Citations (last 4 years)
Citations (over 4 years)
12.3 citations/year
Citations are regulatory findings recorded during state inspections.
208% worse than California average
California average: 4 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Citations: 1
Date: Sep 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to recognize and appropriately act on the clinical change in condition of a resident (Resident 1), which led to avoidable emergency hospital transport and serious health consequences.
Complaint Details
The complaint investigation was substantiated. The facility failed to notify the physician on 9/12/25 and 9/13/25 of abnormal lab results and low blood pressure for Resident 1. Nursing staff did not recognize or act on Resident 1's clinical decline on 9/14/25, leading to emergency hospital admission with sepsis and acute kidney injury. The resident's grandson reported concerns and requested 911 multiple times before emergency services were called.
Findings
The facility failed to notify the physician of abnormal lab results and vital signs for Resident 1, resulting in delayed medical intervention. Resident 1 experienced clinical decline including altered mental status, low oxygen saturation, and was subsequently hospitalized with sepsis and acute kidney injury.
Citations (1)
Failure to immediately notify the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Report Facts
Vital signs: 91
Vital signs: 116
Lab result: 17.93
Oxygen saturation: 75
Hospitalization duration: 19
BUN: 62
Creatinine: 1.89
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Assigned nurse on 9/12/25 who did not complete daily assessment or notify physician of elevated WBC |
| LVN 1 | Licensed Vocational Nurse | Provided care on 9/14/25, assessed Resident 1's low oxygen saturation and clinical decline |
| DON | Director of Nursing | Confirmed failure to notify physician and incomplete resident assessments |
| CNA 2 | Certified Nursing Assistant | Observed Resident 1's decline and reported family concerns on 9/14/25 |
| CNA 3 | Certified Nursing Assistant | Provided care on 9/14/25 and reported Resident 1's complaints of pain |
Inspection Report
Citations: 1
Date: Sep 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements following concerns about the facility's failure to recognize and appropriately act on a resident's clinical change in condition.
Findings
The facility failed to notify the physician of abnormal lab results and vital signs for Resident 1, resulting in delayed medical intervention. This led to Resident 1's avoidable emergency hospital admission with sepsis and acute kidney injury.
Citations (1)
F 0580: The facility failed to immediately notify the resident, physician, and family of significant changes in Resident 1's condition, including abnormal lab results and vital signs, leading to actual harm.
Report Facts
Elevated WBC: 17.93
Blood Pressure: 91
Heart Rate: 116
Oxygen Saturation: 75
Hospitalization Duration: 19
BUN: 62
Creatinine: 1.89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in failure to complete daily assessment and notify physician of elevated WBC |
| LVN 1 | Licensed Vocational Nurse | Named in assessment and notification failures related to Resident 1 |
| DON | Director of Nursing | Confirmed failures in notification and assessment protocols |
| CNA 2 | Certified Nursing Assistant | Reported observations of Resident 1's decline and family concerns |
| CNA 3 | Certified Nursing Assistant | Reported Resident 1's complaints and pain prior to decline |
Inspection Report
Annual Inspection
Citations: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, specifically focusing on medication administration and related care practices.
Findings
The facility failed to provide services meeting professional standards for two residents when their medications were unavailable and the licensed nurse did not notify the physician. This failure posed a risk of worsening health conditions and delayed medical response for the affected residents.
Citations (1)
Failure to notify the physician when medications were unavailable and not administered to residents, risking worsening chronic conditions.
Report Facts
Residents affected: 2
Medication doses not administered: 4
Medication doses held: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated licensed nurse should have notified physician when medications were unavailable and not given |
| Licensed Vocational Nurse | Licensed Vocational Nurse | Interviewed regarding medication administration and notification procedures |
| Registered Nurse | Registered Nurse | Interviewed regarding medication administration and documentation procedures |
Inspection Report
Citations: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration at the nursing facility.
