Citations (last 5 years)
Citations (over 5 years)
6.8 citations/year
Citations are regulatory findings recorded during state inspections.
70% worse than California average
California average: 4 citations/yearCitations per year
16
12
8
4
0
Occupancy
Latest occupancy rate
85% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Citations: 1
Date: Sep 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's failure to maintain Wander Guard bracelets in safe operating condition.
Findings
The facility failed to ensure that Wander Guard bracelets were maintained with operational batteries and proper cleaning, risking resident elopement. Interviews and policy reviews confirmed lack of processes for battery testing and sanitation.
Citations (1)
F 0908: The facility failed to ensure Wander Guard bracelets were maintained in safe operating condition, including battery testing and cleaning, for two of three sampled residents. This failure could result in resident elopement due to malfunctioning alarms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of process for verifying Wander Guard functionality | |
| Licensed Nurse (LN1) | Interviewed about training and knowledge of Wander Guard checks |
Inspection Report
Complaint Investigation
Citations: 1
Date: May 5, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding whether resident assessments were properly performed and signed by registered nurses (RNs) in accordance with professional standards.
Complaint Details
The investigation was complaint-driven, focusing on whether resident assessments were properly completed and signed by qualified nursing staff. The complaint was substantiated as deficiencies were found in RN assessment practices and documentation.
Findings
The facility failed to ensure that assessments for two sampled residents were performed or validated by an RN. Several SBAR Communication forms were either unsigned or signed only by licensed vocational nurses (LVNs), which is outside their scope of practice.
Citations (1)
F 0658: The facility failed to ensure two sampled residents' assessments were performed by a registered nurse to meet professional standards. Several SBAR Communication forms were unsigned or signed by LVNs without RN validation.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding assessment documentation and acknowledged deficiencies. | |
| Administrator | Interviewed regarding assessment documentation and acknowledged deficiencies. |
Inspection Report
Annual Inspection
Census: 323
Capacity: 379
Citations: 0
Date: Apr 29, 2025
Visit Reason
The inspection was an unannounced annual facility inspection conducted to review compliance with licensing requirements, including emergency disaster plans, infection control, medication audits, fire safety, and facility conditions.
Findings
The inspection found the facility to be generally in good repair and clean, with passing fire safety inspections and adequate food supplies. The inspection was not fully completed and will continue at a later date.
Report Facts
Smoke detectors: 129
Carbon Monoxide Detectors: 9
Food supply days: 2
Food supply days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjan Albert | Administrator | Met with Licensing Program Analyst during inspection |
| Mark Jeffries | Licensing Program Analyst | Conducted the facility annual inspection |
Inspection Report
Routine
Citations: 9
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare regulations and standards at Samarkand Skilled Nursing Facility.
Findings
The facility was found deficient in multiple areas including privacy breaches of electronic health records, delayed transmission of resident assessment data, incomplete care plans, medication administration errors, failure to ensure residents were free from unnecessary drugs, expired medications and supplies, and food safety violations.
Citations (9)
F 0583: The facility failed to maintain privacy and confidentiality of residents' electronic health records by leaving them exposed on an open computer.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessment data for two residents within required timeframes, causing delayed validation and potential billing errors.
F 0656: The facility failed to develop a care plan for urinary catheter care for one resident, risking urinary tract infections and other complications.
F 0657: The facility failed to update the care plan after a resident's fall, increasing risk for recurring falls due to lack of updated prevention measures.
F 0755: The facility failed to provide prescribed eye drop medication for glaucoma to a resident when supply ran out, risking vision loss.
F 0757: The facility failed to ensure residents were free from unnecessary drugs by not following physician orders for pain and blood pressure medications and not assessing pain levels properly.
F 0758: The facility failed to justify continued use of psychotropic drugs beyond 14 days and did not monitor side effects or sleep hours for certain medications.
F 0761: The facility failed to remove expired medical supplies and unopened expired medications from storage, risking resident exposure to ineffective products.
F 0812: The facility failed to label food items with preparation and expiry dates and did not maintain adequate sanitizing solution concentration, risking foodborne illness.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Expired medical supplies: 3
Expired medication: 1
Sanitizing solution concentration: 170
Expired food items: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN4 | Registered Nurse | Named in privacy breach finding for leaving electronic health records exposed |
| DON | Director of Nursing | Acknowledged multiple deficiencies including privacy breach, medication errors, and psychotropic drug monitoring failures |
| LN1 | Licensed Nurse | Interviewed regarding delayed MDS transmissions and medication administration |
| LN2 | Licensed Nurse | Interviewed regarding urinary catheter care plan deficiency |
| LN3 | Licensed Nurse | Interviewed regarding pain medication administration without assessment |
| LN5 | Registered Nurse | Observed medication pass where glaucoma medication was not administered |
| DM | Dietary Manager | Validated findings of expired food and inadequate sanitizing solution concentration |
| DA1 | Dietary Aide | Tested sanitizing solution concentration in kitchen buckets |
Inspection Report
Complaint Investigation
Capacity: 379
Citations: 0
Date: Dec 4, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations that staff falsified residents' medical documentation and billed residents for services not rendered.
