cannula connected to a working oxygen concentrator set at 1.5 L/min. The resident’s record showed diagnoses including COPD, chronic respiratory failure with hypoxia, and heart failure, and the MDS indicated a BIMS score of 12, reflecting moderate impairment. The resident’s order summary showed an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath with a start date of 3/29/26. However, the care plan still listed an intervention to give 2 L/min via oxygen nasal cannula and showed a revision date of 11/13/2024. During interviews and record review, the LVN, ADON, and DON all confirmed that the care plan had not been updated to reflect the current oxygen order and stated that the care plan should have been revised. The facility’s policy stated that care plans are developed and implemented for each resident and revised as resident conditions change. The ADON stated that LNs revise care plans and that the MDS nurse reviews them to ensure orders match the care plan. The DON stated the care plan should have been updated and revised to match the resident’s needs and to avoid confusion and ensure the correct order was followed.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary bathing and hygiene assistance for Resident 13, who was unable to perform activities of daily living independently. Resident 13 was admitted with diagnoses including gastrostomy tube placement, paraplegia, fecal incontinence, functional urinary incontinence, and major depressive disorder. The MDS dated 3/16/26 showed a BIMS score of 6, indicating severe cognitive impairment, and the resident was described by staff as totally dependent on facility staff for ADLs. During interview, Resident 13 stated, "They don't bathe me," and said he did not recall the last time he had a bath and wanted one because he felt dirty. Review of the EMR and shower task showed showers documented on 3/11/26, 3/18/26, 3/21/26, 3/25/26, 3/28/26, and 4/4/26, with other days marked Not Applicable. The ADON stated Resident 13 was scheduled for showers on Wednesdays and Saturdays, that residents should receive showers twice a week, and that the expectation was for CNAs to document completed showers or refusals. The ADON also stated the shower schedule was not consistent and that there were instances of 7 days between showers. The DSD reviewed the shower sheet and EMR and stated that Not Applicable meant the shower did not happen. The DSD stated there was no refusal documented on the shower sheets and confirmed that if a shower was not done, a bed bath could be provided. The IP and DON both stated staff should have offered a bed bath and documented refusals if the resident declined. Facility policies stated residents would be offered and assisted with showering or bathing based on their needs, preferences, and care plan, and that bathing and hygiene assistance would be provided in a manner that protects skin integrity and infection control.
Nonfunctional Bed Rail Left Unsecured
Penalty
Summary
The facility failed to ensure a resident’s bed rails were maintained in safe working condition. During observation, the resident was lying in bed with the head of bed elevated and bilateral bed rails up, and she stated that the left bed rail had broken and did not stay up when staff turned her. The left bed rail was observed to not hold steady and would drop when hands were placed on it. The resident stated the rail had not been securely locked for about 2 to 3 months and that she had reported the problem to LNs, CNAs, and maintenance staff. The resident involved was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, contracture of the left hand, generalized anxiety disorder, unspecified visual loss, and muscle weakness. Her MDS indicated she was cognitively intact, dependent on staff for multiple activities of daily living, used a wheelchair, and was always incontinent of bowel and bladder. Her care plan and bed safety assessments identified bilateral bed rails as an enabler and support for mobility, positioning, and safety, and the resident stated she was partially blind and had glaucoma. When CNAs entered the room to reposition the resident, they repositioned her without using the bed rail. One CNA stated she was not aware the bed rail was broken until it was checked during the observation and acknowledged it was a safety issue. A maintenance assistant later confirmed the left bed rail was not securely locked and said he had just been notified. The maintenance director stated the bed and rails were inspected quarterly or when issues were reported, that the last inspection had been months earlier, and that there was no definite schedule for inspecting bed rails. The maintenance log showed multiple requests related to the resident’s bed rails, and the facility policies and job descriptions stated that equipment was to be maintained in safe working condition and that staff were to report defective equipment.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure nurse staffing information was accurately posted each day. During observation, interview, and record review, surveyors found that the staffing hour sheets reflected projected staffing hours rather than the actual hours worked by RNs, LVNs, and CNAs. On review of the staffing sheet dated 4/8/26, the Employee Services Representative stated the posted hours were projected hours and not actual hours worked. The representative also explained that the left side of the sheet combined licensed staff hours for RNs and LVNs, while the right side included CNA and RNA hours. The posted staffing information did not distinguish individual staff titles, and the report did not identify whether licensed staff were RNs or LVNs. During interviews, the Employee Services Representative, DON, and ADMIN acknowledged that the posting reflected scheduled or projected staffing rather than actual hours worked, and that residents, visitors, and the public would not be able to determine the actual staffing from the posting. The facility policy titled Posting Direct Care Daily Staffing Numbers required the form to include the type and category of nursing staff, the actual time worked during the shift for each category and type, and the total number of licensed and non-licensed staff working for the posted shift.