Findings
The facility failed to provide services meeting professional standards for two residents when their medications were unavailable and the licensed nurse did not notify the physician. This failure posed a risk of worsening health conditions and delayed medical response.
Citations (1)
F 0658: The facility failed to notify the physician when medications for Resident 1 and Resident 5 were unavailable and not administered. This failure risked worsening chronic health conditions and delayed medical response.
Report Facts
Residents sampled: 5
Medications not administered: 4
Medications held: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) | Interviewed regarding medication administration and notification procedures | |
| Registered Nurse (RN) | Interviewed regarding medication administration and documentation practices | |
| Director of Nursing (DON) | Interviewed regarding facility policy and standard practice for notifying physicians of unavailable medications |
Inspection Report
Citations: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration following a failure to administer prescribed medications to a resident as ordered by the physician.
Findings
The facility failed to administer medications as ordered to one resident on 5/23/25 due to medication unavailability and did not notify the prescribing physician as required. This failure posed a risk of worsening chronic conditions, health deterioration, rehospitalization, or death. The licensed nurse did not follow facility policies and procedures for missed medication doses.
Citations (1)
Failure to administer prescribed medications to Resident 1 on 5/23/25 due to medication unavailability and failure to notify the physician.
Report Facts
Residents Affected: 4
Residents Affected: Few
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN 2) | Interviewed regarding medication administration and facility policy | |
| Director of Staff Development (DSD) | Interviewed regarding medication administration and facility policy |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to administer medications as ordered to Resident 1 on 5/23/25.
Complaint Details
The complaint investigation found that Resident 1 was not administered multiple medications on 5/23/25 due to unavailability, and the licensed nurse did not notify the physician as required. The failure was substantiated with potential risk to Resident 1's health.
Findings
The facility failed to follow professional standards and its own policies by not administering prescribed medications to Resident 1 due to unavailability and failing to notify the prescribing physician. This failure posed a risk of worsening chronic conditions, health deterioration, rehospitalization, or death for Resident 1.
Citations (1)
F 0658: The facility failed to administer prescribed medications to Resident 1 on 5/23/25 due to medication unavailability and did not notify the physician as required. This failure could lead to worsening chronic conditions and health decline.
Report Facts
Deficiencies cited: 1
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN 2) | Interviewed regarding medication administration failure | |
| Director of Staff Development (DSD) | Interviewed regarding medication administration failure and facility policies |
Inspection Report
Routine
Citations: 9
Date: Dec 10, 2024
Visit Reason
Routine inspection of Morning Star Post Acute nursing home to assess compliance with regulatory standards including resident dignity, medication administration, infection control, food safety, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy during care, improper medication administration and storage, inadequate infection prevention practices, unsanitary kitchen conditions, failure to implement water management program for Legionella, and call lights not within reach of residents.
Citations (9)
F 0557: Facility failed to ensure residents were treated with dignity and respect by not providing privacy during blood sugar checks, blood pressure checks, and medication administration for multiple residents.
F 0658: Licensed Vocational Nurse allowed Resident 14 to self-administer inhalers without required assessment, physician order, or care plan, risking incorrect medication dosing.
F 0677: Facility failed to provide assistance with personal hygiene and grooming for Resident 22, resulting in poor hygiene and potential health risks.
F 0755: Contracted pharmacist failed to check expiration date of lorazepam in emergency kit, placing residents at risk of receiving expired medication during emergencies.
F 0761: Treatment cart left unlocked; multiple medications lacked open or expiration dates; discontinued medications improperly stored without labels, risking medication errors and adverse reactions.
F 0812: Kitchen had brown, grey, and black debris on vents, shelves, food carts, toaster, and freezer with freezer-burned beef roast, risking cross contamination and foodborne illness.
F 0880: Facility failed to implement Water Management Program for Legionella since 4/8/22 and allowed oxygen nasal cannulas to be on the floor, risking infection and cross contamination.
