Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Acc Care Center during CMS and state inspections, most recent first.
A resident with orthostatic hypotension, dementia, and prior pelvic fracture had multiple documented falls and was placed on fall precautions that included use of fall mats at the bedside. Progress notes and incident records described several unwitnessed and witnessed falls, including head injuries and a clavicle fracture, while documentation showed that a fall mat had been incorrectly positioned on one side of the bed and later not in place at all. During surveyor observations and interviews, the resident’s family member and an LN confirmed that no fall mats were present at the bedside despite the resident’s fall history, and the facility’s own policy and the Quality and Compliance Coordinator’s statements indicated that properly placed fall mats were required as part of the resident’s comprehensive care plan.
A cognitively intact resident receiving orthopedic aftercare reported being left alone in a shower room twice by a CNA, who left to retrieve a hairbrush from central supply and then from the resident’s room. Another CNA stated she witnessed the resident being left alone at least once, and the involved CNA confirmed in a written statement and interview that she left the resident unattended on both occasions. A nurse and a nurse manager stated that residents are not to be left alone in shower rooms due to safety concerns, and facility policies on bathing and resident supervision require staff to remain with residents throughout showers and emphasize supervision as a core safety component.
The facility failed to follow a resident’s ST order and prior swallow precautions for a resident with dementia and dysphasia, as the resident was observed eating independently in bed while staff were unaware of the swallowing guidance and the DON confirmed the ordered ST eval was not completed. The facility also gave another resident carvedilol and valsartan outside ordered BP hold parameters and did not document physician notification for significant ordered weight changes. The DON confirmed the medication and weight-order deviations.
The facility failed to provide accurate catheter care and monitoring for two residents. One resident’s straight catheter use was not correctly documented or evaluated after the resident was able to void on his own, and staff confirmed the order remained in place despite the resident not needing it. Another resident with a suprapubic catheter did not receive ordered site care on some days and did not receive every-shift UTI monitoring on multiple shifts, which the DON and nursing staff confirmed.
Surveyors found a medication pass error rate above the allowed threshold after an LPN gave a resident the wrong aspirin dose, cut a buprenorphine/naloxone sublingual film despite label and manufacturer directions, administered methenamine with milk/dairy present despite order restrictions, and another resident’s ordered lidocaine patch was not available for administration. The DON and CP stated staff were expected to follow physician orders and manufacturer specifications, and the facility’s medication pass had 4 errors in 33 opportunities.
Improper Medication Storage and Unlocked Medication Cart: A medication refrigerator was observed at 36 F with methotrexate injections and several suppository medications inside, even though the package inserts stated they should be stored at room temperature. In addition, an unlocked medication cart was left unattended in a hallway outside a resident room, and LN acknowledged forgetting to lock it; the DON stated unattended carts are expected to be locked, and the facility policy required medication carts and supplies to be locked or attended by authorized staff.
Deteriorated kitchen shelving, scratched nonstick pans, and a damaged can opener were observed during a kitchen tour. Metal shelving under the cook's station and shelves in the walk-in refrigerator showed discoloration and rust-colored markings, and the Plant Operations Manager stated the surfaces could not be cleaned properly or sanitized. Two nonstick fry pans had scratched coatings, and the can opener blade had dark discoloration and missing metal at the tip, creating a potential physical contaminant hazard during food prep.
Staff failed to wear required PPE for residents on EBP during direct care. A hospice nurse provided skin assessment and wound care to one resident without PPE despite EBP signage, and an RNA assisted another resident with toileting in the bathroom without a gown and gloves. The IP and DON stated gowns and gloves were expected for high-contact care such as toileting and wound care, and PPE supplies were posted outside the rooms.
Call Lights Not Within Reach for Two Residents With Impaired Vision: Two residents with severe or highly impaired vision had call lights out of reach. One resident who was blind was observed in bed searching for his call light and stating he could not find it, while another resident returning from dialysis was uncomfortable in a wheelchair with her call light about 3 feet away. RN/RNA staff confirmed the call lights were not accessible, despite care plans and the facility policy requiring call lights to be within reach.
Unnecessary quetiapine use without adequate indication. A resident with stroke history, dementia, weakness, and repeated falls received quetiapine for mood/behavior regulation and later for psychosis, but the record lacked a clear rationale tied to documented hallucinations or targeted behaviors. The CP requested more specific indications, behavior monitoring, and consideration of dose reduction or discontinuation, while staff observed the resident as drowsy, confused, and a fall risk. The MD acknowledged the black box warning for antipsychotic use in dementia and stated the resident had not been referred to psychiatry.
Psychotropic Medication Used Without Documented Rationale for Dementia-Related Behaviors: A resident with vascular dementia was given Seroquel for yelling, restlessness, and verbal aggression, but the record did not show documented non-pharmacological interventions or a physician rationale before the medication was started or increased. The chart also added psychotic disturbance and psychosis diagnoses without documented assessment supporting hallucinations, delusions, or other psychotic symptoms, and staff interviews confirmed the resident’s behaviors were more consistent with yelling, frustration, loneliness, and attention-seeking than psychosis.
Controlled Medication Not Reconciled After Administration: A resident’s oxycodone 5 mg count was not properly reconciled after administration. During narcotics counting, one pill was left unaccounted for, and LN documentation showed the dose was charted in the MAR but not in the narcotics log. LN stated the medication had been given earlier and that administration and reconciliation should be documented immediately after giving the dose; the DON stated LNs should sign the narcotics log after popping the medication.
Food Allergy Not Accommodated on Meal Tray: A resident with an onion allergy was served a meal tray that included mixed oriental vegetables containing onion. The meal ticket identified the allergy, the resident ate in his room and received food in bowls, and the resident was legally blind. The CDM said dietary staff review allergy banners and the nursing floor checks trays before service, but a CNA delivered the tray with the allergen still present.
A resident with a history of blood clots was prescribed aspirin 81mg twice daily until a specific date, but due to a miscommunication between the physician and a nurse, the medication was stopped a month early. This error was discovered after the resident was hospitalized, and the family informed the DON. The facility's policy on medication orders was not followed, resulting in the resident not receiving the prescribed aspirin.
