Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pacific Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that nursing staff failed to document ordered wound and skin treatments for five residents with complex medical conditions, including diabetes, COPD, venous stasis ulcers, skin tears, peri-anal rash, MASD, and fungal rash. Review of Treatment Administration Records showed multiple missing nurse initials for ordered treatments on specific shifts, despite physician orders for daily or every-shift wound care. Facility leadership, including the DON, ADON, and Administrator, stated that standard practice requires following physician orders and documenting care, and that if wound care is not documented, it is considered not done. Another LVN confirmed that documentation after providing wound care is required to ensure continuity of care and to reflect the treatments residents receive, indicating that the missing entries represented a failure to meet professional standards and facility policy for charting and documentation.
The facility did not ensure that all residents were treated equally in matters of transfer, discharge, and service provision, regardless of their payment source.
A resident did not receive restorative nursing assistant (RNA) services after being discharged from physical therapy, leading to a contracture in the right hand. The resident, with a history of hemiplegia and hemiparesis, was not transitioned to RNA services due to a lack of coordination between PT and RNA staff. The Director of Nursing acknowledged the failure to follow the process, which was crucial for maintaining the resident's activities of daily living.
The facility failed to inform and document information on how to formulate an advance directive for four residents, violating their rights. Interviews revealed that residents were not informed about advance directives, and staff acknowledged the lack of documentation. The facility's policy requires informing residents of their rights to establish an advance directive, but this was not consistently followed.
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by cold room temperatures, exposed wiring, and malfunctioning equipment. Two residents experienced discomfort due to cold rooms, while another resident's room had holes with exposed insulation and wiring. Additionally, a resident faced issues with a broken bed and poor TV reception, affecting their comfort and quality of life.
A facility failed to properly store and label medications, with two inhalers lacking open and expiration dates, and two medication refrigerators operating outside the recommended temperature range. This affected medications for several residents, risking their potency and effectiveness. Observations and interviews confirmed these deficiencies, highlighting the need for adherence to storage and labeling policies.
The facility's cook staff failed to accurately measure milk and margarine for pureed rice, affecting 12 residents on a pureed diet. Cook 1 used incorrect measuring techniques, leading to potential inconsistencies in nutrient content. The RD acknowledged the importance of following recipes but had not verified staff measurements. The DON noted the absence of a policy for pureed food preparation, while Cook 2 described a different measurement approach.
The facility failed to maintain safe and sanitary food preparation and storage practices. Observations included unlabeled potatoes and thawing beef kabobs, a dietary aide not washing hands after scratching their ear, and dust on the ceiling above a fan in the food storage room. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to maintain effective infection control, with issues such as improper storage of nebulizer mouthpieces, catheter bags on the floor, and lack of Enhanced Barrier Precautions for residents with wounds. Additionally, oxygen tubing was found on the floor, and opened medical supplies were improperly stored, posing infection risks.
The facility failed to maintain secure handrails in the hallways, increasing fall risk for residents. Observations revealed broken and loose handrails, with missing parts exposing metal brackets and screws. The Maintenance Supervisor acknowledged the risk and noted the use of the TELS System for repair notifications, but obsolete parts hindered replacements. Facility policies emphasized a safe environment, yet the handrails were not adequately maintained.
Two residents in the facility were observed without dignity bags covering their foley catheter drainage bags, leaving the urine visible and violating their right to dignity. Staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The facility's policies emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Two residents were transferred to the hospital without receiving written information about the facility's bed hold policy, despite verbal notifications. The facility's policy required written notice, but it was not provided, leading to potential confusion and disputes over bed availability.
The facility failed to implement comprehensive care plans for several residents, leading to potential risks and unmet needs. A resident with a Foley catheter lacked a care plan, increasing infection risk. Another resident's visual needs were unmet due to missing glasses, risking injury. Two residents on anticoagulants lacked care plans for monitoring side effects, highlighting the need for individualized care plans.
A facility failed to update a resident's care plan after a stage two pressure ulcer had healed, leaving active treatment interventions in place. Staff interviews revealed that accurate care plans are crucial for guiding resident care, and the Director of Nursing acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy requires regular evaluation and revision of care plans.
Two residents in the facility received incorrect oxygen flow rates, contrary to physician orders. One resident with COPD was given 2.5 LPM instead of the ordered 2 LPM, while another resident with multiple health issues had an oxygen flow rate set at 3 L/min instead of 2 L/min. Additionally, the second resident's oxygen tubing was not labeled with the date, risking infection. These actions were against the facility's policy and procedure for oxygen administration.
