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 Shafter Nursing Care during CMS and state inspections, most recent first.
The facility failed to ensure an RN was on duty for 8 consecutive hours a day, 7 days a week. Review of staffing sign-in sheets showed no RN available for a consecutive 8-hour shift on multiple dates, and the DSD confirmed there was no RN present in the building for 8 hours on those days. The facility policy stated that F727 requires an RN onsite at least 8 consecutive hours daily.
A resident’s quarterly MDS incorrectly listed Depression and Schizophrenia as active diagnoses even though the DI did not document either diagnosis. During record review, the MDSC confirmed the resident had no active diagnosis of Depression or Schizophrenia and was not taking medication for either condition, and stated the assessment was not completed accurately before submission.
A resident's lunch tray was prepared with spinach even though the resident's meal ticket listed spinach as a disliked food. During tray line, an aide confirmed the tray was ready for delivery and stated she had not noticed the spinach and should have removed it. The facility policy stated resident food preferences would be adhered to within reason and disliked foods would be substituted from the appropriate food group.
Hand hygiene was not offered to two residents before lunch trays were delivered, including one resident who was cognitively intact and stated he had not received hand hygiene. In the kitchen, a cook was observed handling food with an uncovered beard while checking food temperatures, despite the facility’s dress code requiring a beard restraint.
A resident’s responsible party was informed by phone by an SSD that the resident would be discharged to a room and board setting but did not receive or sign the written Notice of Medicare Non-Coverage (NOMNC), did not fully understand the notice, and was not informed of appeal rights. Review of the NOMNC showed no representative signature, and although an alternate delivery form indicated phone notification, there was no documentation that the responsible party verbalized understanding of the NOMNC or was advised of the option to appeal.
The facility failed to ensure food was stored and dated properly, and maintained at safe temperatures, potentially leading to foodborne illnesses. Observations revealed unsealed and undated food items, and lasagna trays left at unsafe temperatures. The Dietary Supervisor and Certified Dietary Manager confirmed these lapses, which were against the facility's policies.
The facility failed to obtain informed consent for psychotherapeutic drugs for eight residents, as required by their policy. The VRIC forms lacked signatures from residents or their representatives, and interviews with the DON and MDSN confirmed this oversight. The facility's policy mandated informed consent before administering such medications, which was not adhered to.
The facility failed to have an RN on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews with the DSD, revealing numerous days from July to December 2024 where no RN was present for the required duration. The DSD confirmed the facility's non-compliance with their RN Staffing Coverage Policy, potentially impacting resident care.
The facility failed to complete Performance Evaluations for two CNAs, potentially impacting patient care. CNA 3 and CNA 4, hired in 2023 and 2021 respectively, did not have completed evaluations in their files. The facility's policy requires evaluations to provide feedback on job performance, which were not conducted, leaving CNAs unaware of areas needing improvement.
The facility failed to complete a quarterly MDS assessment for a resident, as confirmed by the MDS Nurse. The resident's admission MDS was completed, but the quarterly assessment due in October was overdue. Facility policy requires timely assessments, including quarterly ones, to be conducted every three months.
The facility failed to update the PASRR Level 1 screenings for two residents with serious mental illness diagnoses. A resident's PASRR from GACH was negative despite a history of Schizoaffective Disorder, Anxiety, and Depression, and the MDSN did not verify its accuracy. Another resident's PASRR was also negative, missing diagnoses of Schizophrenia and Schizoaffective Disorder, Bipolar Type. The DON acknowledged the error and the facility's responsibility to ensure accurate PASRR completion.
A resident at high risk for falls due to medical conditions was not provided with necessary footwear and was in a dimly lit environment, leading to a fall and a nondisplaced fracture of the right femur. The care plan required footwear to prevent slipping and a well-lit environment, but these interventions were not followed. Staff interviews confirmed the resident was barefoot at the time of the fall, and the necessary footwear could not be found.
The facility failed to develop discharge care plans for two residents, potentially leading to unmet care needs upon discharge. Despite the residents expressing their post-discharge preferences, the Director of Nursing confirmed that discharge care plans were not completed, contrary to the facility's policy.