A facility failed to protect residents from misappropriation of controlled medications, specifically oxycodone, leading to unaccounted doses and potential resident harm. A nurse altered medication orders and removed medications and count sheets, resulting in discrepancies. An audit revealed 1,915 doses were missing, and the facility's policy on employee conduct was reviewed.
A nurse in an LTC facility entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for multiple residents. This led to discrepancies in medication counts and potential misuse of medications. The facility's policy requires medications to be administered only with authorized prescriptions, which was not followed in this case.
A facility failed to maintain accurate accountability of controlled medications, specifically Oxycodone, for its residents. An LPN manipulated medication orders and records, including forging physician signatures and altering narcotic count sheets, leading to unaccounted doses. The facility's policies for controlled medication storage and accountability were not followed, compromising resident safety and therapeutic needs.
The facility failed to maintain food safety standards, with wet and dirty pans stored improperly, an unclean ice machine, and expired food items in a resident refrigerator. The Food Services Supervisor and Registered Dietician confirmed the issues, while the Plant Operations Manager admitted to not performing necessary deep cleaning. These deficiencies risked foodborne illness for residents.
The facility's dishwashing machine failed to reach the required temperatures and sanitizer concentration levels, placing 89 residents at risk for foodborne illness. The Dietary Aide and Food Service Supervisor confirmed the deficiencies, and the machine company technician suggested that insufficient hot water pressure might be the cause.
The facility failed to conduct annual performance evaluations and competency assessments for five CNAs, as required by their policy. Interviews and record reviews with the DON, CCN, and ADM confirmed the absence of these evaluations for 2024, despite the facility's policy mandating participation in a competency-based training program.
A facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate. An LN crushed and administered uncrushable medications, oxybutynin ER and pantoprazole DR, to a resident, contrary to facility guidelines. Additionally, a prescribed dose of calcium-vitamin D was not administered due to a failure to order the medication on time. The DON confirmed these errors, which violated the facility's medication administration policies.
The facility failed to follow its medication storage policy, resulting in several deficiencies. An expired insulin vial was found in a medication cart, a multi-dose inhaler lacked an open date label, and 16 pills were stored without proper labeling. These actions violated the facility's policy, which requires medications to be stored in original containers with legible labels and outdated medications to be removed immediately.
The facility failed to follow prescribed therapeutic diets for several residents, including incorrect portion sizes and textures. Six residents on fortified diets did not receive extra butter, and four on small portion diets received incorrect salmon portions. Additionally, residents on dysphagia mechanical soft diets received incorrect textures, and a resident on a bite-size texture diet was served ground chicken instead of cubed. The preparation of pureed vegetables did not follow the recipe, resulting in a runny consistency.
The facility failed to provide required in-service training for CNAs in abuse prevention and dementia management. Four employed CNAs and one contracted CNA lacked abuse prevention training, while two employed CNAs and both contracted CNAs had not received dementia management training. The absence of training documentation was confirmed by the DON and ADM, raising concerns about the CNAs' competency in resident care.
A resident with memory impairment and weakness was not treated with dignity during meal assistance when a CNA stood while feeding her, contrary to facility policy. The resident showed discomfort, and interviews with staff confirmed the expectation to sit beside residents during feeding to ensure dignity.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, with anxiety and depression, lacked an activities care plan and was isolated due to a language barrier. Another resident, with Parkinson's disease, had a skin laceration that was not addressed in a care plan. Staff interviews confirmed the absence of necessary assessments and care plans, contrary to facility policy.
A resident with an endocrine disorder and difficulty swallowing did not have their care plan updated after a physician ordered blood sugar checks due to hypoglycemia symptoms. Despite staff awareness of the order, the intervention was not documented in the care plan, contrary to facility policy.
Two residents experienced deficiencies in care at the facility. A resident with Parkinson's disease had no documented assessment for a new finger laceration, confirmed by a nurse and the DON. Another resident with pulmonary fibrosis received incorrect oxygen therapy, as observed and confirmed by a nurse, contrary to physician's orders. The facility's policy mandates adherence to prescriber orders.
The facility failed to provide necessary communication aids for two residents with language barriers, impacting their ability to communicate effectively. One resident, who spoke only Spanish, and another with severe cognitive impairment and a primary language of Taishanese, both lacked communication boards at their bedsides despite care plans indicating their need. Staff were unaware of the absence of these resources, highlighting a failure to adhere to facility policies on communication for residents with limited English proficiency.
A resident with a Stage 4 pressure injury did not receive a required low air loss mattress upon readmission to the facility, despite care plan and physician orders. Facility staff confirmed the absence of the mattress, citing a misunderstanding about hospice responsibilities, although the facility had the necessary equipment available.
A resident did not receive their prescribed calcium-vitamin D during a medication pass because it was not ordered on time, as observed by a licensed nurse. The physician's orders required the medication twice daily, but it was unavailable. The DON confirmed that medications should be timely ordered and available. Facility policies stated that medications must be administered per physician orders.
The facility failed to honor food preferences for four residents, leading to dissatisfaction with meals. A resident received sausage, which she disliked, and reported never being asked about her food preferences. Another resident was served scrambled eggs, which she disliked, and her dietary profile lacked documentation of preferences. A third resident's meal ticket indicated a dislike for carrots, yet her meal tray included them. A fourth resident, who was underweight, did not receive the Healthshake and Udon soup as per her dietary orders. The facility was unable to provide a policy for residents' food preferences.
The facility failed to follow infection control protocols for three residents. A resident's oxygen and nebulizer tubing were not labeled or dated, contrary to facility policy. Another resident with MRSA had a bandage change where the nurse did not change gloves or sanitize items, risking contamination. A third resident's oxygen equipment was also found unlabeled and undated, violating infection control guidelines.