A resident with reduced mobility and no cognitive deficits experienced discomfort due to long, jagged toenails, as the facility failed to provide proper toenail care. Despite policies requiring routine care, staff did not adequately trim, file, or document the resident's toenail care, leading to potential risks of injury or infection.
A resident's foley catheter tubing was improperly managed, being wrapped around her prosthetic leg, posing a risk of falls or injury. Staff interviews revealed a lack of training and adherence to facility policies, highlighting a deficiency in ensuring resident safety.
The facility did not post accurate daily staffing information, omitting the total number and actual hours worked by RNs, LVNs, and CNAs. The Assistant Staff Development Coordinator admitted the posted form was incomplete, and the Administrator was unaware of CMS requirements. This deficiency prevented residents and families from accessing accurate staffing details.
A resident was administered mirtazapine for several months without documented attempts at a gradual dose reduction (GDR), despite no recorded depressive episodes. The facility's policy requires quarterly evaluations and documentation of GDR assessments, which were not followed.
A resident in an LTC facility was administered potassium chloride 20MEQ by RN 1 without following the manufacturer's instructions. The medication was given without a meal and the resident was allowed to lie down immediately after, contrary to guidelines. The resident had a history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease, and was cognitively intact.
A resident in an LTC facility did not have a completed POLST on file, despite being admitted with multiple serious health conditions. The resident was cognitively intact and had expressed a DNR preference, but the lack of a POLST meant their end-of-life wishes might not be honored in an emergency. The facility's policy required timely completion of such documents, but the POLST remained incomplete for a month, which was acknowledged as unacceptable by the ADON.
An LVN at an LTC facility failed to perform necessary assessments and inaccurately documented care for a resident who was hospitalized. The LVN recorded vital signs, pain assessments, and enteral feeding interventions that were not provided while the resident was in a general acute care hospital. This resulted in an inaccurate clinical record, as confirmed by the ADON and DON, who stated the documentation was unacceptable and illegal.
A facility failed to ensure accurate documentation by an LVN, who recorded care for a resident while they were hospitalized. The resident, with multiple health conditions, was transferred to a hospital for shortness of breath, yet the LVN documented vital signs, pain assessments, and enteral feeding as if the resident were still in the facility. Interviews with the ADON and DON confirmed the documentation was inappropriate and illegal, as it falsely indicated care was provided. The LVN admitted to the mistake, acknowledging the failure to accurately document the resident's care.
The facility's kitchen was found in unsanitary conditions with debris, buildup, and dead cockroaches present. Observations revealed a golden-colored buildup behind the stove, debris on the floor in various areas, and a black substance on the pantry storage counter. The presence of dead cockroaches was also noted, indicating a failure to maintain cleanliness and pest control as per the facility's guidelines and FDA Food Code.
The facility failed to maintain an effective pest control program, evidenced by dead cockroaches in the kitchen and other areas. Staff confirmed awareness of the issue, and pest control reports indicated ongoing live cockroach activity despite treatments. The facility did not adhere to FDA Food Code requirements for pest prevention and cleanliness.
A resident developed a preventable Stage 3 pressure ulcer due to the facility's failure to implement the prescribed skin integrity care plan, including daily and weekly skin assessments. The resident, who had multiple diagnoses and moderate cognitive deficits, was admitted without pressure ulcers but later readmitted to an acute hospital with a Stage 3 ulcer. Staff interviews confirmed the care plan was not followed, and the Director of Nursing acknowledged the facility's failure to adhere to its skin integrity policy.
