Shafter Nursing Care

In the surveyor’s words

From the most serious findings on record at Shafter Nursing Care, in the surveyor’s own words.

• Actual harm, isolatedF656Nov 19, 2024

  Based on observation, interview, and record review, the facility failed to implement one of six sampled residents' (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) when the facility did not ensure Resident 1's room was well-lit and Resident 1 was wearing footwear (item of clothing that covers and protects the foot, including the soles of the feet) when walking. These failures resulted in Resident 1 sustaining a nondisplaced fracture (broken bone that did not move out of alignment) of the neck of the right femur (thigh bone) requiring open reduction and internal fixation (surgical procedure that treats severe bone fracture or dislocation by realigning the bones and stabilizing them with internal hardware [tools or devices used in… […]

• Actual harm, isolatedF602Sep 17, 2024

  Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from financial abuse when: 1. The facility did not have a policy & procedure in place to protect vulnerable residents who do not have the mental capacity to manage their own financial matters. 2. The Social Services Director (SSD), as the perpetrator (culprit/wrongdoer), used Resident 1 ' s credit card (a plastic card you can use to buy goods and services and pay for them later) and debit card (a payment card that can be used in place of cash to make purchases or withdraw cash) without Resident 1 ' s consent when more than $6,500 in unauthorized purchases were made by her (SSD). […]

• Actual harm, isolatedF692Apr 13, 2022

  Based on interview and record review, the facility failed to ensure the nutritional needs for eight of 12 sampled residents (Resident 1, Resident 7, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15) were met when the facility failed to: 1a. Complete a Nutritional Assessment by a Registered Dietician (RD) and develop a care plan for weight loss for one of 12 sampled residents (Resident 1). 1b. Complete a Nutritional Assessment by a RD and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Complete Nutritional assessments by a RD for six of 12 sampled residents (Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, and Resident 15). […]

• Actual harm, isolatedF692Feb 1, 2021

  Based on interview and record review, the facility failed to follow its' policy and procedure in providing adequate nutrition for one of three sampled residents (Resident 1) when: 1. Weekly weights recommended by Certified Dietary Manager (CDM) were not implemented. 2. Weight loss of 20 pounds (lbs-unit of measurement)/-11.8% in one month was not reported to the Primary Care Physician (PCP) and to the Responsible Party (RP). 3. Fortified Diet (FD) recommended by Registered Dietitian (RD)was not followed through. 4. Nutrition assessment was not conducted by RD for the month of July, 2020 when Resident 1 started to have a weight loss of 20 lbs/-11.8 % in one month. These failure resulted in Resident 1's unplanned total weight loss of 30 lbs (-17.65%) in 45 days. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF727Apr 9, 2026

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.Findings:During a concurrent interview and record review on 4/7/26 at 11:52 a.m. with Director of Staff Development (DSD), facility's Nursing Staffing Assignment and Sign-In Sheet (NSASS), dated January 2026 was reviewed. The NSASS indicated, there was no RN available to work in a consecutive 8 hour shift on 1/17/26 and 1/24/26. DSD stated there was no RN present in the building for 8 hours a day on 1/17/26 and 1/24/26.During a concurrent interview and record review on 4/7/26 at 11:54 a.m. with DSD, facility's NSASS, dated December 2025 was reviewed. […]