F 0911: Facility bedrooms exceeded four residents per room in three rooms, but met space and privacy requirements; waiver recommended to continue.
F 0919: Call lights were not within reach for Residents 104, 19, and 30, placing them at risk of not being able to summon assistance in emergencies.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 54
Residents affected: 3
Number of beds in rooms exceeding 4 residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in dignity/privacy deficiency for not providing privacy during blood sugar check |
| LVN 3 | Licensed Vocational Nurse | Named in dignity/privacy deficiency for not providing privacy during blood pressure check and medication administration |
| LVN 2 | Licensed Vocational Nurse | Named in self-administration medication deficiency and infection control deficiency |
| DON | Director of Nursing | Named in multiple interviews regarding expectations for privacy, medication administration, infection control, and call light placement |
| DM | Dietary Manager | Named in kitchen sanitation deficiencies |
| IP | Infection Preventionist | Named in infection prevention deficiencies and Legionella Water Management Program oversight |
| MD | Maintenance Director | Named in Legionella Water Management Program oversight and kitchen sanitation |
| LVN 5 | Licensed Vocational Nurse | Named in call light deficiency |
| CNA 2 | Certified Nursing Assistant | Named in call light deficiency |
| CNA 3 | Certified Nursing Assistant | Named in call light deficiency |
Inspection Report
Routine
Citations: 16
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident rights, care planning, medication administration, food and nutrition services, infection control, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide written notification for room changes, incomplete care plans for anticoagulant use and weight loss monitoring, inadequate pain assessment for cognitively impaired residents, incomplete dialysis documentation, expired medication storage, improper food preparation and sanitation practices, unsanitary environmental conditions including pest presence and shower cleanliness, and overcrowded resident rooms.
Citations (16)
F 0559: The facility failed to provide written notification before room changes for three residents, violating their right to receive written notice explaining the reason for the move.
F 0656: The facility failed to develop and implement comprehensive care plans for anticoagulant use and weight loss monitoring for three residents, placing them at risk for complications.
F 0658: The facility failed to ensure professional standards of care for weight monitoring, resulting in unmonitored weight loss for one resident.
F 0692: The facility failed to monitor and intervene appropriately for severe unplanned weight loss in one resident, including inadequate documentation and evaluation of nutritional interventions.
F 0697: The facility failed to provide pain management consistent with professional standards for a cognitively impaired resident by using an inappropriate pain assessment tool.
F 0698: The facility failed to ensure dialysis post-weight assessments were completed and documented for one resident, risking delayed identification of dialysis complications.
F 0761: The facility failed to discard expired medication found in a medication cart, risking administration of ineffective medication.
F 0802: The facility failed to ensure dietary staff properly calibrated thermometers, followed sanitizer test strip instructions, prepared food portions according to menu guidance, and served food textures consistent with diet orders, risking foodborne illness, choking, and nutritional deficiencies.
F 0803: The facility failed to ensure pureed meat was prepared to a smooth consistency without chunks for residents on pureed diets, risking choking.
F 0805: The facility failed to ensure food was prepared in a form designed to meet individual needs for six residents, including serving regular textured vegetables to mechanical soft diet residents and chunky pureed meat to pureed diet residents, risking choking and aspiration.
F 0812: The facility failed to maintain a sanitary kitchen environment, including lack of air gap in the three-compartment sink, presence of debris and damaged refrigerator shelves, holes under ice machine, dirty microwaves, and uncovered hair of dietary staff, risking cross contamination and foodborne illness.
F 0814: The facility failed to dispose of garbage under sanitary conditions when the dumpster was uncovered and overfilled, risking attraction of pests and cross contamination.
F 0880: The facility failed to implement an effective infection prevention and control program, including failure of a nurse to perform hand hygiene during medication administration, uncovered linen cart with soiled tissue, open linen room door, and unsanitary shower room conditions, risking cross contamination and infection.