Failure to Document and Perform Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and documentation met professional standards of quality and the facility’s own Charting and Documentation policy for five residents. Surveyors identified multiple instances where ordered wound and skin treatments were not documented on the Treatment Administration Records (TARs), and facility leadership consistently stated that if care was not documented, it was considered not done. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator all confirmed that complete and accurate documentation is required to reflect the care provided and that staff are expected to follow physician orders and document wound care after it is performed. For one resident with a history including metabolic encephalopathy, COPD, chronic venous hypertension with ulcer and inflammation of the left lower extremity, prediabetes, and dependence on a respirator and supplemental oxygen, physician orders directed daily-shift wound care to a venous stasis wound on the right lower leg and skin tears on both arms. Review of the TAR for December showed that on a specific day, there were no licensed staff initials for the ordered wound care during the day shift. The ADON stated that LVN 1 had been assigned to this resident for that shift and should have initialed the TAR to indicate the wound care was provided, but did not, and reiterated that if it was not documented, it was not done. For a second resident with diabetes mellitus type 2, cervical disc disorder with radiculopathy, and malignant neoplasm of the skin, the TAR contained an order to cleanse and dress a rash on the right hand every shift until the order was discontinued. On one night shift, there were no licensed staff initials to show that the treatment was provided. The DON stated that LVN 2 had been assigned to this resident that night and should have initialed the TAR but did not, and stated that if LVN 2 did not document the wound care, then it was not provided. For a third resident with hypertensive heart disease, dementia, diabetes mellitus type 2, malignant neoplasm of the prostate, and a cardiac pacemaker, the TAR showed an order for daily care of a skin tear with flap on the left dorsal hand, including cleansing with normal saline, applying steri-strips, and covering with a dry dressing. On a reviewed night shift, there were no licensed staff initials indicating that the ordered treatment was completed. The DON confirmed LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that lack of documentation meant the care was not provided. For a fourth resident with paraplegia, diabetes mellitus type 2, hypertensive chronic kidney disease, severe morbid obesity, and malignant neoplasm of the large intestine, the TAR contained orders to apply antifungal powder to a peri-anal rash every shift and as needed after incontinence episodes, and to cleanse and treat moisture-associated skin damage at the coccyx with a menthol and zinc oxide ointment every shift and as needed after incontinence. On the reviewed night shift, there were no licensed staff initials for these treatments. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR to show the treatments were provided but did not, and reiterated that if LVN 2 did not document the wound care, then it was not provided. For a fifth resident with congestive heart failure, COPD, diabetes mellitus type 2, severe morbid obesity, benign neoplasm of cranial nerves, schizoaffective disorder, and dependence on a respirator and supplemental oxygen, the TAR showed an order to cleanse abdominal folds, pat dry, apply antifungal powder, and monitor and report to the MD for worsening every shift for a fungal rash over a 14-day period. On the reviewed night shift, there were no licensed staff initials indicating that this treatment was performed. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that if LVN 2 did not document the wound care, then it was not provided. LVN 1 and LVN 2 were not available for interview. Another LVN stated that standard practice is to follow physician wound care orders and document after providing care, and that if wound care is not documented, it is considered not provided, emphasizing that documentation is required to indicate continuity of care and to reflect the wound care residents receive. The facility’s Charting and Documentation policy defined the resident’s clinical record as an account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition, and stated that it provides a multidisciplinary record of the physical and mental status of the resident. The identified missing documentation of ordered wound and skin treatments for all five residents showed that the facility did not adhere to this policy or to the stated standard of practice that care must be documented to demonstrate it was provided.
Unequal Treatment in Transfers, Discharges, and Services Based on Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Failure to Provide Restorative Nursing Services Post-PT Discharge
Penalty
Summary
The facility failed to provide necessary restorative nursing assistant (RNA) services to a resident after the discontinuation of physical therapy (PT) services. The resident, who was discharged from PT on March 6, 2024, did not receive the prescribed range of motion (ROM) exercises until February 4, 2025, resulting in a lapse of nearly 11 months. This failure potentially contributed to the development of a contracture in the resident's right hand, as observed by the occupational therapist during a reevaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was initially receiving PT and occupational therapy (OT) services to address functional limitations and prevent further decline. Despite the PT discharge summary indicating a good prognosis with consistent staff follow-through, the transition to RNA services was not executed. The RNA program, which was supposed to maintain the resident's current level of function, was not implemented due to a lack of coordination and communication between the PT and RNA staff. Interviews with facility staff revealed that the process for transitioning residents from PT to RNA services was not followed. The RNA did not receive the necessary restorative therapy referral form from the PT, and the MDS Coordinator was not informed of the need for RNA services. The Director of Nursing acknowledged the breakdown in the process and the importance of following through with PT recommendations to maintain residents' activities of daily living (ADLs).
