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Citation history
Health deficiencies cited at Smith Ranch Skilled Nursing & Rehabilitation Cente during CMS and state inspections, most recent first.
The facility failed to timely develop and implement care plans for IV therapy for three residents. One resident with muscle wasting and adult failure to thrive received IV hydration via a peripheral IV for several days before an IV therapy care plan addressing risks such as phlebitis and extravasation was initiated. Another resident with cellulitis and asthma had a peripheral IV placed for IV antibiotics, and a third resident with sepsis and acute pyelonephritis received D5NS IV fluids for dehydration, yet neither had an IV therapy care plan initiated. An LN and the DON acknowledged that residents on IV therapy should have IV therapy care planned, and facility policies required comprehensive, individualized care plans and daily review by charge nurses.
An LVN without IV certification documented performing IV-related tasks, including PIV flushes, tubing changes, cap changes, and IV antibiotic administration for two residents, despite facility leadership and the LVN herself acknowledging that non‑certified LVNs should not manage IV therapy. On at least one evening shift when an RN had called off, there was no RN on duty to cover residents requiring IV therapy, yet the LVN’s entries on IV administration records indicated completion of ordered IV care. Separately, two medication-related in‑service attendance records for different dates, instructors, and topics showed the exact same set of 16 nurse signatures in the same order, and the DON and Administrator could not explain this duplication, demonstrating inaccurate training documentation.
Surveyors found that three residents receiving IV therapy did not receive care in accordance with physician orders and facility policy. For two residents, PIV lines were inserted and used without documented physician orders to insert them, and for all three residents there were no documented orders to remove the PIVs or clear documentation of when and how the lines were removed. Records showed that ordered IV fluids were not consistently administered, and required PIV flushes and IV site assessments for signs of infiltration, phlebitis, hematoma, and infection were missed on multiple shifts. Facility leadership and nursing staff acknowledged that IV insertion and removal require physician orders and that these interventions and assessments should be documented, but chart reviews confirmed repeated omissions in orders and documentation.
Nursing staff inaccurately documented IV medications and related IV care tasks under the names of non‑performing nurses. For several residents receiving IV fluids, IV antibiotics, and PIV flushes, an LVN who was not IV‑certified entered MAR and eMAR entries indicating that she had administered IV therapies and completed IV tubing, cap changes, and flushes, even though these tasks were actually performed by RNs or an NP. Another LVN documented a PIV flush as if she had performed it when it was done by an NP. Interviews with the LVNs, RNs, and DON confirmed that the performing nurse was expected to document under their own login and that documenting care provided by someone else was considered inaccurate or false documentation, contrary to facility policies requiring the individual administering the medication to complete the MAR.
A resident with asthma and COPD exacerbation did not receive IV ceftriaxone and scheduled ipratropium‑albuterol nebulizer treatments in accordance with MD orders. The MAR showed the IV antibiotic was not started at the originally ordered time and was later given hours after a revised start time, with no documented reason or MD notification. A medication audit further showed that the resident’s twice‑daily nebulizer treatments were administered more than one hour late on multiple occasions, again without explanatory documentation. Facility staff, including nurses and the DON, acknowledged that medications were expected to be given within one hour of the scheduled time and that late or missed doses, especially antibiotics, required documentation and MD notification, which did not occur in this case.
The facility did not post required contact information for the California Department of Public Health (CDPH), making it difficult for residents to file complaints. Interviews with residents and staff confirmed that CDPH contact information was not available in public areas, and residents were unaware of how to contact the agency.
Multiple failures in food storage and preparation were observed, including unwashed produce, dirty food transport carts, expired food items not discarded, contaminated rice not removed, improperly sealed food containers, and lack of proper labeling on opened food. These issues were confirmed by dietary staff and were not in accordance with facility policies, affecting a population of 73 residents.
The QAPI committee did not identify or address missed treatments in the RNA program, resulting in multiple residents not receiving restorative nursing services as ordered by physicians. Audits showed numerous missed visits, and interviews with the DON and DOR revealed a lack of awareness and oversight regarding the issue.
Licensed nurses documented the administration of Budesonide to a resident with COPD and asthma, even though the medication was never dispensed by the pharmacy and was not available in the medication cart. Multiple nurses confirmed they had recorded giving the medication on several occasions, and the DON verified the inaccuracy. Facility policies and professional standards requiring accurate documentation and verification of medication availability were not followed.