Failure to Implement Care-Plan Fall Mat Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident with a documented history of falls, specifically the absence of fall mats at the bedside as ordered in the resident’s fall precautions. The resident was admitted in January 2026 with orthostatic hypotension, dementia, and a pelvic fracture, and a progress note dated 4/1/26 documented that the resident did not have capacity to make medical decisions. The care plan dated 3/1/26 reflected an unwitnessed fall that led to implementation of fall precautions, and subsequent care plan entries on 3/17/26 and 3/24/26 documented additional falls, including a minor head injury and a witnessed fall with head impact requiring transfer to the ED. Facility incident records dated 4/2/26 confirmed unwitnessed falls on 3/1/26 and 3/17/26 and a witnessed fall on 3/24/26. A progress note from 3/1/26 described the resident found on the floor next to the left side of the bed while the fall mat was placed on the right side. Further documentation showed that on 3/17/26 the resident was found on the floor near the door with a 2 cm laceration to the right side of the head, and a hospital discharge summary dated 4/1/26 listed diagnoses including a possible syncopal episode, orthostatic hypotension, and an acute distal left clavicular fracture. On 4/2/26, during observation and interview in the resident’s room, the resident’s family member confirmed that no fall mats were in place at the bedside and stated that fall mats should have been present for safety. A concurrent observation and interview with a licensed nurse confirmed that fall mats were not in place despite the resident’s history of falls and that fall mats were part of the resident’s fall precautions. The Quality and Compliance Coordinator stated that after a fall, a change in condition should be documented and care plans updated to include fall precautions such as ensuring the call light is within reach, the bed is in the lowest position, and a fall mat is properly placed at the bedside. The facility’s care plan policy required that residents receive the services and items included in the comprehensive, person-centered care plan, which was not followed in this case regarding the fall mat intervention.
Resident Left Unattended in Shower Room Contrary to Supervision Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a shower area free from accident hazards when a cognitively intact resident receiving orthopedic aftercare was left alone in the shower room on two occasions. The resident, admitted in March 2026 with a diagnosis of encounter for orthopedic aftercare, reported that a CNA left her alone in the shower room twice to obtain a hairbrush. During an observation and interview in the resident’s room, the resident, seated in a wheelchair with her right leg raised, stated that the CNA left her unattended in the shower room on both occasions. A second CNA reported witnessing the first CNA leave the resident alone in the shower room at least once during her shift. In a written statement dated 3/22/26 and in a subsequent telephone interview, the first CNA acknowledged leaving the resident alone in the shower room to retrieve a brush from central supply and then again from the resident’s room. A licensed nurse and the nurse manager both stated that no resident should be left alone in the shower room and that doing so is a safety risk. Review of the facility’s Bath/Shower policy from 2001 indicated staff must stay with the resident throughout the bath and never leave the resident unattended in the shower, and the Safety and Supervision of Residents policy from July 2017 emphasized resident supervision as a core component of the facility’s safety system.
Failure to Follow Swallowing Precautions, BP Medication Hold Parameters, and Weight Reporting Orders
Penalty
Summary
The facility failed to ensure Resident 102 received speech therapy evaluation and treatment in accordance with the physician’s order and prior speech therapy recommendations. Resident 102 was admitted with diagnoses including dementia and dysphasia, and the MDS dated 7/7/25 indicated severely impaired cognition. The physician ordered speech therapy evaluation and treatment on 6/26/25, but the clinical record contained no documented evidence that the order was followed or that the physician was informed the evaluation had not occurred. The resident had a prior speech therapy evaluation and plan of care from 7/2/24 documenting swallowing problems, coughing and choking with meals, and referral for dysphasia due to need for meal assistance and aspiration risk. The discharge summary from 7/12/24 recommended swallow techniques/precautions, altered liquids/solids, upright posture during meals, and close supervision for oral intake. During observation on 9/2/25, Resident 102 was seen eating breakfast independently in bed while a sign labeled “Swallowing Guidelines” was hanging upside down and folded in half above the resident’s head. A CNA stated the sign did not have the resident’s name, listed the son’s phone number, and said it indicated 1:1 assistance/supervision during meals, but he was not aware of any swallowing precautions and believed the resident always ate by herself. An RNA stated the resident always ate in her room independently and was not aware of swallowing issues or aspiration precautions. The ST could not recall whether a swallow evaluation and treatment had been completed in the last 6 months, and the DON confirmed the 6/26/25 ST order was not completed and said there was miscommunication. The facility also failed to follow physician-ordered hold parameters for Resident 8’s BP medications and failed to report ordered weight changes. Resident 8 was admitted with atherosclerotic heart disease, heart failure, and HTN, and the MDS indicated the resident was cognitively intact. The MAR showed carvedilol 6.25 mg twice daily was administered on multiple occasions when SBP was below the ordered hold parameter of 110, and valsartan 40 mg half tablet twice daily was administered on multiple occasions when SBP was below the ordered hold parameter of 105. The DON confirmed the medications were given outside the ordered parameters and stated staff were expected to follow physician orders. Resident 8 also had a physician order for daily weights and notification of the MD for weight changes of 2 lbs or more in 24 hours or 5 lbs in 1 week. The MAR showed weight changes of 6.2 lbs in 24 hours, 5.6 lbs over 5 days, and 4 lbs in 24 hours, and the DON confirmed there was no documentation of physician notification for the significant weight changes. The DON stated staff were expected to follow the doctor’s order and that the doctor might have put interventions in place if notified.
Inadequate catheter care and monitoring
Penalty
Summary
The facility failed to ensure adequate catheter care for two residents. One resident had a straight catheter order after a Foley catheter was removed, but the catheter use was not accurately documented, the need for continued use was not evaluated, and the order was not individualized to the resident’s changing voiding status. The resident’s record showed multiple MAR entries marked as not performed or held, and nursing notes documented that the resident was able to void on his own and refused straight catheterization. Staff interviews confirmed the resident did not have a catheter at the time, that documentation had been entered incorrectly, and that the physician should have been notified when the resident was voiding without catheter use. The assistant director of nursing also confirmed there was no care plan for the straight catheter. A second resident had a suprapubic catheter and orders for daily site care and every-shift monitoring for signs and symptoms of UTI, including foul smell, cloudy urine, and discharge. The record showed that the ordered monitoring was not completed on multiple shifts in July and August, and the suprapubic insertion site care was not completed on two days in August. The resident’s care plan directed staff to observe for infection or skin changes around the site and to provide daily and as-needed suprapubic catheter care. During interviews, nursing staff and the DON confirmed the missed catheter care and monitoring. One nurse stated the suprapubic catheter site needed to be observed closely because it could be a breeding ground for bacteria, and the DON confirmed the ordered care and monitoring were not done as documented. The facility policy stated catheter care was intended to prevent catheter-associated complications, including UTIs, and required documentation of catheter care, assessment data, and refusal information.