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for four residents, which is a violation of their rights. The deficiency was identified through interviews and record reviews, revealing that the facility did not document information on how to obtain an advance directive in the residents' charts. This oversight could potentially prevent the residents' wishes from being followed if they become unable to make decisions. Interviews with residents revealed that they were not informed about the option to formulate an advance directive. For instance, one resident stated that the facility did not discuss advance directives with her, and another resident mentioned that he had provided a copy of his advance directive to the facility, but it was not documented in his medical record. The facility's staff, including the Licensed Vocational Nurse and the Social Services Director, acknowledged that there was no documentation of discussions about advance directives with the residents. The facility's policy and procedure documents indicate that residents should be informed of their rights to establish an advance directive upon admission. However, interviews with staff members, including the Director of Nursing and the Assistant Director of Nursing, revealed that the facility did not consistently follow these procedures. The Social Services Director and other staff members admitted that there was no documentation to show that residents were offered assistance with formulating an advance directive, highlighting a systemic issue in the facility's handling of advance directives.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Two residents, identified as Resident 34 and Resident 57, experienced discomfort due to cold room temperatures at night. Despite complaints to the staff, the room temperatures were not maintained within the recommended range of 71-81 degrees Fahrenheit. The Maintenance Supervisor admitted to checking room temperatures only during the day and not at night, which contributed to the residents' discomfort and potential health risks. Another deficiency was observed in Resident 42's room, where a large hole and a smaller hole with exposed insulation and wiring were found behind the bed. The holes posed potential environmental hazards, including the risk of electrocution. Despite the presence of these hazards, no maintenance order was placed in the TELS system to address the issue, and the holes remained partially unaddressed for some time. The Maintenance Assistant and Supervisor acknowledged the oversight and the potential risks associated with the exposed wiring and uncovered outlets. Additionally, Resident 305 experienced issues with a malfunctioning bed and poor television reception, which affected the resident's comfort and quality of life. The bed was stuck in a seated position, and the TV channels were not clear due to antenna issues. Although the Maintenance Supervisor was aware of the problems, there was a lack of timely and effective repairs, as indicated by the absence of recent maintenance requests in the TELS system. These deficiencies highlight the facility's failure to provide a homelike environment and ensure the safety and comfort of its residents.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label drugs and supplies in accordance with acceptable standards of practice. Two inhalers, belonging to two residents, were not labeled with an open date or expiration date. This oversight was confirmed during observations and interviews with LVNs and the Director of Infection Prevention. The lack of labeling could lead to the administration of expired medications, which may not be effective and could potentially cause adverse reactions. The facility's policy requires medications to be labeled with open and expiration dates to ensure their potency and effectiveness. Additionally, the facility did not maintain proper temperature control in two of its medication refrigerators. Observations revealed that the temperatures in these refrigerators were outside the recommended range of 36°F to 46°F. Medications stored in these refrigerators, belonging to three residents, were at risk of losing their potency due to improper storage conditions. Interviews with the ADON and DON confirmed that the refrigerators were out of range for several hours, and the medications stored within them were discarded and replaced. The facility's policy on the storage and expiration of medications emphasizes the importance of maintaining appropriate temperature and sterility conditions. The failure to adhere to these guidelines resulted in the potential degradation of medications, which could lead to ineffective treatment and adverse reactions for the residents involved. The report highlights the need for regular inspections and compliance with storage requirements to ensure the safety and efficacy of medications administered to residents.
Inaccurate Measurement of Ingredients in Pureed Diets
Penalty
Summary
The facility's cook staff failed to accurately measure milk and margarine while preparing a pureed rice recipe for 12 residents on a pureed diet. During an observation, Cook 1 used a 1/2 cup metal measuring cup three times to measure 1.5 cups of milk, but the milk did not level to the top edge of the measuring cup each time. Additionally, Cook 1 used a round plastic measuring cup to measure margarine, which left open areas between the block of margarine and the measuring cup wall, resulting in an inaccurate measurement. Cook 1 added a total of 2 additional cups of 2% milk to achieve the targeted pudding texture for the pureed rice. Cook 1 acknowledged the importance of following the recipe to ensure the correct consistency and nutrient content. The Registered Dietician (RD) confirmed the importance of following pureed recipes to achieve the right consistency and stated that additional milk would not significantly increase protein content or harm residents. However, the RD had not verified whether staff were properly measuring ingredients. The Director of Nursing (DON) stated that the facility did not have a policy for pureed food preparation but expected cooks to follow recipes. Cook 2, who also prepared pureed rice, described a different measurement approach, using a cylinder plastic measuring cup for milk and melted margarine for easier blending. The facility's job descriptions emphasized the importance of preparing food according to standardized recipes and ensuring high-quality food provision.