A resident with severe cognitive impairment was financially abused by the Social Services Director (SSD) who used the resident's credit and debit cards without consent, resulting in over $6,500 in unauthorized charges. The facility lacked a policy to protect vulnerable residents from financial exploitation, and the SSD impersonated the resident to access her accounts. Despite the resident's inability to manage her finances, the facility failed to prevent this abuse.
A facility failed to report a financial abuse allegation involving a resident to the CDPH within 24 hours and did not conduct a thorough investigation within five business days. The SSD impersonated the resident to reset her bank pin, and the police were involved due to credit card fraud concerns. Despite these events, the SSD, DON, and Administrator did not report the abuse allegation to the CDPH, violating the facility's policy on abuse investigation and reporting.
The facility failed to conduct required reference checks for an LVN and a CNA before their hire dates, as per their abuse prevention policy. This oversight was identified during interviews and record reviews, where it was found that the employee files lacked documented reference checks. The Director of Staff Development acknowledged the incomplete files, which could potentially place residents at risk for abuse.
The facility failed to administer a resident's Percocet within the ordered time frame, resulting in a delay of 59 minutes beyond the allowed parameter. The DON confirmed the medication should have been administered and documented by 1:00 p.m., but it was given at 1:59 p.m.
RN Not On Duty for Required 8 Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week. During interview and record review with the Director of Staff Development, the facility's Nursing Staffing Assignment and Sign-In Sheets showed that no RN was available to work a consecutive 8-hour shift on 1/17/26 and 1/24/26 in January 2026, and no RN was available to work a consecutive 8-hour shift on 12/24/25 in December 2025. The Director of Staff Development stated there was no RN present in the building for 8 hours a day on those dates. The facility policy titled RN Staffing Coverage Policy, dated 8/9/2016, stated that F727 requires nursing homes to have an RN onsite at least 8 consecutive hours a day, 7 days a week.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to accurately complete the quarterly MDS assessment for one resident. In the MDS dated 3/9/26, Section I listed active diagnoses in the last 7 days as Depression and Schizophrenia. However, the resident’s Diagnosis Information dated 3/9/26 did not contain documentation of either Depression or Schizophrenia. During a concurrent interview and record review on 4/9/26 at 9:35 a.m. with the MDS Coordinator, the resident’s MDS active diagnosis section was reviewed and the MDS Coordinator stated the resident did not have an active diagnosis of Depression or Schizophrenia and was not taking medication for either condition. The MDS Coordinator stated she did not complete the assessment accurately and should have reviewed it before submitting. The facility policy stated the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments, and that persons completing any portion of the MDS must sign attesting to the accuracy of the information.
Meal Preference Not Honored for Resident Who Disliked Spinach
Penalty
Summary
The facility failed to ensure meal preferences were honored for Resident 82. Resident 82's Meal Ticket dated 4/7/26 indicated a dislike for spinach. During a concurrent observation and interview in the kitchen, a dietary aide checked Resident 82's lunch tray during tray line and the tray was observed to contain Meatballs and Gravy, Penne pasta with Garlic & Herbs, Zesty Spinach, Fresh [NAME] Salad, and Chocolate Cake. The dietary aide stated the tray was ready to be delivered to Resident 82 and, after reviewing the Meal Ticket, stated she had not noticed the spinach on the tray and should have removed it because Resident 82 did not like spinach. The facility policy titled Food Preferences stated resident food preferences would be adhered to within reason and substitutes for disliked foods would be given from the appropriate food group.
Hand hygiene and beard restraint not followed
Penalty
Summary
Hand hygiene was not provided for two sampled residents before their lunch trays were given. Resident 19 had a BIMS score of 15 and was cognitively intact. During a concurrent observation and interview in Resident 19’s room, the resident was sitting up in bed eating lunch and stated that the CNA had not offered hand hygiene and that he would like his hands cleaned. When asked, CNA 1 stated she had not provided hand hygiene and said she should have offered it. In a concurrent observation and interview in Resident 86’s room, CNA 1 delivered the resident’s lunch tray and stated she had not provided hand hygiene before giving the tray and that she should have offered it. The facility policy titled Hand Hygiene During Mealtime stated that hand hygiene is offered to all residents prior to meal tray service and that staff must ensure residents clean their hands before trays are passed or meals are served. In the kitchen, one of two sampled cooks, Cook 1, was observed uncovering food to check the temperature while wearing a beard that was not covered with a beard restraint. During the interview, Cook 1 stated he should have been wearing a beard restraint while in the kitchen. The CDM stated the cook should have been wearing a beard restraint and that it was her expectation for all staff in the kitchen to use a hair or beard restraint. The facility’s DRESS CODE policy stated that if applicable, beards and mustaches must wear a beard restraint.