Complaint Details
The complaint alleged staff falsified records for Physical and/or Occupational Therapy and billed residents for services not rendered. No specific residents or contact information were provided by the reporting parties. Interviews, document reviews, and resident statements were conducted. The complaint was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegations of falsified medical documentation and billing for services not rendered. Records, therapy notes, billing invoices, and staff schedules were reviewed and found consistent. The allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 379
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Marjan Albert | Administrator | Met with Licensing Program Analyst during investigation |
| Irene Carrillo | Director of Rehabilitation | Interviewed regarding therapy services and billing |
Inspection Report
Citations: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional nursing standards, specifically regarding the performance of post-fall assessments and other nursing assessments by qualified staff.
Findings
The facility failed to ensure that Resident 1's post-fall assessment and other nursing assessments were performed by a registered nurse (RN) as required. Licensed vocational nurses (LVNs) performed assessments independently without RN validation or cosignature, which is outside their scope of practice.
Citations (1)
F 0658: The facility failed to ensure Resident 1's post-fall and other nursing assessments were performed by an RN to meet professional standards. LVNs performed assessments independently without RN validation or cosignature, which is outside their scope of practice.
Inspection Report
Annual Inspection
Census: 317
Capacity: 379
Citations: 0
Date: Apr 24, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be clean, safe, sanitary, and in good repair with functioning safety equipment and accessible outdoor areas. The medication record review was initiated but not completed due to time constraints, and the inspection will be continued at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Bigler | Met with during the inspection and conducted the facility tour. | |
| Danielle Tervo-Shiffman | Administrator/Director | Named as facility administrator/director. |
| Kelly Burley | Licensing Program Manager | Conducted the inspection and named in the report. |
| Melisa Rankin | Licensing Program Analyst | Conducted the inspection and named in the report. |
Inspection Report
Annual Inspection
Census: 335
Capacity: 379
Citations: 0
Date: Feb 13, 2023
Visit Reason
An unannounced infection control annual inspection was conducted to evaluate compliance with infection control policies and procedures.
Findings
No deficiencies were observed during the visit; all infection control requirements were being followed, including screening, isolation, testing, PPE use, and staff background clearance.
Report Facts
Capacity: 379
Census: 335
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Small | Administrator | Facility Administrator mentioned in report |
| Linda Perez | Executive Director | Met during inspection and toured facility |
| Scott Bigler | Health Care Administrator | Met during inspection and toured facility |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing inspection |
| Jeannette Olson | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Routine
Citations: 14
Date: Feb 10, 2023
Visit Reason
Routine inspection of Samarkand Skilled Nursing Facility to assess compliance with healthcare regulations including resident care, dietary services, medication management, and facility safety.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs (call bell accessibility), inadequate posting of Ombudsman contact information, failure to provide timely Medicare Non-Coverage notices, incomplete documentation of resident transfers, untimely transmission of Minimum Data Set assessments, failure to follow care plans, medication errors including expired drugs and incorrect psychotropic medication dosing, insufficient dietary management qualifications and oversight, failure to follow dietary menus and portion sizes, unsafe food handling practices, and failure to provide food in appropriate form for residents with swallowing difficulties.
Citations (14)
F 0558: The facility failed to ensure Resident 53's call bell was accessible, placing the resident at risk for unmet healthcare needs.
F 0575: The facility failed to post the Ombudsman contact information in at least four locations frequently visited by residents.
F 0577: The facility failed to make the previous survey results binder readily accessible to residents and representatives.
F 0582: The facility failed to provide the Notice of Medicare Non-Coverage timely for Resident 29, denying the resident an opportunity to appeal.
F 0622: The facility failed to document Resident 23's condition during wound specialist appointment and hospital transfer, increasing risk for adverse outcomes.
F 0640: The facility failed to timely transmit Minimum Data Set assessments for four residents, resulting in non-compliance with regulatory requirements.
F 0657: The facility failed to follow and evaluate Resident 53's care plan regarding call bell accessibility, risking unmet health care needs.
F 0755: The facility failed to meet residents' pharmaceutical needs by storing expired medications and administering a psychotropic medication dose ten times higher than consented for Resident 322.
F 0758: The facility failed to ensure appropriate indications for psychotropic medications for Residents 36 and 39, resulting in unnecessary medication use.
F 0801: The facility failed to employ a qualified Dietary Manager and ensure frequent consultation by the Clinical Dietitian, resulting in lapses in food safety, sanitation, and meal service accuracy.
F 0803: The facility failed to follow menu portion sizes during meal service and did not follow therapeutic diet orders for Resident 100, risking unmet nutritional needs.
F 0804: The facility failed to follow standardized puree recipes for Resident 6, adding excessive thickener that could reduce nutritive value.