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. A box of potatoes was found in the kitchen without a label indicating the received date or use-by date. The Dietary Manager (DM) acknowledged that the potatoes were not dated and stated that all food should be labeled to ensure kitchen staff are aware of how long food has been on the shelf. The Registered Dietician (RD) also confirmed that unlabeled or undated foods pose a risk of serving expired or spoiled food to residents, potentially leading to foodborne illnesses. Additionally, a dietary aide was observed scratching their ear and continuing to handle clean cups without washing their hands. The DM stated that staff should wash their hands after touching their head or face to prevent cross-contamination. The RD emphasized the importance of handwashing to promote infection control and food safety practices, noting that failure to do so could result in residents acquiring foodborne illnesses. Further observations revealed that thawing frozen beef kabobs in the walk-in refrigerator were not labeled with a prepared by or use-by date. The DM admitted that the kabobs should have been labeled and dated, as this practice helps prevent the use of old food that could be contaminated. Dust was also identified on the ceiling above the fan in the food storage room, which the DM stated could affect temperature control and lead to spoiled food. The Supervisor of Maintenance acknowledged the responsibility to clean the fan and ceiling, noting that dust in the storage room could create a fire hazard and potentially contaminate food, leading to foodborne illnesses for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Resident 34's nebulizer mouthpiece was found on top of the machine next to a urinal, which was not stored in a bag as required to prevent cross-contamination. This oversight was acknowledged by both the Licensed Vocational Nurse and the Director of Infection Prevention, who confirmed that the improper storage posed a risk for respiratory infections. Resident 37's foley catheter bag and tubing were observed on the ground, which is against the guidelines for catheter maintenance. The Registered Nurse and the Director of Staff Development both recognized that this practice increased the risk of cross-contamination and infection. Similarly, Resident 152's urinal was found on a bedside table with food and personal items, which was not sanitary and posed a risk for infection, as noted by the Certified Nursing Assistant. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with surgical wounds, as observed with Residents 152 and 305. Licensed nurses did not use gowns during wound care, and therapy staff did not follow EBP when assisting Resident 306 with Activities of Daily Living. Additionally, Resident 505's oxygen tubing was found on the floor, which was not stored properly, increasing the risk of contamination. The facility's storage practices were also deficient, as evidenced by an opened debridement tray found in a treatment cart and staff personal belongings stored in a utility supply room, both of which posed potential infection control issues.
Failure to Maintain Secure Handrails in Hallways
Penalty
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on each side, which increased the risk of falls for residents using the handrails for assistance with walking. During an observation in the Station 2 Hallway, a handrail was found to be broken and loose, and another was missing a curved piece of wood, exposing the metal bracket and screws. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged that broken and loose handrails posed a risk of injury to residents. The Maintenance Supervisor stated that the facility used the TELS System to notify the maintenance department of repair needs, and any staff member could access this system. Despite being notified of the broken handrails, the curved ends were obsolete and could not be replaced. The facility's policy and procedure documents emphasized the importance of maintaining a safe, clean, and comfortable environment, with regular facility rounds and oversight by the Executive Director, Director of Nursing, and Maintenance/Housekeeping Supervisor. However, the failure to maintain the handrails in good condition was a deviation from these policies.
Failure to Provide Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to ensure dignity for two residents by not providing dignity bags for their foley catheter drainage bags, leaving the urine visible to anyone entering their rooms. For Resident 3, observations on multiple occasions revealed that the catheter bag was uncovered, and staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The Director of Nursing confirmed that Resident 3's right to dignity was violated due to the lack of a privacy bag. Similarly, Resident 305 was observed with an uncovered catheter bag while lying in bed. The resident, who was cognitively intact, was unaware if the urinary bag was covered when outside the room. Staff members, including a CNA and an LVN, stated that a dignity cover should have been used to protect the resident's privacy and dignity. The facility's policies on resident rights and dignity emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Failure to Provide Written Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to two residents, Resident 3 and Resident 455, during their transfers to the hospital. Resident 3 was transferred to the hospital without receiving a written notice of the facility's bed hold policy, despite verbal notifications being made to the resident's responsible party (RP). Interviews with the Licensed Vocational Nurses (LVN) and the Admissions Coordinator (AC) revealed that while verbal communication occurred, no physical documentation of the bed hold policy was provided, which is a requirement according to the facility's policy and procedure. Resident 455, who was cognitively intact, also did not receive a written bed hold policy upon transfer to the hospital. The Social Services Director (SSD) and LVN confirmed that the resident was not provided with the policy, as it was not standard practice for residents with non-Medi-Cal insurance. The facility's policy and procedure documents did not clearly mandate the provision of a physical copy of the bed hold policy upon transfer, leading to this oversight. The Director of Nursing (DON) acknowledged the importance of providing the bed hold policy to ensure residents and their representatives understand the terms and can ask questions if needed. The facility's failure to provide the necessary documentation could lead to confusion and disputes regarding bed availability and the terms of the bed hold, as the residents were not adequately informed in writing as required by the facility's own policies.
