State Center Specialty Care

In the surveyor’s words

From the most serious findings on record at State Center Specialty Care, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 19, 2022

  Based on clinical record review, resident and staff interviews, the facility failed to provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the Nursing Staff did not complete a thorough assessment and provide treatment according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #23). Resident #23 noted with multiple bruises which had not been assessed, documented nor were additional interventions put in to place by/at the time of the Survey. Resident #23 had bruises in different stages of healing. The facility reported a census of 38. Finding Include: 1. […]

• No harm, potential for more than minimal, patternF803Jan 22, 2026

  Based on observation, staff interview, menus and policy review, the facility failed to follow the menu approved by the facility Dietician for the pureed meal. The staff failed to provide bread as listed on the menu. In addition, the staff didn't post the menu correctly after substitution changes. The facility reported a census of 36 residents. Findings include: A facility document titled, Diet Type Report, dated 1/20/26 revealed 3 residents required pureed diets. A facility document titled, Diet Spreadsheet, signed by the Dietitian on 10/13/25 outlined the cycling pureed menu for the lunch meal included, an eight-ounce servicing of king ranch chicken, a half cup serving of pinto beans, a half cup serving of corn, and a wheat roll. Those on regular diet included an ice cream sundae. […]

• No harm, potential for more than minimal, patternF726Dec 20, 2023

  Based on resident and staff interviews, and facility policy review the facility failed to assure one (1) staff member remained awake and in full work status while working and failed to assure staff not use an e-cigarette ([NAME] pen) while in the facility and/or during provision of direct cares. The facility reported a census of 39 residents. Findings Include: During an interview 12/12/23 at 2:28 p.m., Resident #1 (identified by the facility as cognizant) indicated one (1) night Staff A, Certified Nursing Assistant (CNA), entered her room and slept in her recliner. The resident indicated there had been another night the same staff member used a [NAME] pen and smoked it in her room. […]

• No harm, potential for more than minimal, patternF584Aug 30, 2023

  Based on observation, resident interview, family interview, and staff interview, the facility failed to maintain a homelike environment related to urine odors in the hallways and resident rooms, stains and debris on the hallway carpet, scratches on and holes in the walls of resident rooms. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed the resident had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. The MDS documented the resident had a diagnosis including Fragile X syndrome and was independent with activities of daily living (ADLs). […]

• No harm, potential for more than minimal, patternF550Jul 19, 2022

  Based on clinical record review, resident and staff interviews, the facility failed to speak to residents with dignity and respect for 4 of 4 residents (Residents #7, #21, #31 and #39 ). The facility reported a census of 38. Findings Include: 1. Resident #7's Minimum Data Set (MDS) Assessment Tool, dated 4/14/22, revealed resident Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident's cognition intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Resident #7's Care Plan dated 4/20/22 revealed resident's Advanced Directive request as being full code, and to provide opportunities for expression of feelings to maintain psychosocial well-being but did not address how the resident preferred to be called by his name. […]