Medication Administration Errors and Missing Medication During Pass
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% after surveyors identified 4 errors out of 33 opportunities for error during an observed medication pass, resulting in a 12.12% medication error rate. The deficiency involved two sampled residents, including Resident 110 and Resident 45, during observation, interview, and record review. For Resident 110, LN 1 administered 81 mg of enteric-coated aspirin even though the physician order was for aspirin delayed release 325 mg. LN 1 stated the wrong dose was mistakenly given. LN 1 was also observed cutting buprenorphine 2 mg/naloxone 0.5 mg sublingual film for administration, despite the package label stating not to cut, chew, or swallow the film and the manufacturer insert stating the film must be administered whole. In addition, LN 1 administered methenamine hippurate 1000 mg while the resident had an uneaten meal tray containing milk and other foods, even though the physician order directed avoidance of citrus fruits and juices and milk/dairy. LN 1 stated being unaware of the order to avoid giving the medication with milk or citrus. For Resident 45, LN 8 did not have the ordered lidocaine transdermal patch 5% available during the medication pass. The resident had current orders for lidocaine external patch 5% one time a day for lower back pain and one time a day for lower posterior neck pain. LN 8 stated the patch was not available for administration, and the DON stated all medications were expected to be available for resident administration during the medication pass.
Improper Medication Storage and Unlocked Unattended Medication Cart
Penalty
Summary
Medications and biologicals were not stored in accordance with accepted storage requirements when the medication refrigerator in the medication storage room was observed at 36 F and contained methotrexate injections, acetaminophen suppositories, hemorrhoid suppositories, and hydrocortisone suppositories. The package inserts for these products stated they should be stored at room temperature, 68 to 77 F, and the facility’s policy stated medications requiring room temperature storage are kept between 59 F and 86 F. LN 3 confirmed the refrigerator temperature and the presence of these medications in the refrigerator, and the ADON, DON, and consultant pharmacist all stated these medications should be stored at room temperature according to manufacturer instructions. A medication cart was also observed left unlocked and unattended in the hallway outside a resident room with the privacy curtain drawn, and no staff was seen using or monitoring the cart. LN 9 stated the cart should have been locked when unattended and acknowledged forgetting to lock it, while the DON stated unattended medication carts are expected to be locked to prevent access by unauthorized residents, staff, and visitors. The facility policy stated medication carts and medication supplies are locked or attended by persons with authorized access.
Deteriorated Kitchen Surfaces and Damaged Food Prep Equipment
Penalty
Summary
Food was stored, prepared, distributed, and served under unsanitary conditions when kitchen equipment and surfaces were observed to be deteriorated. During the kitchen tour, the metal shelving under the cook's station was observed with dull discoloration and loss of sheen, and multiple shelves inside the walk-in refrigerator were observed with dark brown and rust-colored markings. On return to the kitchen, the Plant Operations Manager observed the same surfaces and stated they were different in sheen, could not be cleaned properly anymore, and that the shelving inside the walk-in refrigerator was likely not made for refrigerators and could not be sanitized. Additional food service equipment was observed to be damaged during the kitchen tour. Two nonstick fry pans had scratches on the nonstick coating, and a manual can opener blade had significant dark discoloration along the cutting edges, consistent with buildup or corrosion. The report states the can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation. These conditions were identified in the kitchen serving meals for 93 residents.
Failure to Use Required PPE for Residents on EBP
Penalty
Summary
The facility failed to follow and maintain an effective infection prevention and control program when staff did not wear the required PPE for residents on enhanced barrier precautions (EBP). Outside Resident 79’s room, EBP signage and PPE supplies were observed at the entrance, but the Hospice Nurse entered the room, pulled the curtain for privacy, and provided direct care, including checking the resident’s skin and performing wound care on the right knee, without wearing PPE. The nurse confirmed the resident was on EBP and stated she was not wearing PPE while providing care, and also stated she was not aware the resident was on EBP. Outside Resident 68’s room, EBP signage and PPE supplies were also observed at the entrance. Restorative Nursing Assistant 1 entered the bathroom to assist Resident 68 without wearing PPE and was later observed assisting the resident in the bathroom without PPE. RNA 1 stated she did not think a gown was needed and that she only needed gloves, while the resident could clean herself. LN 5 stated that gown and gloves were needed for direct care activities, including assisting in the bathroom. The Infection Preventionist stated that for residents on EBP, staff are expected to wear gowns and gloves for high-contact care activities, including toileting and wound care, and the DON stated staff were expected to follow the protocols when an EBP sign was posted.
Call Lights Not Accessible for Two Residents With Impaired Vision
Penalty
Summary
The facility failed to ensure that the call lights were accessible for 2 of 34 sampled residents with impaired vision, Resident 19 and Resident 2. Both residents had care plans that included interventions to keep the call light within reach and to encourage them to call staff for assistance. The facility policy titled, "Answering the Call Light," stated that call lights must be accessible to residents in bed, on the toilet, in the shower or bathing facility, and from the floor. Resident 19 was admitted in 2021 with diagnoses including lung disease, muscle weakness, and blindness. His MDS dated 3/7/25 indicated he was cognitively intact and had severely impaired vision. During observation on 9/2/25, he was in bed with his breakfast tray in front of him and was touching around the tray because he could not see. He stated he could not find coffee and was waiting for his CNA. He then searched around his bed and under his pillow for his call light, stating he could not find it and that it was very frustrating. His call light was observed hanging above his head on the right side of the bed frame, lowered all the way to the floor and not accessible. RNA 2 confirmed the call light was not within reach and stated the resident was legally blind. Resident 2 was admitted in 2024 with diagnoses including kidney failure requiring renal dialysis, anxiety disorder, and legal blindness. Her record also indicated she spoke a language other than English, and her MDS showed moderately impaired cognition and highly impaired vision. During observation on 9/3/25, she was in a specialized high-back wheelchair positioned parallel to her bed, sliding down in the chair, turning her head, speaking in her native language, rubbing her right hip, and appearing uncomfortable. Her call light was observed on the bed about 3 feet away from her reach. LN 10 stated she had not checked on the resident since she returned from dialysis, confirmed the call light was not within reach, and stated the resident was unable to call for help and should have her call light within reach at all times.