F 0911: The facility failed to ensure resident rooms held no more than four residents in three rooms, housing eight residents each, risking inadequate privacy and space.
F 0921: The facility failed to maintain a safe, clean, and sanitary environment, including presence of mold and missing grout in shower rooms, dirty call light cords, and fire hazard from plastic packaging on fan cord.
F 0925: The facility failed to maintain an effective pest control program when two winged bugs were found in a resident's shower, risking spread of bacteria and illness.
Report Facts
Residents affected by room overcrowding: 8
Weight loss: 54
Weight loss: 33
Weight loss: 20
Weight loss: 23
Weight loss: 37
Weight loss: 40
Weight loss: 32
Medication expiration date: 2023
Medication administration times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Failed to perform hand hygiene during medication administration to Resident 51 |
| LVN 3 | Licensed Vocational Nurse | Used incorrect pain assessment tool for Resident 2 |
| LVN 5 | Licensed Vocational Nurse | Administered pain medication to Resident 2 |
| DON | Director of Nursing | Acknowledged deficiencies in pain assessment, infection control, and dialysis documentation |
| RD | Registered Dietitian | Reviewed dietary deficiencies and food preparation issues |
| CDM | Certified Dietary Manager | Reviewed dietary deficiencies and food preparation issues |
| DOM | Director of Maintenance | Acknowledged environmental and safety deficiencies |
| IP | Infection Preventionist | Reviewed infection control deficiencies and environmental sanitation |
Inspection Report
Routine
Citations: 3
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and infection prevention and control requirements, specifically regarding the use and care of oxygen therapy equipment for sampled residents.
Findings
The facility failed to develop comprehensive care plans for three sampled residents regarding the use of supplemental oxygen and nebulizer machines, and failed to maintain proper infection prevention practices for oxygen therapy equipment, placing residents at risk for respiratory infections due to cross contamination.
Citations (3)
Failure to develop a comprehensive care plan for supplemental oxygen use including proper replacement and storage of nasal cannula for Resident 2.
Failure to develop comprehensive care plans for nebulizer machine use including proper replacement and storage of nebulizer masks for Residents 1 and 3.
Failure to maintain an effective infection prevention and control program related to oxygen therapy equipment, including improper storage and lack of dating of nasal cannula and nebulizer masks for Residents 1, 2, and 3.
Report Facts
Residents sampled: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding improper storage and replacement of Resident 2's nasal cannula. |
| Licensed Vocational Nurse 2 | LVN | Interviewed regarding care plans and infection control for Residents 1, 2, and 3. |
| Certified Nursing Assistant 1 | CNA | Interviewed regarding improper storage and dating of nebulizer mask for Resident 3. |
| Infection Preventionist | IP | Interviewed regarding infection prevention practices and reviewed physician orders. |
| Administrator | ADM | Interviewed regarding facility expectations for licensed nurses on oxygen therapy equipment care. |
Inspection Report
Annual Inspection
Citations: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, specifically regarding the implementation of physician orders for resident care.
Findings
The facility failed to provide services meeting professional standards for one resident when a physician's order for a floor mat to reduce fall injury risk was not implemented. Licensed nurses did not follow the physician's order, increasing the resident's risk of injury from falls.
Citations (1)
Failure to implement physician order for floor mat to reduce fall injury risk for Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Validated absence of floor mat in Resident 1's room and confirmed resident was a fall risk. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Observed absence of floor mat during medication pass and stated responsibility to follow physician orders. |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Reviewed fall prevention policy and confirmed professional standard to follow physician orders. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a physician's order for a floor mat for Resident 1, which was intended to reduce injury risk from falls.
Complaint Details
The complaint was substantiated as the facility failed to implement a physician's order for a floor mat to reduce fall injury risk for Resident 1. The failure was confirmed through observations and interviews with staff and review of policies.