F 0805: The facility failed to provide food in the form needed for Resident 18 per diet order and speech therapy assessment, risking choking and inadequate nutrition.
F 0812: The facility failed to maintain safe food handling practices including use of expired garlic, lack of cooling logs for TCS foods, improper scoop storage, failure to use proper sanitizers, and storing food delivery boxes on the floor.
Report Facts
Residents sampled: 19
Residents affected: 53
Expired garlic discard date: 2023
Psychotropic medication dose: 100
Psychotropic medication dose consented: 10
MDS assessments not transmitted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Acknowledged call bell was not accessible to Resident 53 |
| Director of Nursing | Director of Nursing | Acknowledged multiple deficiencies including call bell accessibility, documentation failures, medication errors, and dietary issues |
| MDS Coordinator | Minimum Data Set Coordinator | Acknowledged untimely MDS transmissions and documentation gaps |
| Lead Cook | Lead Cook | Observed food handling deficiencies including improper scoop storage and failure to document cooling |
| Registered Dietitian | Clinical Dietitian | Reported lack of oversight role and insufficient consultation with Dietary Manager |
| Dietary Manager | Dietary Manager | Lacked required qualifications and failed to ensure menu adherence and food safety |
| DW 1 | Dish Washer | Used improper sanitizer on utility cart |
| DA 1 | Dietary Aide | Served incorrect portion sizes during meal service |
| DA 2 | Dietary Aide | Placed salt packet on Heart Healthy diet tray unaware it was contraindicated |
| DA 3 | Dietary Aide | Placed food delivery boxes directly on kitchen floor |
Inspection Report
Annual Inspection
Census: 349
Capacity: 379
Citations: 2
Date: Apr 26, 2022
Visit Reason
An unannounced Annual Infection Control Inspection was conducted to evaluate compliance with criminal background fingerprint clearance requirements and other regulatory standards.
Findings
The inspection found that criminal background fingerprint clearances were not conducted for several staff members (S1, S2, S5), and that staff S3 and S4 were not properly associated with the facility, posing immediate health and safety risks. Civil penalties were issued and a plan of correction was required.
Citations (2)
Criminal background fingerprint clearance was not conducted for Staff 1 (S1), Staff 2 (S2), and Staff 5 (S5), posing an immediate health and safety risk to persons in care.
Licensee did not ensure that Staff 3 (S3) and Staff 4 (S4) were associated with the facility, posing an immediate safety risk to persons in care.
Report Facts
Capacity: 379
Census: 349
Deficiencies cited: 2
Plan of Correction Due Date: Apr 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Harris | Director of Human Resources | Confirmed staff without criminal background fingerprint clearance and association status |
| Jennifer Leggett | Associate Executive Director | Met during inspection and received report and civil penalty notification |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 348
Capacity: 379
Citations: 0
Date: Apr 25, 2022
Visit Reason
An unannounced one-year infection control inspection visit was conducted as a required annual inspection of the facility.
Findings
No deficiencies were cited at the time of the visit. Additional follow-up is needed due to time restraints, and the Licensing Program Analyst will return at a later date to continue the investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Leggett | Associate Executive Director | Met with Licensing Program Analyst during inspection. |
| Karen Harris | Human Resources Director | Met with Licensing Program Analyst during inspection. |
| Michael Easbey | Administrator | Unavailable at the time of the visit. |
Inspection Report
Routine
Citations: 6
Date: May 24, 2019
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, respiratory care, food safety, pain management, infection control, and quality assurance in the nursing facility.
Findings
The facility had multiple deficiencies including failure to clarify conflicting physician orders for end-of-life care, failure to provide humidified oxygen therapy as ordered, food safety violations in storage and handling, inaccurate pain reassessment documentation due to EHR system limitations, and inadequate infection prevention related to oxygen tubing and humidifier bottle maintenance.
Citations (6)
F0658: The facility failed to clarify conflicting physician orders for end-of-life care for one resident, risking non-adherence to resident's wishes in emergencies.
F0695: The facility failed to ensure humidified oxygen therapy was administered as ordered; a resident's humidifier bottle was almost empty and not changed, risking nasal and mouth irritation.
F0812: The facility failed to follow food safety standards including uncovered dirty dishware transport, improper storage of raw chicken, expired milk on tray line, unlabeled tomato slices, and unclean mobile cart near clean water pitchers.
F0842: The facility failed to ensure accurate pain reassessment documentation within one hour post-medication for six residents, and failed to properly document oxygen tubing changes and humidifier bottle maintenance for one resident.
F0867: The facility failed to include the pain reassessment documentation inaccuracy in its Quality Assurance and Performance Improvement program, risking ineffective pain management.
F0880: The facility failed to ensure oxygen tubing was changed weekly and humidifier bottles were changed and dated daily for one resident, risking respiratory infection.
Report Facts
Residents sampled: 18
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
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