Failure to Provide and Document NOMNC and Appeal Rights for a Resident’s Responsible Party
Penalty
Summary
The facility failed to provide a resident’s responsible party with a written Notice of Medicare Non-Coverage (NOMNC), ensure understanding of the notice, and inform her of appeal rights prior to discharge. The responsible party reported that she received a phone call from the Social Service Designee (SSD) stating the resident was being discharged to a room and board setting. She stated she did not fully understand the NOMNC notice and was not given the option to appeal the decision, explaining that she simply complied with what she was told and did not know she had options. Record review with the SSD showed the NOMNC letter for the resident contained a line for the patient representative’s signature to indicate receipt and understanding, but there was no signature from the responsible party. The SSD stated that the responsible party was notified by phone of the NOMNC and that the option to appeal was not discussed because the responsible party was not opposed to discharge. A facility form titled “Optional Form to Document Alternate Delivery Notice of Medicare Non-Coverage” indicated the responsible party was notified by phone, with instructions to document that the representative verbalized understanding of the information. However, upon review of the clinical record, the SSD was unable to provide documentation that the responsible party verbalized understanding of the NOMNC notice.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure food was dated and stored under sanitary conditions, as well as maintained at safe temperatures, which could potentially result in foodborne illnesses for residents. During an observation, a container labeled peas was found with a cracked and unsealed lid, and an egg tray was open, uncovered, and undated. Additionally, a carton of Liquid Pasteurized eggs was opened without an open date, and corn salad bowls were undated. In the dry storage room, a plastic bag containing elbow macaroni was not labeled or dated, and a container of nonfat dry milk was not sealed. These observations were confirmed by the Dietary Supervisor, who acknowledged that the items should have been sealed and dated according to the facility's policies. The facility also failed to maintain food at safe temperatures. Lasagna trays were observed sitting on a shelf above the steam table with temperatures below the safe range. The Certified Dietary Manager confirmed that the lasagna trays should not have been left to cool off on a shelf. Additionally, peas were added to a resident's lunch plate without taking the temperature prior to plating. The facility's policy requires cooked potentially hazardous food to be cooled and reheated in a method to ensure food safety, which was not adhered to in these instances.
Failure to Obtain Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informed consent for psychotherapeutic drugs for eight sampled residents. The policy required that an informed consent form, specifically the VERIFICATION OF RESIDENT INFORMED CONSENT FOR PSYCHOTHERAPEUTIC DRUGS (VRIC), be signed by the resident or their representative before administering such medications. However, the review revealed that none of the VRIC forms for the sampled residents contained the necessary signatures. This oversight was noted across various medications prescribed for conditions such as anxiety, schizophrenia, major depressive disorder, bipolar disorder, and insomnia. Interviews with the Director of Nursing (DON) and the Minimum Data Set Nurse (MDSN) confirmed the absence of signatures on the VRIC forms. The DON acknowledged that the facility did not have residents sign the VRIC forms, while the MDSN pointed out that the forms lacked a designated area for resident or representative signatures and for a nurse to witness the signature. The facility's policy, dated November 30, 2020, explicitly stated the requirement for obtaining informed consent prior to the administration of psychotherapeutic drugs, which was not followed, as confirmed by the Administrator.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews conducted with the Director of Staff Development (DSD) on multiple occasions. The review of the Nursing Staffing Assignment and Sign-in Sheets from July to December 2024 revealed numerous days where no RN was present for the required duration. The DSD confirmed the absence of an RN for the specified hours on these days, acknowledging the facility's non-compliance with their RN Staffing Coverage Policy. The facility's policy, dated August 9, 2016, mandates that an RN must be onsite for at least eight consecutive hours per day, seven days a week. Despite this policy, the facility consistently failed to meet this requirement over several months, as evidenced by the staffing records. The DSD admitted that the facility did not meet the requirement for RN presence, which could potentially impact resident care. The report does not mention any specific residents or their conditions being directly affected by this deficiency.