Deficiencies in Care Plan Implementation in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and unmet needs. Resident 37 did not have a care plan developed for an indwelling Foley catheter, which was necessary due to a neurogenic bladder. This oversight was attributed to a breakdown in communication among staff, resulting in the absence of a care plan that could guide staff in monitoring and managing the catheter, potentially increasing the risk of infection and compromising the resident's safety. Resident 26's care plan interventions for visual needs were not implemented, resulting in the resident not wearing glasses for five days. This failure was due to staff not following the care plan, which required ensuring the resident wore glasses when up. The absence of glasses increased the risk of injury and decreased participation in activities of daily living, as the resident struggled with vision-related tasks and required assistance from staff. Residents 409 and 86 did not have care plans addressing the use of anticoagulants, which are critical for monitoring potential side effects such as bruising and bleeding. The lack of a care plan for Resident 409 meant that the resident did not receive education on anticoagulant side effects or complications, while Resident 86's care plan lacked monitoring interventions for bleeding or bruising. These deficiencies highlighted the importance of having individualized care plans to ensure appropriate monitoring and education for residents on anticoagulant therapy.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident, identified as Resident 120, after a stage two pressure ulcer had healed. The care plan still contained active treatment interventions for the ulcer, which had already resolved. This oversight was discovered during a review of Resident 120's records, which showed that the pressure ulcer had healed on January 15, 2025, but the care plan dated December 2, 2024, had not been updated to reflect this change. Interviews with staff, including CNAs and an LVN, revealed that care plans are essential for guiding resident care, and if they are not accurate, specific care for the resident could be missed. The Director of Nursing (DON) confirmed the importance of accurate care plans for communicating resident needs and acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy and procedure on comprehensive care plans, dated December 2017, indicated that resident progress should be regularly evaluated and care plans revised as appropriate. The DON stated that the care plan for Resident 120 should have been resolved by the end of the nurse's shift on the day the wound was considered healed.
Oxygen Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, Resident 112 and Resident 306, regarding the administration of oxygen. Resident 112, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), emphysema, and obstructive sleep apnea, was observed receiving oxygen at a rate of 2.5 liters per minute (LPM) instead of the ordered 2 LPM. This discrepancy was noted over several days, and the registered nurse (RN) acknowledged the error, stating that the oxygen order was not followed. The Director of Nursing (DON) confirmed that the resident received more oxygen than ordered, which could be detrimental to the resident's health. Resident 306, who was admitted with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Parkinson's disease, and congestive heart failure, was observed with an oxygen flow rate set at 3 L/min instead of the prescribed 2 L/min. The Licensed Vocational Nurse (LVN) confirmed that the oxygen saturation was at 96% and did not require oxygen at the time, indicating that the physician's order was not followed. Additionally, Resident 306's oxygen tubing was not labeled with the date it was placed, which is a requirement to prevent infection and ensure timely changes of the equipment. The facility's policy and procedure for oxygen administration require checking the physician's order for the correct flow rate and method of administration, as well as labeling and changing the oxygen tubing regularly. The failure to follow these procedures for both residents put them at risk for potential health complications, including infection and respiratory issues. The Assistant Director of Nursing (ADON) emphasized the importance of following physician orders and maintaining proper labeling to prevent such risks.
Failure to Provide Proper Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 28, resulting in long, jagged, and uncomfortable toenails. Resident 28, who was admitted with a displaced intertrochanteric fracture of the right femur and required assistance with personal care due to muscle weakness and reduced mobility, reported discomfort from her toenails. Despite having no cognitive deficits, she relied on staff for toenail care, which was inadequately performed, leaving her toenails sharp and uneven. Interviews with staff, including CNAs and LVNs, revealed that routine toenail care was expected to be performed twice a week with each shower, including trimming, filing, and cleaning. However, Resident 28's toenails were observed to be long and jagged, with the right big toenail growing at an angle into the toe, causing discomfort. The staff acknowledged the risk of long, jagged toenails leading to potential injury or infection, yet the care was not documented or performed as required. The facility's policies and training materials emphasized the importance of proper toenail care to prevent infection and maintain hygiene. Despite this, the documentation on the Shower Day Inspection form indicated that Resident 28's routine toenail care was not completed. The Director of Nursing and other staff members confirmed the expectations for toenail care and the failure to meet these standards, as evidenced by the condition of Resident 28's toenails.