Several residents with significant mobility limitations did not receive restorative nursing care as ordered, including range of motion exercises and necessary equipment such as splints. In multiple cases, staff were unaware of or did not follow physician orders, and residents were not evaluated for restorative programs after discharge from physical therapy. This resulted in missed therapy sessions and lack of interventions to maintain or improve residents' functional abilities.
A resident with multiple mental health diagnoses was administered Lamotrigine, a psychotropic medication, without documented informed consent. Review of the medical record and interviews with staff confirmed that the required consent was not obtained or present, despite facility policy mandating written informed consent prior to starting such medications.
Two residents with significant mobility impairments were found unable to access their call lights, as observed by staff and confirmed by interviews. One resident with hemiplegia, paraplegia, and contractures could not reach the call light placed above her right hand, while another with hemiplegia and aphasia had her call light dangling off the bed. Staff, including a CNA, LVN, and the DON, acknowledged that call lights should always be within reach, consistent with facility policy.
Surveyors observed a visibly soiled privacy curtain, dirty clothing piled on a nightstand, and an air conditioner in disrepair with missing vents and food particles in a resident room. Staff confirmed these conditions did not meet facility policies for cleanliness and maintenance.
A resident's MDS assessment inaccurately indicated an active diagnosis of viral hepatitis, even though the resident was not receiving treatment for the condition. Both the MDSC and MDS RN confirmed that the diagnosis should not have been marked as active according to RAI guidelines, leading to the submission of incorrect data to CMS.
A resident with dementia and mobility limitations, identified as at risk for pressure ulcers, was found with her pressure reducing mattress machine turned off for an unknown period. Despite physician orders and care plan interventions requiring the mattress to be on and checked every shift, staff failed to ensure its use until an LVN eventually turned it on after observation.
A resident with dysphagia and severe protein-calorie malnutrition was not weighed daily as ordered by the physician, resulting in 69 missing daily weights over several months. The RD confirmed the missing weights and noted significant weight loss, despite facility policy requiring regular monitoring and documentation of resident weights.
A resident receiving continuous tube feeding for dysphagia and severe malnutrition had their Jevity 1.5 formula, feeding pump bag, and syringe left unlabeled and undated. Both the LVN and DON confirmed that all enteral feeding materials should be labeled and dated per facility policy and manufacturer guidelines, but this was not done, creating the potential for expired formula and equipment to be used.
Surveyors identified a medication error rate of 19.23% after observing five errors among 26 opportunities, including missed and incorrectly administered medications for two residents with complex medical needs. Errors included omitted doses, improper timing, failure to follow administration instructions, and not flushing a G-Tube after medication delivery, all in violation of facility policy.
Medications and supplements, including prescription cream, powdered magnesium, sleep aids, and multivitamins, were found unsecured at the bedside of three residents. Staff, including a CNA and the DON, confirmed that medications should not be accessible at bedside and must be stored in locked compartments, in accordance with facility policy.
A resident with multiple mental health diagnoses, but no memory impairment, gave her credit card to a front desk staff member to purchase personal items. The staff member used the card for personal purchases without proper authorization, despite facility policies and staff training prohibiting such actions. The resident later discovered unapproved charges, leading to feelings of embarrassment and distrust.
Failure to Develop and Implement IV Therapy Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement care plans for residents receiving IV therapy, as required by regulation and facility policy. For one resident admitted in March 2026 with diagnoses including muscle wasting, atrophy, and adult failure to thrive, IV hydration orders for normal saline via a peripheral IV in the right arm began on 3/24/26. The Medication Administration Record showed the IV fluids were administered on multiple dates starting 3/24/26, but the resident’s care plan addressing IV therapy risks such as phlebitis, extravasation, air embolism, and adverse drug reactions was not initiated until 3/30/26, seven days after the IV therapy started. Another resident admitted in February 2026 with cellulitis of the left lower limb and asthma had an order dated 3/13/26 to place a peripheral IV as soon as possible for one day of IV antibiotics. A health status note documented that a new peripheral IV line was placed in the right wrist for administration of ceftriaxone. However, review of this resident’s care plan report printed on 4/2/26 showed no evidence that an IV therapy care plan was ever initiated, despite the documented IV placement and treatment. A third resident admitted in March 2026 with sepsis and acute pyelonephritis had orders for D5NS IV solution to be administered over two days for dehydration at a specified rate, with start dates of 3/25/26 and 3/31/26. A health status note documented that an IV was started in the right upper forearm. Review of this resident’s care plan report printed on 4/15/26 showed no IV therapy care plan was initiated. During interviews, an LN and the DON confirmed that residents receiving IV therapy should have IV therapy care planned, and the DON verified that the IV therapy care plan for the first resident was not initiated when IV therapy started and that no IV therapy care plans were present for the other two residents. Facility policies required comprehensive, individualized, ongoing care plans based on assessments and directed charge nurses to review care plans daily and revise them based on nursing needs.