Incomplete Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PE) for two Certified Nursing Assistants (CNAs), which could impact patient care. During an interview and record review with the Director of Staff Development (DSD), it was found that CNA 3, hired on March 28, 2023, did not have a completed PE in their employee file. Similarly, CNA 4, hired on November 1, 2021, also lacked a completed PE. The facility's policy and procedure on Employee Performance Evaluation mandates that employees receive performance evaluations, which are to be kept in their personnel files. The absence of these evaluations means that the CNAs may not be aware of areas needing improvement, potentially affecting the quality of care provided to patients.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessment was completed for one of the sampled residents, identified as Resident 77. During an interview, the MDS Nurse confirmed that MDS assessments are required on admission, quarterly, annually, and at discharge, and must be completed within 14 days of the Assessment Reference Date (ARD). A review of Resident 77's clinical record revealed that the admission MDS was completed on July 30, 2024, but the quarterly MDS assessment, due in October 2024, was not completed and was overdue. The facility's policy, dated November 2019, mandates that the resident assessment coordinator ensures timely and appropriate assessments, including quarterly assessments conducted not less frequently than three months following the most recent assessment of any type.
Failure to Update PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to adhere to its policy and procedure for Pre-Admission Screening and Resident Review (PASRR) for two residents with serious mental illness diagnoses. For Resident 66, the PASRR Level 1 screening conducted by the General Acute Care Hospital (GACH) was negative, incorrectly indicating no serious mental disorder despite the resident's history of Schizoaffective Disorder, Anxiety, and Depression. The Minimum Data Set Nurse (MDSN) admitted that there was no process in place to verify the accuracy of the PASRR against the resident's diagnoses, which should have prompted a new PASRR Level 1 screening upon admission. Similarly, for Resident 38, the PASRR Level 1 screening from GACH was also negative, failing to acknowledge the resident's diagnoses of Schizophrenia, Major Depressive Disorder, Anxiety, and Schizoaffective Disorder, Bipolar Type. The Director of Nursing (DON) acknowledged that the PASRR was incorrectly completed by the GACH and emphasized that it is the facility's responsibility to ensure the PASRR reflects all current diagnoses. The facility's policy mandates that a new PASRR Level 1 should be completed if there is a significant change in the resident's mental or physical condition or if the MDS does not match the PASRR from GACH.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a care plan for a resident, resulting in a fall and subsequent injury. The resident, who was at high risk for falls due to conditions such as spondylosis, muscle weakness, anemia, and unsteadiness on feet, was not provided with the necessary footwear and was in a dimly lit environment at the time of the incident. The care plan specifically required the resident to wear footwear to prevent slipping and to keep the environment well-lit, but these interventions were not followed. On the night of the incident, the resident attempted to sit on the edge of the bed after using the restroom and slipped, resulting in a nondisplaced fracture of the neck of the right femur. The resident was barefoot, and the room was dimly lit, which contributed to the fall. The resident's Minimum Data Set indicated that walking was not attempted due to safety concerns, and the resident required substantial assistance with footwear, which was not provided at the time of the fall. Interviews with staff revealed that the resident was supposed to wear nonskid footwear when walking, but the footwear could not be found at the time of the incident. The resident expressed fear of falling again and stated that assistance was needed for walking. The facility's policy on care planning emphasized the need for a comprehensive, person-centered care plan based on individual needs, which was not adequately implemented in this case.
Failure to Develop Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop discharge care plans for two residents, which could lead to unmet care needs upon their discharge. Resident 2 was admitted and later discharged without a discharge care plan, despite expressing a wish to return to room and board when appropriate. Similarly, Resident 3 was admitted and discharged without a discharge care plan, even though they expressed a desire to move to an assisted living facility upon discharge. The Director of Nursing (DON) confirmed that neither resident had a discharge care plan, which is expected to be completed after the Multidisciplinary Care Conference (MCC). The facility's policy and procedure on care planning, revised in 2017, mandates that a comprehensive person-centered care plan be developed for each resident, including discharge plans as appropriate. The DON acknowledged that discharge planning should begin at admission and involve a team effort. However, the review of the residents' care plans revealed that the facility did not adhere to its policy, as the discharge care plans were not developed for the two residents in question.