Unnecessary Drug Regimen and PRN Pain Order Deficiencies
Penalty
Summary
Resident 84 was admitted with diagnoses including unspecified dementia, depression, and COPD. During observation, the resident was lying in bed and stated she had been in the facility long enough and had no concerns, though she felt staff could do better with care. Staff described the resident as alert and oriented with confusion, and reported that she had physically and verbally aggressive behaviors during care. The resident was receiving Namenda for memory loss, but the record review and staff interviews found no written informed consent for the medication and no monitoring of side effects or behaviors related to its use. During the review of Resident 84’s record, the LVN stated she did not find an informed consent for Namenda and was not sure if one was needed. The LVN stated informed consent was important to let the family and resident know of medication side effects and to allow a decision about continuing the medication. The LVN/ADON stated the medication classification in PCC was wrong and should have been changed, and stated there was no behavior monitoring or medication side effect monitoring in place. The DON stated there was no informed consent for Namenda because it was used for memory loss, and also stated there was no monitoring for medication side effects and behavior in place. Resident 133 was admitted with diagnoses including osteoarthritis, injury of muscle fascia and tendons, and rheumatoid arthritis. During observation, the resident was lying in bed with legs flexed and crossed and stated she was not comfortable, that repositioning was not helping, and that she needed to be repositioned. She stated she had leg pain all the time because of her arthritis. Record review and staff interviews showed the resident had two PRN pain medication orders, oxycodone HCL and acetaminophen, both given daily, but there were no pain parameters with either order. The LVN/ADON stated the facility did not use pain parameters except for hospice residents and was not sure how nurses decided which medication to administer. RN 1 stated she used pain scale ranges to decide which medication to give, but also stated the resident did not have pain parameters with the medication orders. The DON stated licensed nurses monitored pain every shift and decided which medication to administer based on the resident’s complaint of pain, and confirmed the facility did not add pain parameters to the pain medication orders.
Failure to Serve Menu Item at Lunch
Penalty
Summary
The facility failed to follow the established menu for lunch when cornbread listed on the 4/8/26 menu was not served to Residents 41, 53, and 95. During a kitchen observation, a cook was plating lunch trays with ham, beans, and steamed cabbage, and a pan of squared cornbread was present on the food counter. However, when Residents 53, 41, and 95 were observed in the dining room during lunch, each was served ham, beans, and steamed cabbage without cornbread, and each stated they had not received it. During interview, the cook stated he missed adding cornbread at the beginning of lunch and thought he forgot about it when plating started. The CDM stated cooks were expected to follow the menu and that residents needed the correct amount of carbohydrate, protein, and other nutrients to stay healthy. The RD stated residents should be served all menu items unless a doctor ordered otherwise or the resident did not want the item, and that not receiving all items could lead to weight loss. The DON stated all items on the menu should have been served to the three residents and that the facility menus were based on nutritional values for each day. The facility policy stated each resident should receive a nourishing, palatable, well-balanced diet and that staff should inspect trays to ensure the correct meal is provided.