LVN Performed IV Therapy Outside Scope and Duplicated In‑Service Attendance Records
Penalty
Summary
The deficiency involves a failure to ensure that nursing services were provided in accordance with professional standards of practice and scope of practice requirements, and a failure to maintain accurate training documentation. A Licensed Vocational Nurse (LVN), identified as LN 3, performed IV-related tasks despite not being IV certified, and the facility’s own leadership acknowledged that such actions were outside the LVN scope of practice. The facility also produced two in-service attendance records for different medication-related trainings that contained identical staff signatures in the same order, which the DON and Administrator could not explain, indicating inaccurate training documentation. For one resident admitted in March 2026 with diagnoses including muscle wasting/atrophy and adult failure to thrive, orders dated 3/24/26 directed that a peripheral IV (PIV) in the right arm be flushed with 5 mL normal saline before and after medications twice daily. The resident’s IV Administration Record for March 2026 showed that these PIV flushes were documented as completed by LN 3 on multiple evening shifts (3/24/26, 3/29/26, and 3/31/26) at 9 p.m. A review of the Nursing Staffing Assignment and Sign-In Sheet for 3/24/26 showed that the evening shift RN had called off and there was no RN on duty to cover residents requiring IV therapy. The DON later confirmed that LN 3 was not IV certified, did not meet training requirements to perform IV therapy, and that based on the documentation, LN 3 had completed the IV tasks. For another resident admitted in February 2026 with diagnoses including cellulitis of the left lower limb and asthma, physician orders dated 3/17/26 required changing primary intermittent IV tubing every evening shift, changing the PIV cap after each use every evening shift, and flushing the PIV with 5 mL normal saline before and after medications on day and evening shifts. The IV Administration Record for March 2026 showed these IV tubing changes, cap changes, and flushes documented as completed by LN 3 on an evening shift. In an interview, this resident stated that LN 3 administered IV antibiotics, changed the IV tubing, and flushed the IV line when providing IV care. In a separate phone interview, LN 3 confirmed she was an LVN without IV certification and stated she was not allowed to change IV tubing or caps, flush IV lines, or start IV fluids or antibiotics. The DON and Administrator both acknowledged that LVNs should not provide IV therapy without IV certification and that performing such tasks would be outside their scope of practice. The deficiency also includes inaccurate training documentation related to medication administration education. A facility document titled "ON DUTY: In-Service Compliance Class Attendance Record" dated 1/7/26 showed an in-service conducted by DON 2 on standards of safe medication administration, including best practices, error reduction, and timely and accurate documentation, and contained 16 nurse staff wet signatures plus the instructor’s signature. A second document with the same title dated 2/25/26, for a class on prevention of medication errors across multiple routes (PO, SQ, IM, IV, enteral, intranasal, optic, and otic) and conducted by the DON, contained the exact same 16 staff wet signatures in the same order as the 1/7/26 record. The DON and Administrator confirmed that the two in-services were held on different dates, by different instructors, and with different topics, and they could not explain why the 2/25/26 attendance sheet was an exact copy of the 1/7/26 sheet. Facility policies on staffing and competency required that nursing staff meet licensure and certification requirements, work within scope of practice, and that competency and training be established and monitored by nursing leadership, as well as a medication error prevention document instructing staff to stay within scope of practice (e.g., IV pushes as RN-only).