Unnecessary quetiapine use without adequate indication
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medication use when Resident 42 received quetiapine without an adequate indication and without a documented rationale that addressed the drug’s risks. Resident 42 was admitted after an intracranial hemorrhage and had a history of stroke, non-Alzheimer’s dementia, difficulty walking, muscle weakness, and risk for falls and injury. After admission, the resident was diagnosed with vascular dementia with behavioral disturbance, unspecified psychosis, insomnia, and repeated falls. Resident 42 had an order for quetiapine 25 mg, including 12.5 mg in the morning and 25 mg at bedtime, and later an order for quetiapine 12.5 mg once a day and 25 mg at bedtime for mood and behavior regulation. The consultant pharmacist’s medication regimen reviews requested that the quetiapine indication be made more specific, that targeted behaviors and behavior monitoring be included, that the dose reduction related to daytime drowsiness be confirmed, and that discontinuation be considered. Another review noted seven falls in two months and identified quetiapine, trazodone, blood pressure medications, the diuretic, and gout-related medication and conditions as possible contributors, with a recommendation for reduced quetiapine dosing. During interview and observation, CNA 2 stated the resident was a fall risk, was friendly, sometimes yelled out, did not get verbally or physically aggressive, slept well at night, and slept in the wheelchair during the day. The resident was observed at the nurse’s station appearing awake but drowsy and confused to place and person. The CP stated quetiapine was prescribed for psychosis and acknowledged the black box warning for increased risk of death in dementia patients. The MD stated the resident’s vascular dementia diagnosis was based on history and assumption rather than diagnostic testing, stated the resident had active hallucinations and disorientation before quetiapine, and acknowledged the black box warning, involuntary movements, and death. The record also showed no order for monitoring hallucinations, PASRR assessments negative for serious mental illness, and the facility policy stating antipsychotics are generally used for psychosis in the absence of dementia.
Psychotropic Medication Used Without Documented Rationale for Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure a resident with vascular dementia received appropriate treatment and services when psychotropic medication was used without documented non-pharmacological interventions or a documented rationale before initiation. The resident was admitted with cerebral infarction resulting in right-sided paralysis and vascular dementia without behavioral disturbance. The resident’s MDS showed mild cognitive impairment and no indicators of psychosis, including hallucinations, delusions, or disorganized thinking. The care plan for impaired cognition included administering medications as ordered, asking yes/no questions, and cueing, reorienting, and supervising as needed. The resident was started on Seroquel for verbal aggression and verbalization of wanting to die related to unspecified dementia after nursing documented disruptive behaviors, increased restlessness, verbal aggression toward staff, and statements about wanting to die. The physician ordered Seroquel and laboratory testing to rule out UTI, and directed nursing to continue Seroquel while tests were pending. Later, the Seroquel dose was increased, but the clinical record did not contain physician documentation explaining the rationale for the increase. The record also did not show attempts to reduce the dose after the medication was started. A new diagnosis of unspecified dementia with psychotic disturbance was later added, followed by a diagnosis of unspecified psychosis, but the record did not contain documented evidence of a physician assessment or evaluation supporting psychosis. Physician notes did not document psychosis, and nursing notes reviewed over a later period did not show hallucinations, delusions, or other symptoms of psychosis. During interviews, the DON and physician acknowledged that the resident did not exhibit typical signs of psychosis and that the resident had behaviors such as yelling, screaming, repetitive requests, and attention-seeking, but the record did not show that these behaviors were evaluated as related to unmet needs or other medical conditions before the psychotropic medication was used and continued.
Controlled Medication Not Reconciled After Administration
Penalty
Summary
The facility failed to account for and reconcile administered controlled medication for one resident, who was receiving oxycodone 5 mg for pain. During observation of medication storage, the narcotics count for the resident’s oxycodone showed 8 pills remaining from a dispensed count of 15, with 6 administration entries documented in the medication cart narcotics log, leaving 1 pill unaccounted for. The controlled medication count was being performed in the hallway outside the resident’s room by LN 4. During interview, LN 4 stated the oxycodone had been administered earlier in the morning and was charted in the patient chart, but not in the narcotics log. LN 4 stated the expectation was to document medication administration and reconciliation immediately after administering the medication and that failing to do so could result in a discrepancy with oncoming staff. The MAR showed oxycodone 5 mg documented as administered by LN 4 at 6:55 a.m. The DON stated that LNs should sign the narcotics log after popping the medication. Facility policy stated that the individual who administers the medication dose records the administration directly after the medication is given, and that current controlled medication accountability records are kept in the MAR or a separate Controlled Drug binder.
Food Allergy Not Accommodated on Meal Tray
Penalty
Summary
Resident 19’s allergy to onion was not accommodated when the resident was served a meal that included mixed oriental vegetables containing onion. The resident’s meal ticket identified an onion allergy, and the ticket also indicated that the resident ate in his room and received food in bowls. Resident 19’s diagnosis included a history of being legally blind. During lunch meal plating, the menu included Orange Beef, rice, Oriental Vegetables with peppers, onions, and broccoli, a roll, and a cookie. The CDM stated that dietary staff are trained to look for food allergies listed on the meal ticket banner and expected cooks to review the allergy list and make modifications, and also stated that the nursing floor would check the meal before giving the tray to the resident to ensure the meal does not contain allergens. During the meal observation in Resident 19’s room, a CNA removed the tray from the cart and, after the survey team lifted the lids, one of the resident’s bowls was found to contain mixed oriental vegetables with onion.