Findings
The facility failed to provide services meeting professional standards for one of three sampled residents by not implementing a physician's order for a floor mat beside Resident 1's bed. Licensed nurses did not follow the physician's order, increasing the resident's risk of injury from falls.
Citations (1)
F 0658: The facility failed to follow a physician's order for a floor mat beside Resident 1's bed, increasing the risk of injury from falls. Licensed nurses did not ensure the order was implemented despite Resident 1's history of falling and cognitive deficits.
Inspection Report
Routine
Citations: 13
Date: May 19, 2022
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to develop timely and comprehensive care plans, failure to follow physician orders for nutritional supplements, inadequate supervision during resident transfers, improper medication labeling, failure to monitor psychotropic medications with gradual dose reductions, inadequate infection control practices, and failure to provide nutritionally equivalent meal options for residents with dietary restrictions.
Citations (13)
F0655: The facility failed to develop and implement a baseline care plan for Resident 23's oxygen use within 48 hours of admission, placing the resident at risk for oxygen decline.
F0656: The facility failed to develop a person-centered comprehensive care plan for Resident 23 that reflected interventions to ensure safety during activities of daily living, risking unmet care needs and injury.
F0658: Resident 26 did not receive prescribed two-calorie nutritional supplements on multiple days, resulting in risk for weight loss and failure to meet professional standards of care.
F0689: The facility failed to ensure adequate supervision during mechanical lift transfers for Resident 23, as only one staff member assisted, increasing risk of falls and injury.
F0692: Resident 26 experienced severe weight loss due to failure to provide adequate nutritional intake and supplementation, with documented poor meal consumption and missed supplement doses.
F0757: The facility failed to monitor Resident 33 for side effects of anticoagulant medication, increasing risk of serious adverse events such as bleeding.
F0758: Resident 25 received unnecessary psychotropic medications without gradual dose reduction despite no documented behaviors, increasing risk of adverse side effects.
F0761: Injectable insulin pen for Resident 43 was not labeled with a pharmacy prescription label including resident name, dose, and directions, risking medication errors.
F0802: Food service staff (Cook 2) lacked competency in the proper two-step cooling process for potentially hazardous foods, risking foodborne illness.
F0806: Resident 25 was served yogurt as a protein substitute that did not meet the nutritive value of the planned entrée, risking inadequate nutrition and weight loss.
F0842: Resident 294's physician order for high calorie nutritional supplement was not accurately documented or recorded as given in the electronic medical record for four of six meals.
F0880: Infection prevention and control program was inadequate as rapid COVID-19 nasal swab tests were carried uncovered through the facility and glucometers were not properly cleaned and disinfected.
F0911: The facility failed to ensure resident bedrooms accommodated no more than four residents, with three rooms housing eight residents each.
Report Facts
Weight loss: 10
Missed nutritional supplement doses: 10
Residents per room: 8
Temperature: 135
Temperature: 70
Temperature: 41
Distance: 280
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Named in findings related to oxygen care plan, medication administration, and infection control practices. |
| DON | Director of Nursing | Named in findings related to care plan expectations, medication monitoring, and infection control oversight. |
| LVN 1 | Licensed Vocational Nurse | Named in findings related to medication administration and nutritional supplement documentation. |
| CNA 3 | Certified Nursing Assistant | Named in findings related to nutritional supplement documentation. |
| AD | Admissions Director | Named in infection control finding related to improper handling of rapid COVID-19 nasal swab test. |
| DSM | Dietary Services Manager | Named in findings related to food service competency and nutritional supplement oversight. |
| RD | Registered Dietitian | Named in findings related to nutritional assessments and dietary planning. |
| CP | Clinical Psychologist | Named in findings related to psychotropic medication monitoring and gradual dose reduction. |
| SSD | Social Service Director | Named in findings related to psychotropic medication management and family communication. |
| LVN 2 | Licensed Vocational Nurse | Named in findings related to nutritional supplement documentation. |
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