Failure to Obtain Orders and Follow IV Therapy Protocols for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide quality IV-related care and to follow physician orders for three residents receiving IV therapy. For two residents, peripheral IV catheters (PIVCs) were inserted and used without documented physician orders to insert the lines, and for all three residents there were no documented physician orders to remove the PIVCs once IV therapy was completed. The medical records for these residents lacked documentation of when the PIVCs were removed, who removed them, and the condition of the IV sites at removal. The Director of Nursing (DON) and nursing staff stated that physician orders were required to start and discontinue PIVs and that insertion and removal should be documented in progress notes, but review of the records confirmed these orders and documentation were missing. One resident admitted with muscle wasting, atrophy, and adult failure to thrive had orders for normal saline and D5NS IV fluids, as well as orders to monitor the IV site every shift and to flush the PIV twice daily, with a documented PIV site in the right arm for hydration. There was no evidence of a physician’s order to insert or remove the PIVC. The IV administration record showed that ordered PIV flushes were not completed on multiple shifts, and ordered monitoring of the IV site for signs of infiltration, phlebitis, hematoma, and infection was not completed on several day and night shifts. Progress notes indicated instructions to leave the IV site in and later that IV hydration would be discontinued, but there was no documentation of when the PIVC was actually removed. A second resident admitted with cellulitis of the left lower limb and asthma had intact cognition and an order to place a PIV for IV antibiotics, along with orders for ceftriaxone IV, IV site monitoring every shift, tubing changes, PIV cap changes, and PIV flushes. Progress notes documented a new PIV line to the right wrist, and the MAR showed that ceftriaxone was administered for several days and then completed. However, there was no evidence of a physician’s order to remove the PIV and no documentation of when the PIVC was removed. The IV administration record showed that ordered PIV flushes and IV site monitoring were not completed on specified day and night shifts. A third resident admitted with sepsis and acute pyelonephritis, with moderately impaired cognition, had orders for D5NS IV fluids for hydration on two separate courses, as well as orders for PIV flushes every shift, PIV cap changes, and IV site monitoring every shift, with a documented PIV site in the right arm. There was no evidence of a physician’s order to insert or remove the PIVC. Progress notes documented that an IV was started on the right upper forearm but did not indicate when the PIVC was removed or any instruction to leave the PIV in place. The MAR and IV administration records showed that ordered IV fluid infusions were not completed on multiple days, and that ordered IV site monitoring and PIV flushes were not completed on numerous day, evening, and night shifts. The DON confirmed that these orders were not documented as completed and stated that without documentation there was no way to know if the orders were followed. Facility policies on resident quality of care, documentation of medication administration, and IV administration required accurate documentation of venipuncture or vascular access device site condition, monitoring for insertion site complications, review of provider orders, flushing the catheter when infusion is complete, and documenting procedures in the medical record. The facility’s Charge Nurse job description required charting nurses’ notes in an informative and descriptive manner reflecting care provided and reviewing MARs for completeness and accuracy in transcription of physician orders. Despite these policies and stated expectations, the records for the three residents showed missing physician orders for PIV insertion and removal, incomplete documentation of PIV removal, and multiple instances where physician orders for IV fluids, PIV flushes, and IV site monitoring were not carried out or not documented as completed.
Inaccurate IV Medication and Treatment Documentation by Non‑Performing Nurses
Penalty
Summary
The deficiency involves inaccurate and misleading documentation of IV medications and related IV care tasks by nursing staff, specifically when the nurse documenting was not the nurse who performed the task. For one resident with muscle wasting, atrophy, and adult failure to thrive, the MAR and IV Administration Record showed IV fluids and PIV flushes documented as administered by an LVN (LN 3). Progress notes, however, indicated that these IV therapies and flushes were actually performed by RNs (RN 1 and RN 3), while LN 3 entered the documentation under her own credentials. Multiple eMAR Medication Administration Notes explicitly recorded that IV hydration and PIV flushes "done by" RN 1 or RN 3 were documented by LN 3, rather than by the performing RN. For a second resident admitted with cellulitis of the left lower limb and asthma, with intact cognition, the order summary and MAR showed IV ceftriaxone and associated IV tasks (changing primary intermittent IV tubing, changing PIV caps, and flushing the PIV with NS) documented as administered by LN 3. eMAR Medication Administration Notes clarified that these IV antibiotics and IV care tasks were actually performed by RN 3 or RN 1, but were documented by LN 3. The resident herself stated that LN 3 administered her IV antibiotics, changed the IV tubing, and flushed the IV line when IV care was provided. Despite this, the facility’s Director of Staff Development Consultant later stated that LN 3 was not IV certified. For a third resident admitted with sepsis and acute pyelonephritis, the IV Administration Record showed a PIV flush with NS documented as administered by LN 4. A corresponding eMAR Medication Administration Note indicated that the PIV flush was actually done by a Nurse Practitioner but documented by LN 4. Interviews with LN 3 and LN 4 confirmed that they were LVNs and not IV certified, and both acknowledged that it was not acceptable to document medications or physician orders as completed when they had not personally performed the tasks. The DON, upon review of the records, confirmed that PIV flush orders were cross-charted by LN 3 as done by RNs multiple times and stated that this type of charting was not acceptable. Facility policies on medication administration and documentation required that the individual administering the medication document and sign the MAR, including their initials, signature, and title, and emphasized procedures to ensure accuracy and safety of medication administration.