Incorrect Discontinuation of Aspirin for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality for a resident when their prophylactic aspirin was discontinued incorrectly. The resident, who was initially admitted with a broken thigh bone and later readmitted with blood clots in the lungs and legs, was prescribed aspirin 81mg twice daily until December 24, 2024. However, the medication was stopped prematurely on November 24, 2024, due to a miscommunication between the physician and a licensed nurse regarding the stop date. This error was discovered after the resident was hospitalized, and the family notified the Director of Nursing (DON) about the issue. The DON confirmed that the medication administration record indicated the incorrect stop date and acknowledged the mistake. The physician also confirmed that the aspirin was intended to be continued until December 24, 2024, but was stopped earlier than planned. The facility's policy on medication and treatment orders, which emphasizes consistency with safe and effective order writing, was not adhered to in this instance, leading to the resident not receiving the prescribed aspirin as ordered.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their controlled medications, specifically oxycodone, resulting in a lack of accountability for these medications. The issue was identified when a licensed nurse (LN 2) discovered that the narcotic count for a resident was missing during a shift change. The count sheet for another resident's medication was also missing, although the medication itself was present. The night shift nurse (LN 3) confirmed that the narcotic count had been accurate the previous night, and both nurses attempted to locate the missing medication without success. Further investigation revealed that LN 1 had borrowed keys to the medication cart and subsequently altered medication orders without proper documentation. LN 1 was suspected of diverting oxycodone by placing orders, discontinuing them, and removing the medication and count sheets to cover up the discrepancies. The Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that an audit revealed 1,915 doses of oxycodone were unaccounted for, and LN 1's actions were identified as the cause of the discrepancies. The facility's policy on employee conduct was reviewed, highlighting that unauthorized possession or removal of property could lead to disciplinary action. Interviews with other licensed nurses (LN 4 and LN 5) emphasized the importance of accurate medication administration and documentation. The facility's failure to maintain accountability for controlled medications posed a risk of uncontrolled pain and suffering for residents, as the missing medications were not available for their intended use.
Unauthorized Medication Orders and Prescriptions by Nurse
Penalty
Summary
The facility failed to ensure professional standards of practice were followed when a Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents. This resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. The issue was discovered during a narcotics count when LN 2 and LN 3 noticed discrepancies in the medication count for several residents. Specifically, the medication for one resident was missing, and the count sheet for another resident was missing, although the medication was present. LN 1 had borrowed the keys to the medication cart and later informed the other nurses that the order had been discontinued and changed, without any progress notes or physician authorization. Further investigation revealed that LN 1 had created and discontinued orders, and altered count sheets without proper authorization. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that LN 1 had been entering orders into the electronic chart, writing prescriptions, and signing them without physician authorization. The facility's policy and procedure require medications to be administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The Medical Director also verified that the signatures on the prescriptions were not his, indicating falsification of documents.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications, specifically Oxycodone, for a census of 84 residents. Multiple doses and Controlled Drug Records (CDR) for Oxycodone were missing and unaccounted for. Random controlled medication audits of the Medication Administration Record (MAR) and CDRs for seven of nine sampled residents did not reconcile, indicating discrepancies in medication administration. Licensed Nurse (LN 1) was found to have entered orders, written prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents. The investigation revealed that LN 1 manipulated medication orders and records. LN 1 was reported to have borrowed keys to access medication carts, altered narcotic count sheets, and forged physician signatures on prescriptions. The Assistant Director of Nursing (ADON) and Administrator (ADM) confirmed that LN 1's actions included ordering medications, discontinuing them, and removing both the drugs and count sheets to cover up the discrepancies. This led to a significant number of Oxycodone doses being unaccounted for, raising concerns about potential abuse or misuse of these medications. The facility's policy and procedure for controlled medication storage and accountability were not followed, as evidenced by the discrepancies in the MAR and CDRs. Interviews with staff indicated a lack of adherence to the expected process of medication administration and record-keeping. The facility's failure to maintain accurate records and ensure proper authorization for medication orders compromised the safety and therapeutic needs of the residents.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage and maintenance of kitchen equipment and food items. During an inspection, several metal pans and cooking pans were found stored in the clean and ready-to-use areas while still wet and containing food debris. Some pans had significant scrapes and greasy substances on their surfaces. The Food Services Supervisor confirmed these conditions and acknowledged that the pans should be completely dried and free of debris before storage. The Registered Dietician also stated that the pans needed to be clean and dry, and those with scrapes and black substances were unacceptable. Additionally, the ice machine in the kitchen was found to be unclean, with slimy pink and black substances on various components, including the ice baffle and water curtain. These substances were easily removed with a paper towel, indicating a lack of routine cleaning. The Plant Operations Manager, who was new to the position, confirmed the presence of these substances and admitted that he had not performed any deep cleaning of the ice machine. The last recorded deep clean was several months prior, contrary to the facility's policy requiring monthly maintenance. Furthermore, outdated food items were discovered in the resident's food refrigerator located in the family room. Items such as juice, milk, sliced fruits, and protein supplements were found past their expiration dates. The Director of Nursing confirmed these items were out of date and should have been discarded. The Registered Dietician indicated that monitoring the refrigerator was the responsibility of the nursing staff. These deficiencies had the potential to lead to foodborne illness for the majority of the residents receiving facility-prepared foods.
Dishwashing Machine Fails to Meet Safety Standards
Penalty
Summary
The facility failed to maintain the dishwashing machine in safe operating condition, as it did not reach the required minimum temperatures and sanitizer concentration levels. During an interview, the Dietary Aide (DA) stated that the wash and rinse water temperatures should be at 120 degrees Fahrenheit, and the sanitizer concentration should be 100 PPM. However, observations and tests revealed that the dishwashing machine's temperatures did not reach the required 120 degrees Fahrenheit, and the sanitizer concentration was not detected. The Food Service Supervisor (FSS) confirmed these findings and noted that the machine was new, and some staff, including DA 2, had not received proper training due to being on vacation. Further investigation revealed that the dishwashing machine's temperature gauge showed inadequate temperatures, and the sanitizer test strip did not change color, indicating no sanitizer was present. The dishwashing machine company technician suggested that insufficient hot water pressure might prevent the machine from reaching the required temperature when the facility's hot water demand was high. The facility's policy required immediate reporting and correction of inadequate temperatures and sanitizer concentrations, but these measures were not effectively implemented, placing 89 out of 91 residents at risk for foodborne illness.