Financial Abuse of Resident by Social Services Director
Penalty
Summary
The facility failed to protect a resident from financial abuse, as evidenced by the unauthorized use of the resident's credit and debit cards by the Social Services Director (SSD). The resident, who had severe cognitive impairment and was diagnosed with dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, and bipolar disorder, was unable to manage her own financial matters. Despite this, the facility did not have a policy in place to protect vulnerable residents from financial exploitation. The SSD impersonated the resident to gain access to her financial accounts, resulting in over $6,500 in unauthorized charges. These charges included purchases at gas stations, grocery stores, clothing stores, and other retail outlets. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 6, signifying severe cognitive impairment, and she required supervision with activities of daily living. Interviews with facility staff and the resident revealed that the resident did not leave the facility to make these purchases, and there was no documentation of her going out for shopping trips as claimed by the SSD. The facility's failure to have a policy for financial protection and the SSD's actions led to the resident being a victim of financial abuse. The Business Office Manager confirmed the lack of a policy, and the Administrator later suspended and terminated the SSD after an investigation. The facility's policy on abuse prevention stated a zero-tolerance for abuse and misappropriation of property, yet the SSD's actions directly contradicted this policy, resulting in significant financial loss for the resident.
Failure to Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of financial abuse involving a resident to the California Department of Public Health (CDPH) within the required 24-hour timeframe and did not complete a thorough investigation within five business days. The Social Services Director (SSD) admitted to impersonating the resident to reset her bank pin number, and the police department was involved due to concerns of credit card fraud. Despite these events, neither the SSD, Director of Nursing (DON), nor the Administrator reported the financial abuse allegation to the CDPH. The facility's policy and procedure on abuse investigation and reporting, dated July 2017, mandates that all reports of abuse, neglect, exploitation, or misappropriation of resident property be promptly reported to local, state, and federal agencies and thoroughly investigated. The Administrator acknowledged awareness of the financial abuse allegation when the police arrived but did not take steps to report it to the CDPH. This oversight in following the established protocol for reporting and investigating abuse allegations led to the deficiency noted in the report.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding abuse prevention by not completing reference checks for two employees before their hire dates. Specifically, the facility did not conduct reference checks for a Licensed Vocational Nurse (LVN 2) and a Certified Nursing Assistant (CNA 5) prior to their employment. During an interview and record review, it was revealed that LVN 2's reference checks were not documented, and the Director of Staff Development (DSD) acknowledged that the employee file was incomplete. Similarly, CNA 5's employee file lacked evidence of reference checks, and the DSD admitted that the reference check was not followed up. The facility's policy, titled "Abuse Prevention," mandates that all applicants undergo reference checks with current and/or past employers to prevent abuse, neglect, and other violations. This policy applies to all employees working in California. The failure to complete these checks for LVN 2 and CNA 5 had the potential to place residents at risk for abuse, as the facility did not ensure that these staff members were safe to work with residents. The absence of documented reference checks indicates a breach in the facility's screening process, which is a critical step in preventing abuse and ensuring resident safety.
Failure to Administer Medication on Time
Penalty
Summary
The facility failed to ensure that ordered medication for one of three sampled residents was administered within the ordered time frame. Specifically, Resident 1's Percocet, which was scheduled to be administered at 12:00 p.m., was not given until 1:59 p.m., which is 59 minutes outside the allowed parameter for administration. During an interview, Resident 1 confirmed that the medication was delayed, and the Director of Nursing (DON) acknowledged that the medication should have been administered and documented by 1:00 p.m. A review of the facility's policy and procedure on medication administration indicated that medications should be administered in a safe, accurate, and effective manner and documented immediately following administration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 195 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shafter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayshire Riverwalk Post-acute | 10.4 mi | — | 26 | 1 |
| Kern River Transitional Care | 14.3 mi | — | 2 | 0 |
| Rosewood Health Facility | 16.8 mi | — | 16 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 17.1 mi | — | 17 | 0 |
| The Orchards Post-acute | 17.4 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shafter Nursing Care.
100% money-back within 48 hours.
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.