Failure to Administer IV Antibiotics and Nebulizer Treatments as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV antibiotics and scheduled breathing treatments were not administered in accordance with physician orders. The resident was admitted with cellulitis of the left lower limb and asthma, and had an intact cognition score (BIMS 15). Physician orders included ceftriaxone 1 g IV every 24 hours for seven days for an acute COPD exacerbation, and ipratropium‑albuterol 3 mL via nebulizer every 12 hours for asthma. The facility’s own policies required medications to be administered safely, in a timely manner, and within one hour of the prescribed time, and required adherence to prescriber orders and documentation of provider notification if there were complications or issues with IV administration. Review of the Medication Administration Record (MAR) for March showed that the ceftriaxone order had an initial start date and time of 3/13 at 9 p.m., but on that date the administration was documented with a code of “2” (No med required – Outside Parameter) instead of being given as ordered. A progress note entered later that night stated the RN would start the ceftriaxone the following morning, but the MAR then reflected a new start date and time of 3/15 at 3 p.m., and the antibiotic was actually administered at 7:15 p.m. on 3/15. There was no documented evidence in the progress notes explaining why the ceftriaxone was not administered as originally ordered on 3/13 or why it was administered late on 3/15, and no documentation that the physician was notified of the delay or any change in the order. The resident also had an order for ipratropium‑albuterol nebulizer treatments every 12 hours, with multiple start dates and discontinuations documented on the respiratory MAR. An audit of medication administration for the month showed that, based on the scheduled administration times, the breathing treatments were administered more than one hour late on 17 out of 60 opportunities. Review of the resident’s progress notes revealed no documentation explaining the late administration of these treatments. The resident’s care plans for shortness of breath, asthma, and antibiotic therapy directed staff to administer medications and breathing treatments as ordered by the physician. During interviews, two licensed nurses and the DON stated that medications, including breathing treatments and antibiotics, were expected to be administered within one hour before or after the scheduled time, that antibiotics had to be given on time, and that late administration required documentation of the reason and physician notification. The DON confirmed that the IV antibiotic was not administered as ordered and that there was no evidence of physician notification regarding the delay, and also confirmed that the breathing treatments were administered late on multiple occasions.
Failure to Post State Agency Contact Information for Resident Complaints
Penalty
Summary
The facility failed to publicly post the contact information for the California Department of Public Health (CDPH), as required, which prevented residents from being able to file complaints regarding their care or the facility. During interviews, all eight Resident Council members reported not knowing how or where to file complaints with CDPH and could not recall seeing any posted information. Observations conducted with the Activities Director and the Administrator confirmed that CDPH contact information was not posted on either the first or second floor of the facility. The Director of Nursing also confirmed that the facility did not have CDPH contact information posted for residents. A review of the facility's policy on Resident Rights indicated that residents have the right to communicate with outside agencies, but this right was not supported by the required postings.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in a safe and sanitary manner, as evidenced by multiple observations and staff interviews. Dietary staff did not rinse romaine lettuce as instructed on the packaging before chopping and plating it for resident meals. The Dietary Aide stated the lettuce was not rinsed because it was believed to be pre-cleaned, but both the packaging and facility policy required rinsing before use. The Kitchen Manager confirmed this was not in accordance with facility procedures. Additionally, two food transport carts used to move food from the Main Kitchen to the Nourishment Room were found to be dirty, with visible hair, residue, and substances on their surfaces. These carts were present in clean areas of the kitchen and were not cleaned prior to use, contrary to facility policy requiring all food service equipment to be cleaned and sanitized after each use. Multiple food items in the walk-in refrigerator and freezer were observed to be past their use-by dates and had not been discarded as required. The Registered Dietician confirmed these items should have been removed before or on their expiration dates. Further deficiencies included a bin of uncooked rice contaminated with a green leafy substance, which was not discarded, and several food items in both the freezer and dry storage that were left open to the air and not stored in sealed containers. Many opened food items were also not properly labeled with open or use-by dates. These failures were confirmed by staff and were not in compliance with the facility's policies and procedures for food storage, preparation, and handling. The kitchen served a population of 73 residents.