Failure to Conduct Annual CNA Evaluations and Competency Assessments
Penalty
Summary
The facility failed to conduct annual performance evaluations and assess staff competency in skills and techniques for five Certified Nursing Assistants (CNAs). This deficiency was identified during interviews and record reviews with the Director of Nursing (DON), Clinical Compliance Nurse (CCN), and the Administrator (ADM). The personnel records for CNAs hired between 1991 and 2022 showed no completed performance evaluations or competency assessments for the year 2024. The DON and ADM confirmed the absence of these evaluations, acknowledging that this oversight could potentially impact the CNAs' ability to provide quality care. The facility's Policy and Procedure (P&P) on the Competency of Nursing Staff, revised in October 2017, mandates that all nursing staff participate in a competency-based staff development and training program as required by state law. Despite this policy, the facility did not adhere to its guidelines, as evidenced by the lack of documentation for performance evaluations and competency assessments. The CCN admitted difficulty in locating these records, further highlighting the facility's failure to ensure that CNAs maintained the necessary skills and competencies to deliver adequate care to residents.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate during a medication administration observation. A Licensed Nurse (LN) crushed and administered uncrushable medications to a resident, specifically oxybutynin ER and pantoprazole DR, which are extended-release and delayed-release medications, respectively. These medications were listed in the facility's document as not to be crushed, as confirmed by the LN and the Director of Nursing (DON). Crushing these medications can alter their intended release and effectiveness, leading to potential side effects. Additionally, the LN failed to administer a prescribed dose of calcium-vitamin D to the same resident, as the medication was not ordered on time and was unavailable during the medication pass. The facility's policy and procedure for medication administration require medications to be administered as prescribed by the attending physician. The DON confirmed that the medication should have been ordered and available for administration as per the physician's orders.
Medication Storage Policy Violations
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several deficiencies. An expired vial of Humulin R insulin was found in a medication cart, which was confirmed by a licensed nurse and the Director of Nursing (DON) as a practice that could lead to negative resident outcomes. The facility's policy clearly states that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, this expired insulin vial was not removed, indicating a lapse in following the established procedures. Additionally, a multi-dose inhaler of fluticasone propionate/salmeterol was found without an open date label, making it impossible to determine its expiration date. The manufacturer's instructions require the product to be discarded 30 days after opening, but without an open date, this could not be verified. Furthermore, 16 pills were stored in a plastic cup without proper labeling, including the name, strength, expiration date, and lot number. The facility's policy mandates that medications be stored in their original containers with legible labels, yet this was not followed, posing a risk of administering incorrect or expired medications.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the prescribed therapeutic diets for several residents during lunch meals on specific dates. Six residents on fortified diets did not receive the required extra melted butter on their vegetables, as observed during meal distribution. Additionally, four residents on small portion diets were served incorrect portions of salmon, receiving three ounces instead of the prescribed two ounces. These discrepancies were confirmed through interviews with the Food Services Director and the Food Services Supervisor, who acknowledged the errors in portion sizes and the failure to follow the menu. Further issues were identified with residents on dysphagia mechanical soft diets. Two residents received pureed chicken instead of the required ground chicken, and another resident received an incorrect portion of broth. Additionally, a resident on a bite-size texture diet was served ground chicken instead of cubed chicken. These inconsistencies were confirmed through interviews and a review of the facility's daily spreadsheet, which outlined the specific dietary requirements for each resident. The preparation of pureed vegetables also did not follow the prescribed recipe, as the cook did not measure ingredients or drain the vegetable juice before blending. This resulted in a runny consistency, as confirmed by a Registered Dietitian who tasted the puree. The dietitian acknowledged the incorrect textures, measurements, and portion sizes provided to the residents. The facility's diet manual and job descriptions emphasize the importance of following recipes and portion control, which were not adhered to in these instances.
Deficiency in CNA Training for Abuse Prevention and Dementia Management
Penalty
Summary
The facility failed to ensure that both employed and contracted Certified Nursing Assistants (CNAs) received the required in-service training and demonstrated competency in skills and techniques necessary for abuse prevention and dementia management. Specifically, four out of seven employed CNAs and one out of two contracted CNAs lacked abuse prevention training, while two employed CNAs and both contracted CNAs had not received dementia management training. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have the necessary documentation to confirm that these trainings had been completed. During interviews, the Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of training documentation for the CNAs and CCNAs. The Clinical Compliance Nurse (CCN) noted that the facility relied on a staffing agency to provide training documentation for contracted staff, which was not available. The facility's policy required all nursing staff to participate in a competency-based training program, including abuse prevention and dementia management, upon hire and annually. The lack of documentation and training raised concerns about the CNAs' ability to provide competent care to residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure the dignity of a resident during meal assistance, as observed in the case of a resident with memory impairment and weakness. During a lunch meal, a CNA stood up while assisting the resident, contrary to the facility's policy and procedure, which emphasizes sitting beside residents to promote a dignified dining experience. The resident showed discomfort by turning her face away and attempting to push the CNA's hands away. Interviews with the CNA, a Restorative Nursing Aide, and the Director of Nursing confirmed that the expected practice is to sit beside residents during feeding to maintain their dignity and comfort. The facility's policies on dignity and resident rights, reviewed during the investigation, also support this practice, highlighting the importance of treating residents with respect and ensuring a dignified existence.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 148, who was admitted with diagnoses including anxiety, depression, and difficulty walking, did not have an activities care plan developed or implemented. Despite being alert and oriented, Resident 148, who primarily speaks Spanish, was observed to be isolated in his room without engagement in activities. Interviews with staff, including a Licensed Nurse, Certified Nursing Assistants, and the Activities Director, revealed that Resident 148 was not assessed for activities, and his language barrier was not addressed, resulting in a lack of participation in activities. Resident 4, admitted with conditions such as Parkinson's disease and osteoarthritis, had a skin laceration with staples that was not addressed in a care plan. Upon returning from the hospital, there was no documented assessment or care plan for the laceration, as confirmed by a Licensed Nurse and the Director of Nursing. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented for each resident, including assessments and interventions for new injuries, which was not followed in this case.
Failure to Update Care Plan for Resident with Hypoglycemia
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident 71, after a physician ordered an additional intervention. Resident 71 was admitted with diagnoses including an unspecified endocrine disorder, hyperlipidemia, and difficulty swallowing. The Minimum Data Set (MDS) indicated that the resident had no memory impairment and required partial assistance with activities of daily living. Despite a verbal order to check the resident's blood sugar levels as needed due to symptoms of hypoglycemia, this intervention was not documented in the resident's nutrition care plan. Observations and interviews revealed that Resident 71 expressed dissatisfaction with the food quality and variety, and reported experiencing chills, a symptom of low blood sugar, without having her blood sugar checked. Interviews with staff, including a CNA and a licensed nurse, confirmed awareness of the resident's symptoms and the physician's order for blood sugar checks. However, the licensed nurse admitted that the care plan was not updated to include this intervention. The Director of Nursing acknowledged the expectation for nurses to update care plans with new interventions, as outlined in the facility's policy on comprehensive care plans.