Food Preferences Not Followed for Resident With Cabbage Dislike
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were followed when the resident was served cabbage even though the care plan listed cabbage as a dislike. During a concurrent observation and interview, the resident stated that he did not enjoy his lunch, describing the cabbage as soggy and the beans as having no flavor, and said he only ate the ham and was ready to eat again but would wait for dinner. The resident’s admission record showed diagnoses of right-sided hemiplegia, major depressive disorder, and chronic kidney disease, and the MDS indicated a BIMS score of 12, reflecting moderate cognitive deficits. A concurrent review of the resident’s care plan with the CDM showed the plan documented “no liver, no spinach, no cabbage.” The CDM stated the resident should not have been served cabbage because it was listed as a dislike. The RD stated residents should be served all menu items unless listed as a dislike on their preferences, and the DON stated the resident’s food preferences should have been followed and that serving disliked foods could cause the resident not to eat the food, resulting in unintended weight loss. The facility policy titled Resident Food Preferences stated nursing staff will document the resident’s food and eating preferences in the care plan.
Improper Air Gaps at Ice Machine and Food Prep Sink
Penalty
Summary
The facility failed to store and prepare food in accordance with professional food service standards for 49 residents who were served food from the ice machine and kitchen. During an initial kitchen tour with the CDM, the food preparation sink was observed with black pipes going into the wall and a drain sink under and to the left of the food preparation sink that was not being used. The CDM stated the white plastic piece on top of the black pipe was an air gap installed by maintenance. During a later observation with the MD, the facility's ice machine had two pipes going from the ice machine to the drain on the floor, and one pipe was inserted into the drain beyond the level of the floor. The MD stated the hopper pipe from the ice machine was going past the lip of the sink drain and that the ice machine drain did not have an air gap. During another observation with the MD in the kitchen, the food preparation sink was seen with the white plastic piece connected to the black pipe coming from the sink. The MD stated the white plastic piece was an air gap for garbage disposal and that he had installed it. In interview, the MD stated he had installed an inline air gap on the pipe under the food preparation sink after using Google to search for one, chose it because it went along with the existing plumbing, and did not look up regulations or food code before installing it. The Administrator stated there should have been an air gap for the ice machine drain and that the facility should follow the regulations for an air gap at the food preparation sink. The facility policy stated sinks, drains, and equipment that discharge into the plumbing system shall maintain a proper air gap when required, and drain pipes must not be placed directly into a sewer or floor drain without the proper gap.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to have an effective pest control program to keep the kitchen free of flies for 51 residents who ate food prepared there. During an initial tour of the kitchen, two flying insects were observed around the dishwashing area. The Dietary Aid stated there had not been a problem with flies in the kitchen until that day and explained that the kitchen had negative airflow over the exit door to help control flies. The Dietary Aid also stated that if flies were found in the kitchen, staff would notify the Certified Dietary Manager. On a later observation, one flying insect was seen on a wood countertop near the food processor, then flying around food being prepared and landing on metal tongs sitting on top of a pan of cornbread. The Certified Dietary Manager stated she had observed two flies in the kitchen on one day and one fly in the kitchen the next day, and stated her expectation was that the kitchen had no flies. A maintenance request log documented a problem of flies in the building, and the facility's pest control policy stated the facility would maintain a clean, safe environment and take prompt action to keep the building free of insects, rodents, and other pests, with sightings, reports, treatments, and follow-up actions documented.
Failure to Notify Authorities and Maintain Fire Protection System
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors when the fire protection system became nonfunctional for a period of several days. During this time, all fire exit doors were closed as a precaution, and a fire watch was initiated by the Maintenance Supervisor and other staff, with hourly inspections documented. However, the facility did not notify the California Department of Public Health (CDPH) or the California Department of Healthcare Access and Information (HCAI) about the fire protection system malfunction, as required by regulations. The Administrator confirmed that the facility remained under a fire watch and acknowledged unawareness of the notification requirement. Review of facility documents and policies indicated that the fire alarm system is expected to be operable at all times and that maintenance personnel are responsible for keeping the fire alarm system in good working order. The facility's fire watch log and maintenance policies further outlined the procedures to be followed in the event of a system outage, including the implementation of a fire watch. Despite these documented procedures, the required notifications to regulatory agencies were not made during the period when the fire protection system was out of service.