QAPI Oversight Failure Leads to Missed Restorative Nursing Treatments
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to provide adequate oversight of the Restorative Nursing Assistance (RNA) program, resulting in residents not receiving treatments as ordered by physicians. A review of the Restorative Program Monthly Audit for April 2025 revealed 84 missed RNA visits among 13 residents. Additionally, the Order Listing Report indicated that 22 residents were currently receiving RNA services. Despite these missed treatments, neither the Director of Nursing (DON) nor the Director of Rehabilitation (DOR) were aware of any issues with the RNA program. The DOR stated that her responsibilities were limited to staff training and entering RNA orders, while the DON only performed a cursory review of weekly progress notes without verifying that treatments matched physician orders. Further review of QAPI meeting minutes from October 2024 to April 2025 showed no discussion or identification of concerns related to the RNA program. The facility's QAPI plan referenced monitoring clinical care through consultant evaluations, MDS-QI scores, and surveys, but there was no evidence that these tools were used to identify or address the missed RNA treatments. The lack of oversight and failure to audit the RNA program led to residents not receiving the prescribed restorative nursing services.
Inaccurate Medication Documentation Due to Undispensed Medication
Penalty
Summary
Licensed nurses failed to follow professional standards of practice by documenting the administration of Budesonide, a respiratory medication, to a resident with COPD and asthma, despite the medication never being dispensed by the pharmacy. Observations showed that the medication was not present in the medication cart, and multiple nurses confirmed through interviews and record reviews that they had documented giving the medication on several occasions in April and May, even though it was not available. The pharmacy had requested clarification regarding the resident's respiratory medications due to concerns about duplicate therapy, but the facility did not respond, resulting in the medication not being delivered. Further review of the resident's Medication Administration Record (MAR) revealed repeated entries indicating the administration of Budesonide, which was confirmed by the Director of Nursing to be inaccurate since the medication was never dispensed. Facility policies and professional guidelines reviewed during the investigation emphasized the need for accurate, truthful, and comprehensive documentation, as well as verification of medication availability prior to administration. The failure to adhere to these standards resulted in inaccurate documentation for the resident.
Failure to Provide Ordered Restorative Nursing Care to Residents with Mobility Impairments
Penalty
Summary
The facility failed to provide restorative nursing care (RNA) as ordered for four residents with significant mobility and functional impairments. For one resident with a right leg amputation and artificial hip, the care plan and physician orders required active range of motion (AROM) exercises three times a week to prevent decline in muscle strength and contractures. However, the resident did not receive any RNA therapy since January, despite no documented medical reason to withhold therapy. The restorative nursing assistant was unaware of the order, and the Director of Rehabilitation did not follow up with the physician or ensure the therapy was provided. Another resident with hemiplegia, paraplegia, and multiple contractures was ordered to receive passive range of motion (PROM) exercises for both upper and lower extremities three times a week. The resident only received RNA for upper extremities once a week and did not have a brace or splint for contracted hands, despite expressing a goal to regain self-feeding and oral care abilities. The restorative nursing assistant and occupational therapist confirmed the lack of appropriate therapy and equipment, and the Director of Rehabilitation was unaware of the incomplete RNA provision. A third resident with gait abnormalities, right knee contracture, and hemiplegia was ordered to receive RNA for bilateral upper extremities twice a week and PROM three times a week. The resident only received RNA for lower extremities, as the restorative nursing assistant did not review the orders for upper extremity therapy. The Director of Rehabilitation and DON were not aware of the missed therapy. Additionally, a fourth resident with cellulitis and mobility issues was discharged from physical therapy due to insurance coverage ending and was not evaluated for or provided RNA, despite expressing a desire to regain strength and being instructed to use a wheelchair instead of a walker. The Director of Rehabilitation confirmed that the resident should have been encouraged to ambulate with a walker and that no RNA eligibility assessment was performed.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of a psychotropic medication, Lamotrigine, for one resident. The resident was admitted with diagnoses of Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. A review of the resident's medical record and order summary showed that Lamotrigine had been prescribed and administered without a corresponding informed consent form present in the record. The Social Services Assistant confirmed that no informed consent had been obtained for this medication. Further confirmation was provided by the Consultant Pharmacist, who stated that informed consent was required prior to administering Lamotrigine. The facility's own policy and procedure on informed consent, dated February 2025, specifies that written informed consent must be obtained by the prescribing physician or licensed healthcare practitioner and recorded in the resident's medical record before initiating treatment with psychotherapeutic drugs. This policy was not followed in the case of this resident.