Improper Foley Catheter Management Poses Risk to Resident
Penalty
Summary
The facility failed to ensure a resident was free from accidents when the resident's foley catheter tubing was wrapped around her prosthetic right lower leg while she was sitting in her wheelchair. This situation posed a risk of causing a fall or injury to the resident, either by tripping her during a transfer or by the catheter being pulled from her bladder. The resident, who was cognitively intact, was unaware of the tubing being wrapped around her leg and acknowledged the potential danger it posed. Interviews with staff revealed that the catheter was identified as a trip hazard, and it was noted that the physical therapy assistant who transferred the resident was not trained on the proper placement of the catheter. The Director of Staff Development and other staff members acknowledged that the catheter should not have been wrapped around the resident's leg and that the facility's policies and procedures regarding falls management and incident management were not followed. The facility's Incident Management Policy emphasizes the need to provide a safe environment and reduce the incidence of reoccurrence, which was not adhered to in this case.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate daily staffing information, specifically the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) form did not include these details. The Assistant Staff Development Coordinator (ASDC) admitted that the posted form did not reflect the actual hours worked and that the detailed hours were only available on a separate worksheet not accessible to residents or their families. This omission prevented residents and their families from having access to the actual direct care staff hours and the total number of staff providing care daily. In an interview, the Administrator acknowledged that the DHPPD form lacked the necessary information about RN and LVN hours and confirmed that this information should have been posted. The Administrator was unaware of the requirement by the Centers for Medicare & Medicaid Services (CMS) to post such information. The facility used a form provided by the California Department of Public Health (CDPH), but it did not meet the CMS requirements. This oversight resulted in a deficiency as it failed to provide transparency to residents and their families regarding the staffing levels and hours worked by direct care staff.
Failure to Document Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident was administered mirtazapine, a medication used to treat depression, from November 2, 2024, to February 6, 2025, without any documented attempts at a gradual dose reduction (GDR). The resident, who was admitted with diagnoses of depression and anxiety, received mirtazapine daily despite having no recorded depressive episodes. The Licensed Vocational Nurse (LVN) acknowledged that the resident would have benefitted from a GDR and confirmed that no GDR attempt was documented. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the last medication review was conducted in November 2024, but no GDR was recommended. The SSD admitted to not properly documenting the doctor's recommendation regarding a GDR, which would have explained why a GDR was not performed. The facility's policy on psychotropic medication management requires the interdisciplinary team to evaluate the necessity of such medications quarterly, including documentation of GDR assessments, which was not adhered to in this case.
Medication Administration Error for Potassium Chloride
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 556, was free from significant medication errors. The error occurred when RN 1 administered potassium chloride 20MEQ to Resident 556 without following the manufacturer's instructions. The instructions specified that the medication should be taken with a meal and that the resident should avoid lying down for at least 10 minutes after administration. However, RN 1 gave the medication at around 10:10 a.m., after the resident had breakfast at 7:30 a.m., and allowed the resident to lie back down immediately after taking the medication. Resident 556, who was cognitively intact with a BIMS score of 15, had a medical history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease. The Assistant Director of Nursing confirmed that RN 1 did not adhere to the manufacturer's guidelines, which could have affected the medication's absorption and effectiveness. The facility's policy emphasized the importance of verifying medication instructions to prevent errors, but this was not followed in this instance.
Incomplete POLST for Resident in LTC Facility
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST). The POLST, which contains critical medical orders for end-of-life care, was not completed for the resident, who had been admitted to the facility from an acute care hospital with multiple diagnoses including MRSA, Parkinson's disease, schizoaffective disorder, congestive heart failure, and depression. The resident was observed to be cognitively intact with a BIMS score of 15, indicating the ability to make informed decisions about their care. During the review of the resident's records, it was found that there was no completed POLST on file, which was confirmed by the Medical Records Administrator (MRA). The MRA acknowledged the importance of the POLST in emergencies to ensure the resident's treatment preferences, such as DNR status, are honored. The Assistant Director of Nursing (ADON) also emphasized the significance of the POLST in respecting the resident's wishes for medical interventions. The facility's policy required timely completion and auditing of health records, but the POLST had remained incomplete for a month, which was deemed unacceptable by the ADON.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident when an LVN did not perform necessary assessments and continued to document on the resident's clinical record during a period when the resident was admitted to a general acute care hospital. The LVN documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions that were not provided from December 25 to December 30, 2021, while the resident was hospitalized. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. The resident had been admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. On December 25, 2021, the resident was transferred to the hospital due to shortness of breath. Despite the resident's absence from the facility, the LVN documented various medical interventions and assessments as if they had been performed, which was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. The ADON and DON acknowledged that the documentation by the LVN was unacceptable and illegal, as it falsely indicated that services and treatments were provided when they were not. The LVN admitted to the mistake, stating that her electronic signature was on the Medication Administration Record (MAR) and that she was responsible for the inaccurate documentation. The facility's policy and procedure documents emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a licensed nurse performed accurate assessments and documentation for a resident who was admitted to a general acute care hospital. The Licensed Vocational Nurse (LVN 1) documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions for Resident 1 from December 25 to December 30, 2021, despite the resident being hospitalized during this period. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. Resident 1 had multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. The resident was transferred to the hospital on December 25, 2021, due to shortness of breath. Despite this, LVN 1 continued to document care and treatments as if the resident were still in the facility, including enteral feeding orders and pain management interventions. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that LVN 1's documentation was inappropriate and illegal, as it falsely indicated that care was provided when the resident was not present in the facility. LVN 1 admitted to the mistake, acknowledging that her electronic signature was on the Medication Administration Record (MAR) and that she failed to accurately document the resident's care. The facility's policies and procedures emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Unsanitary Kitchen Conditions and Pest Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was a golden-colored buildup and debris accumulation behind the stove, and the floor in various areas, including next to the water inlet, behind the ice machine, and between the pantry and kitchen, was littered with soiled napkins, straws, beverage cups, wrappers, and food debris. The pantry floor had a dark granular substance and a dark glob, while the floor underneath the pantry wire storage rack was scattered with debris such as utensils, jelly cups, brown paper bags, napkins, a hairnet, and saltine crackers in plastic wrap. Additionally, a one-foot length of vinyl baseboard molding was found peeled off and on the floor in the pantry, and the pantry storage counter holding five-gallon water jugs had a black substance buildup. The presence of pests was also noted, with two dead cockroaches found under the food preparation table, one beneath the three-compartment sink area, and another caught in a web near the ceiling by the dishwasher. These unsanitary conditions were confirmed by both the Dietary [NAME] and the Dietary Manager during observations and interviews. The facility's Employee Handbook and the Food and Drug Administration's Food Code emphasize the importance of maintaining clean work areas and controlling pests, which the facility failed to adhere to, potentially risking foodborne illness among residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple dead cockroaches in critical areas such as the kitchen floor beneath the food preparation area, the three-compartment sink, and behind the hallway ice machines. These observations were made during a survey, and interviews with staff confirmed awareness of the cockroach problem. The Dietary Manager and Dietary staff validated the presence of dead cockroaches in the kitchen and pantry areas, acknowledging the importance of cleanliness, which was not maintained. The facility's pest control company had previously treated the kitchen and other areas with roach gel bait, as indicated in service tickets from August 2024. However, the problem persisted, with live cockroach activity noted in the pest control reports. The Food and Drug Administration's Food Code requires that food establishments be protected against pests by sealing openings and maintaining cleanliness, which the facility failed to uphold, leading to the deficiency.
Failure to Implement Skin Integrity Care Plan
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as a moderate risk for developing pressure ulcers, did not develop such ulcers. The nursing care plan, which included daily and weekly skin assessments, was not implemented from 1/6/24 to 1/19/24. This failure resulted in the resident developing a preventable Stage 3 pressure ulcer on the sacrum area. The resident was admitted to the facility with no pressure ulcers or open skin and was later readmitted to an acute hospital with a Stage 3 pressure ulcer due to the facility's negligence in following the care plan. The clinical record review revealed that the resident had multiple diagnoses, including acute respiratory failure, generalized muscle weakness, hypertension, mild cognitive impairment, pneumonia, and morbid obesity. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive deficits. Despite the facility's policy requiring routine skin assessments and an interdisciplinary care plan to maintain skin integrity, these measures were not followed. The resident's skin was not assessed daily or weekly, leading to the late recognition of the pressure ulcer. Interviews with staff, including a CNA and RN, confirmed that the resident's skin integrity care plan was not implemented. The CNA, who was new and assigned to the resident, did not receive proper instructions or documentation regarding the resident's skin assessment. The RN and Assistant Directors of Nursing (ADONs) acknowledged the failure to conduct the required skin assessments. The Director of Nursing (DON) admitted that the facility did not follow its policy on skin integrity, contributing to the development of the Stage 3 pressure ulcer.
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.
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What surveyors actually found near you
We read the 273 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Care Center | 0.2 mi | — | 1 | 0 |
| Orchard Post Acute | 0.7 mi | — | 2 | 0 |
| Twilight Haven | 0.9 mi | — | 0 | 0 |
| Stonehaven Senior Living | 0.9 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 1.8 mi | — | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.