Failure to Provide Adequate Supervision and Individualized Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement effective, individualized interventions to prevent falls for a resident assessed as high risk. The resident, who had a history of left-sided hemiplegia and hemiparesis following a stroke, moderate cognitive impairment, and other significant medical conditions, was known by staff to be impulsive, non-compliant with safety instructions, and did not use the call light to request assistance. Despite these known risk factors, the care plans in place were generic, not tailored to the resident's specific needs, and did not address the root causes of his falls, such as his poor safety awareness and refusal to use assistive devices. The resident experienced three falls within three days. The first fall occurred when the resident attempted to enter a shared bathroom and was struck by the door, resulting in a fall and injuries to his head and hip. The second fall was unwitnessed; the resident was found on the floor after attempting to retrieve pants from his closet, reporting that he blacked out and fell. The third fall was witnessed by staff, occurring when the resident, despite being on non-weight bearing status, stood up in his doorway and fell after turning around. Staff interviews confirmed that the resident routinely ambulated independently, did not use his walker, and did not call for assistance, even after repeated education and reminders. Documentation and interviews with the MDS Coordinator, ADON, and DON revealed that the care plans were not updated promptly after the initial falls and did not specify the level of supervision or assistance required for the resident's activities of daily living. The interventions listed, such as encouraging use of the call light and providing education, were ineffective given the resident's non-compliance and cognitive status. The facility's policy required individualized, resident-centered fall prevention plans, but this was not achieved for this resident, resulting in repeated falls and a hip fracture that required emergency department evaluation.
Failure to Individualize Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was identified as a high fall risk with poor safety awareness and a known behavior of not calling staff for assistance. Despite multiple assessments and staff awareness of the resident's impulsiveness, noncompliance with using the call light, and refusal to use assistive devices, the care plan interventions remained generic and did not address the resident's specific needs. The care plans primarily included standard interventions such as encouraging call light use, education, and routine monitoring, which staff acknowledged were ineffective for this resident. The resident experienced three falls within three days, resulting in a comminuted fracture of the left greater trochanter, pain, and decreased mobility, necessitating transport to the emergency department for assessment and treatment. Interviews with CNAs, LVN, the MDS Coordinator, ADON, and DON confirmed that the resident continued to ambulate independently to the bathroom without supervision, did not use the call light, and refused to use a walker, despite repeated education and reminders. Staff also noted that the care plan was not updated promptly after the initial falls and did not specify the level of supervision or assistance required for the resident's activities of daily living, particularly toileting and ambulation. The facility's own policies required individualized, measurable objectives and interventions that address the underlying causes of problems, as well as ongoing assessment and revision of care plans when residents' conditions change. However, the care plans for this resident did not reflect these requirements, as they failed to address the root causes of the resident's falls—impulsiveness, poor safety awareness, and noncompliance. The lack of individualized interventions and timely updates to the care plan contributed to the recurrence of falls and subsequent injury.