Failure to Ensure Call Light Accessibility for Residents with Physical Limitations
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents with significant physical limitations. One resident, admitted with hemiplegia, paraplegia, and multiple contractures, was observed lying in bed with both hands and neck contracted. The call light was placed by her collar bone, above her right hand, but she stated she was unable to move her hands or call for assistance because the call light was not within her reach. Her roommate confirmed that she often had to press her own call light for this resident, as the call light was frequently not placed within reach. A CNA confirmed the call light was not within reach and acknowledged it should have been. Another resident, admitted with hemiplegia of the left side, need for assistance with care, and aphasia, was observed lying in bed with her call light dangling off the bed, out of reach. An LVN confirmed the resident was unable to reach her call light and stated it should always be within reach. The Director of Nursing also confirmed that call lights should always be accessible to residents. The facility's policy and procedure on answering call lights indicated that staff should ensure the call light is accessible to the resident.
Failure to Maintain Cleanliness and Repair in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents as evidenced by several observed deficiencies. In one room, the privacy curtain between beds was visibly soiled with a brown substance in multiple spots. A CNA confirmed the curtain needed immediate replacement, and the DON stated that curtains are to be changed when soiled, as per facility policy. Additionally, in the same room, approximately eight pieces of dirty clothing were found unfolded and piled on a resident's nightstand. The CNA confirmed the clothing was dirty and should have been placed in a blue mesh bag for laundry, which was also supported by the DON's statement regarding proper handling of soiled clothing. Further, the air conditioner in the same room was found to be in disrepair, with missing and broken vents and visible food particles present. The DON confirmed the air conditioner was dirty and not functioning properly, indicating that maintenance should have been contacted immediately. The Maintenance Supervisor later stated that air conditioners should not have broken or missing vents and that a work order should have been placed right away. Facility policy requires all interior surfaces, fixtures, and equipment to be maintained in good repair to ensure a safe and clean environment.
Inaccurate MDS Assessment for Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses for this resident indicated an active diagnosis of viral hepatitis, despite the resident not receiving any treatment for this condition at the time of assessment. Review of the resident's order summary confirmed there was no treatment for viral hepatitis, and both the MDS Coordinator and MDS Registered Nurse acknowledged that the MDS should not have indicated an active diagnosis, as per the Resident Assessment Instrument (RAI) guidelines, which require active treatment within the past 7 days for such coding. The inaccurate MDS data was transmitted to CMS, resulting in a deficiency related to assessment accuracy.
Failure to Ensure Pressure Reducing Mattress Was Used as Ordered
Penalty
Summary
A deficiency occurred when staff failed to implement physician-ordered interventions to prevent skin breakdown for a resident at risk for pressure ulcers. The resident, who had diagnoses including dementia and mobility issues, was observed in bed with the pressure reducing mattress machine turned off. The resident confirmed the machine was off and could not recall when it was last on or when staff last assisted her out of bed. A CNA also observed the machine was off and acknowledged it should be on but did not turn it on. Later, an LVN entered the room, plugged in the machine, and turned it on, stating it should always be on to prevent the mattress from deflating. Review of the resident's Braden Scale Assessment indicated she was at risk for developing pressure sores, and her care plan included the use of a physician-prescribed pressure reduction mattress. Physician orders specified the mattress should be set to alternating mode, with settings checked for functionality every shift. Despite these orders and care plan interventions, the pressure reducing mattress was not in use for an unknown period, as confirmed by multiple staff and the resident, resulting in a failure to follow prescribed interventions for pressure ulcer prevention.
Failure to Perform Daily Weights for Resident with Malnutrition
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of dysphagia and severe protein-calorie malnutrition was weighed daily as ordered by the physician. The resident's order summary specified daily weights with instructions to notify the physician of significant weight changes. However, a review of the resident's weight records revealed that 69 daily weights were missing over a period of several months. The registered dietician confirmed the missing weights and noted that the resident had significant weight loss and should have been weighed every day. The facility's policy required resident weights to be monitored and recorded at intervals established by the interdisciplinary team, but this was not followed in this case.