Failure to Adhere to Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for two residents. For Resident 4, who was admitted with conditions including Parkinson's disease and osteoarthritis, there was no documented assessment for a new laceration on the index finger. This was confirmed during a record review with a licensed nurse, who acknowledged the absence of necessary assessments and care plans for monitoring the injury. The Director of Nursing also confirmed that assessments and care plans should have been completed to monitor for infection or worsening of the injury. For Resident 65, who was admitted with pulmonary fibrosis and other conditions, the facility did not adhere to the physician's orders for oxygen therapy. The resident was observed receiving oxygen at 2.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by a licensed nurse who acknowledged the importance of following physician orders. The Director of Nursing reiterated that licensed nurses are expected to follow physician's orders as indicated. The facility's policy on administering medications also emphasized adherence to prescriber orders.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that communication needs were met for two residents, Resident 148 and Resident 40, who had language barriers. Resident 148, admitted in 2024, had diagnoses including anxiety, depression, right hip pain, and difficulty walking. The resident's care plans indicated a need for communication aids due to a language barrier, as the resident spoke only Spanish. However, during multiple observations and interviews, it was confirmed that there were no communication resources, such as a communication board, available at the bedside. Staff members, including CNAs and a licensed nurse, acknowledged the absence of these resources, which hindered effective communication with the resident. Resident 40, admitted in 2019, had severe cognitive impairment and a primary language of Taishanese. The care plan noted a communication problem related to a cerebral intracranial hemorrhage and language barrier, with a communication board specified as a tool for interaction. Despite this, observations and interviews revealed that the communication board was missing from the resident's bedside. Staff, including a CNA, licensed nurse, and the Activities Director, were unaware of the board's absence, indicating a lapse in following the care plan. The facility's policies on translation and resident rights emphasized the importance of providing communication tools for residents with limited English proficiency. However, the lack of communication resources for Residents 148 and 40 demonstrated a failure to adhere to these policies, potentially impacting the residents' ability to communicate effectively and receive appropriate care.
Failure to Provide Specialty Mattress for Resident with Stage 4 Pressure Injury
Penalty
Summary
The facility failed to provide a specialty mattress for a resident with a Stage 4 pressure injury, as required by the resident's care plan and physician orders. The resident, who was readmitted to the facility with multiple diagnoses including a Stage 4 pressure injury, was observed without a low air loss mattress, which was necessary for treating his condition. Despite the care plan and orders indicating the need for such a mattress, the resident did not receive it upon his return from the hospital. Interviews with facility staff, including a licensed nurse, the Assistant Director of Nursing, and the Director of Nursing, confirmed the absence of the required mattress. The licensed nurse indicated that the hospice was expected to provide the mattress, although the facility had one available. The Assistant Director of Nursing and the Director of Nursing acknowledged that the resident should have been provided with a low air loss mattress, as per the facility's policy and procedure for pressure ulcer care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to implement pharmaceutical policies and procedures for a resident when calcium-vitamin D was not available during a medication pass. During an observation, a licensed nurse prepared and administered the resident's medications, which did not include the prescribed calcium with vitamin D. The physician's orders indicated that the resident should receive one tablet of calcium-vitamin D twice a day. However, the medication administration record showed that the morning dose was not administered on the observed date. In an interview, the licensed nurse stated that the calcium with vitamin D was not ordered on time, resulting in its unavailability during the medication pass. The Director of Nursing confirmed that medications should be ordered on time and available as prescribed. The facility's policy and procedure documents indicated that the facility must provide routine and emergency drugs and that medications are to be administered according to the physician's written orders.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for four residents, leading to dissatisfaction with meals. Resident 19 received sausage, which she disliked, and reported never being asked about her food preferences. Her dietary profile lacked documentation of likes and dislikes, confirmed by the Food Services Director. Similarly, Resident 77 was served scrambled eggs, which she disliked, and her dietary profile also lacked documentation of preferences. The Director of Nursing expected dietary profiles to be completed with good documentation upon admission. Resident 47's meal ticket indicated a dislike for carrots, yet her meal tray included them, resulting in her not eating the meal. The Medical Record Assistant confirmed this discrepancy. Resident 3, who was underweight with poor food intake, did not receive the Healthshake and Udon soup as per her dietary orders, instead receiving tomato soup. The Food Services Supervisor and Registered Dietician confirmed the oversight. The facility was unable to provide a policy and procedure for residents' food preferences.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention practices for three residents. Resident 47's oxygen and nebulizer tubing were not labeled or dated, which was confirmed by a Licensed Nurse (LN) and the Director of Nursing (DON). The facility's policy required that all tubing be labeled and dated, and changed every seven days or as needed. This oversight was identified during an observation and interview with LN 9, who acknowledged the tubing should have been dated. Resident 63, who had a sacral wound infected with Methicillin-resistant Staphylococcus aureus (MRSA), was subject to improper infection control practices during a bandage change. LN 7 did not change gloves after cleaning the wound and touched multiple items, including a pen and bedside table, with soiled gloves. LN 6 did not sanitize the pen after it was used by LN 7. Both nurses acknowledged the lapse in protocol, and the DON confirmed that hand hygiene was expected, especially given the presence of MRSA. Resident 35's oxygen tubing and face mask were found unlabeled and undated, which was confirmed by LN 3. The Infection Preventionist (IP) and the DON both stated that equipment should be labeled and dated immediately upon change. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 678 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenhaven Healthcare Center | 1.6 mi | ★★★★★ | 27 | 0 |
| Double Tree Post Acute Care Center | 2.7 mi | ★★★★★ | 22 | 0 |
| Capital Post Acute | 3 mi | ★★★★★ | 28 | 0 |
| Cedarwood Post Acute | 3.4 mi | ★★★★★ | 0 | 0 |
| Bridgewood Post Acute | 5.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Acc Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.