Failure to Provide Physician-Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-prescribed therapeutic diet for a resident during lunch on November 1, 2024. The resident, who was on a No Added Salt (NAS) diet with Mechanical Soft texture, was served a piece of uncut country-fried steak. This was contrary to the prescribed diet order, which required the food to be of a mechanical soft texture. The resident expressed difficulty in cutting the meat and only consumed half of it, indicating a preference for soft and small pieces of meat. During an interview, a Licensed Vocational Nurse (LVN) confirmed that the resident was served the wrong diet texture and acknowledged the risk of a choking episode from eating large pieces of meat. The LVN stated that both dietary and nursing staff were responsible for ensuring the resident received the appropriate meal texture and consistency, which was not done in this instance. The Certified Dietary Manager (CDM) also confirmed the failure to follow the physician-ordered diet and highlighted the potential choking risk. The CDM noted that dietary staff should prepare the correct diet, and licensed nurses should verify the meal tray upon arrival to the unit. The Director of Nursing (DON) stated that the standard practice was for dietary staff to verify the diet order during meal plating and for licensed nurses to verify the meal tray contents before serving. The facility's policy and procedure on Tray-Cards/Diet Orders indicated that tray cards should list the resident's diet order and that Nutrition Services staff should check these against physician-prescribed diet orders before each meal service. However, this procedure was not followed, leading to the deficiency.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that staff reported an allegation of abuse involving a resident. According to the facility's policy, any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and other officials as per state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations. In this case, a resident with a history of palliative care, hemiplegia, hemiparesis, and incontinence reported to a Certified Nurse Aide (CNA) that an aide had been rough and hurt them during care. The resident had intact cognition and required extensive assistance with daily living activities. Despite the resident's report, the CNA did not inform the charge nurse or the administrator, instead only telling another CNA. This failure to report was confirmed during interviews with the involved CNAs and the administrator, who was unaware of the incident until the surveyor's inquiry. The Social Service Director began an investigation after being informed by the surveyor, and the resident stated they felt safe and had no physical signs of abuse. The administrator expressed that staff are expected to report any allegations of rough treatment or harm to residents immediately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during a survey. This deficiency was identified through observations, record reviews, and interviews. Two residents were affected by medication errors during the administration process. Resident #78, who was admitted with a diagnosis of generalized muscle weakness, received a multivitamin with minerals instead of the prescribed multivitamin without minerals. The error occurred because the Licensed Vocational Nurse (LVN) did not verify the medication label against the physician's order before administration. Similarly, Resident #43, with a medical history of unspecified dementia and diabetes mellitus type 2, was also given a multivitamin with minerals instead of the ordered multivitamin. LVN #2 failed to check the medication label against the order or seek clarification before administering the medication. Interviews with the Director of Nursing and the Administrator revealed that the facility's expectation was for nurses to match the physician's order with the medication label to prevent such errors, which was not adhered to in these instances.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Observations and measurements revealed that 26 out of 40 resident rooms did not comply with this requirement, with room sizes ranging from 66.8 to 78.8 square feet per resident. Despite the deficiency, interviews with 24 residents indicated no expressed concerns about room size, and the Maintenance Director confirmed the accuracy of the room measurements. The Director of Nursing stated that the facility had a waiver for rooms not meeting the size requirement and expected care to be provided safely and with privacy. The Administrator confirmed there was no policy for room size but expected no difference in care quality for residents in smaller rooms. Both the DON and Administrator reported no complaints or issues related to care provision due to room size, and the Administrator emphasized that the current room sizes allowed for adequate care and privacy.
Failure to Notify LTC-Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman office of a resident's transfer to the hospital. Specifically, the facility did not send a copy of the transfer and discharge notification for a resident who was transferred to an acute hospital. This failure resulted in the LTC-Ombudsman being unaware of the resident's discharge circumstances, which could impact the ability to act promptly should appeals be filed by the resident or their representative. The resident involved had multiple diagnoses, including Metabolic Encephalopathy, Pneumonia, Type 2 Diabetes Mellitus, Hypertension, Congestive Heart Failure, and End Stage Renal Disease. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14 out of 15, the facility's Social Services Director admitted to not being aware of the requirement to notify the LTC-Ombudsman for hospital transfers. This oversight was confirmed by the LTC-Ombudsman, who stated that no transfer and discharge notifications were received from the facility for any residents transferred to the hospital.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 227 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hanford Post Acute | 1.5 mi | — | 0 | 0 |
| Kings Healthcare & Wellness Center Lp | 2.2 mi | — | 0 | 0 |
| Kingsburg Center | 13.4 mi | — | 3 | 0 |
| Bethel Lutheran Home | 15.6 mi | — | 17 | 0 |
| Rolling Hills Care Center | 16 mi | — | 0 | 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.