Failure to Label and Date Enteral Feeding Equipment and Formula
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of dysphagia and severe protein-calorie malnutrition, who was receiving continuous enteral feeding via a g-tube, had their feeding equipment and formula improperly managed. During an observation, it was found that the bottle of Jevity 1.5 formula, the enteral feeding pump bag containing the formula, and a syringe used for enteral feeding were all hanging on a pole in the resident's room without any labels or dates. The items were not marked with the resident's name, room number, formula type, date, or infusion rate as required. Interviews with the LVN and the DON confirmed that all enteral feeding materials should be labeled and dated according to facility policy and manufacturer instructions, which specify that the formula should hang for no more than 24 hours. Review of the resident's orders and facility policy further supported the requirement for proper labeling and dating of enteral feeding equipment and formula. The failure to label and date these items created the potential for expired enteral feeding supplement and equipment to be used for the resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19.23% error rate. One resident with diagnoses including COPD, asthma, and orthostatic hypotension did not receive Budesonide and Midodrine as ordered during the morning medication pass. The nurse responsible stated she forgot the respiratory medications and later discovered Budesonide was not available in the medication cart. The nurse also did not administer Midodrine due to its absence from the cart and did not follow the facility's protocol to check the emergency supply or contact the pharmacy for a stat delivery. Additionally, the same resident did not receive Ipratropium nasal spray at the correct time and the administration did not follow manufacturer instructions, such as priming the spray, instructing the resident to blow their nose, or using the correct head positioning. Trelegy, another respiratory medication, was also administered outside the prescribed time frame. The nurse admitted to being unsure of the correct administration technique for the nasal spray and confirmed that medications should be given within one hour of the scheduled time, as per facility policy. Another resident with dysphagia received Midodrine via G-Tube, but the nurse failed to flush the tube with water after administration, contrary to facility policy. The nurse acknowledged that an additional flush was necessary to ensure the medication cleared the tubing and to prevent clogs. These observed failures were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policies and procedures.
Failure to Secure Medications in Locked Storage
Penalty
Summary
The facility failed to implement safe medication storage practices for three residents. For one resident with dementia, a jar of triamcinolone acetonide cream with a pharmacy label was found on the bedside table. A CNA mistook the medication for a non-prescription ointment and returned it to the bedside. The LVN confirmed that the resident was forgetful and should not have unsupervised access to medications. The DON and Consultant Pharmacist both stated that medications should not be kept at the bedside and must be stored in locked compartments, as per facility policy. In two other cases, one resident had a large container of powdered magnesium, a bottle of sleep aid, and a bottle of PM leg cramp medication on the dresser at bedside, while another resident had a bottle of multivitamins on the bedside table. Both the DON and Consultant Pharmacist confirmed that these medications should not be accessible at bedside and should be dispensed from the pharmacy or kept in the medication cart. The facility's policy requires all medications and biologicals to be stored in locked compartments, which was not followed in these instances.
Misappropriation of Resident Property by Staff
Penalty
Summary
A facility failed to protect a resident from misappropriation of property when a front desk staff member used the resident's credit card for personal purchases. The resident, who had diagnoses including bipolar disorder, depressive disorder with psychotic symptoms, and anxiety disorder, but no memory impairment, had given her credit card to the staff member to buy personal items for herself and for the staff member. However, upon reviewing her bank statements, the resident discovered multiple unapproved transactions. The staff member admitted to using the resident's card several times for fuel and also receiving cash from the resident. Documentation and interviews confirmed that the staff member had used the card for personal benefit and had an agreement with the resident not to inform management. The staff member later apologized in writing for the situation and acknowledged the misuse of the resident's funds. Interviews with facility staff, including the DON, DSD, DSS, and licensed nurses, revealed that staff were trained and expected not to accept credit cards or cash from residents, nor to make purchases for them. The facility's employee handbook and abuse policy also prohibited staff from accepting gifts, tips, or resident property, and emphasized the resident's right to be free from misappropriation and exploitation. Despite these policies and training, the staff member's actions resulted in the resident feeling taken advantage of, distrustful, and embarrassed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Rafael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Professional Post Acute Center | 0.8 mi | — | 2 | 0 |
| Pine Ridge Care Center | 0.8 mi | — | 24 | 0 |
| Northgate Postacute Care | 0.8 mi | — | 2 | 0 |
| Marin Post Acute | 1.3 mi | — | 24 | 0 |
| Villa Marin | 1.6 mi | — | 11 | 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.