Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Health Care Of Sacramento during CMS and state inspections, most recent first.
Kitchen staff were unable to properly calibrate food thermometers during meal service, with repeated failed attempts and inconsistent readings. Staff lacked knowledge of the correct calibration procedure, could not provide relevant policy guidance, and had no record of adequate training or regular calibration documentation, as required by facility policy.
A resident was given escitalopram, an antidepressant, without a documented diagnosis of depression or observed behavioral symptoms to justify its use. The resident's assessments and medical records indicated no depression, and staff interviews confirmed the absence of depressive symptoms or target behaviors. Despite this, the medication was continued, and the facility could not provide a policy on unnecessary medications.
Surveyors found that a medication refrigerator containing lorazepam and a medication cart were both left unlocked and unattended. Facility staff, including the DON and licensed nurses, confirmed these items should have been locked when not in use, as required by facility policy for medication and controlled substance security.
Kitchen waste fat was found uncovered in a silver pot on the floor near a garbage can, and an outdoor grease receptacle bin was repeatedly observed with its lid open and grease residue present. The Certified Dietary Manager confirmed the grease was from the kitchen stove's grease trap and that staff had not received training on proper disposal or pest avoidance. Facility policy required tight-fitting lids and sanitary maintenance, which was not followed.
A resident with cognitive and cardiac conditions eloped from the facility due to inadequate supervision. The individual was later found at a nearby restaurant after being reported missing, and was returned to the facility for medical assessment. The incident occurred despite the resident's dietary restrictions and the facility's policy requiring a safe environment.
The facility failed to safely store food for two residents, as food was found in room refrigerators labeled as coolers, which were not monitored for safe food temperatures. Interviews revealed inconsistencies in staff understanding and enforcement of food storage policies. The DON confirmed that room refrigerators were meant only for beverages, and any outside food should be stored in the gym refrigerator. However, some staff were unaware of these guidelines, leading to improper food storage and a potential risk of food-borne illness.
A resident's responsible party was not provided with a written notice of bed-hold when the resident was transferred to a hospital. Despite the facility's policy requiring notification, the responsible party was not informed about the bed-hold options, as confirmed by interviews with the Director of Nursing and the Admission Coordinator.
The facility failed to develop and update person-centered care plans for several residents, affecting their ability to address medical and psychosocial needs. This included missing care plans for antibiotics, psychotropic medications, and PICC line management, as well as inaccuracies in nutrition interventions. The facility's policy requires care plans to be updated as needed, which was not followed.
Nursing staff failed to follow professional standards in medication administration and IV management for four residents. A resident did not have their heart rate or blood pressure checked before receiving digoxin and midodrine. Another resident received Lovenox injections without proper site rotation. Additionally, a resident's PICC line was not monitored or had its dressing changed as required, and another resident's port-a-cath was not flushed due to missing physician orders.
A facility failed to accurately document the administration of controlled medications for a resident, leading to potential misuse. The DON confirmed discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for hydrocodone/acetaminophen, with late or missing entries. This failure to follow policy could result in harm if doses were administered without proper documentation.
A LTC facility was found to have an 18.18% medication error rate during a medication pass observation. Errors included administering medications on an empty stomach, failing to rotate injection sites, and not providing prescribed medications due to unavailability. These actions were contrary to physician's orders and manufacturer's specifications, affecting the therapeutic effect of the medications for two residents.
A resident received expired doses of insulin lispro and insulin glargine due to the failure of nursing staff to check expiration dates before administration. The facility's policies require expired medications to be discarded and replaced, but these procedures were not followed, resulting in the administration of ineffective insulin.
The facility failed to properly store and label medications, including tubersol, insulin, and inhalers, as observed during inspections of medication carts. Medications were found stored at incorrect temperatures, missing opened dates, and some were expired. Interviews confirmed these practices could risk resident safety, as facility policies on medication storage and labeling were not adhered to.
A facility failed to maintain effective infection control practices during medication administration. An LPN did not perform hand hygiene before or after glove use and did not disinfect a pill cutter after use, contrary to facility policy. These actions increased the risk of infection spread among 39 residents.
A resident experienced skin irritation and discomfort after a Licensed Nurse applied Bengay instead of the prescribed Voltaren Arthritis Pain gel. The nurse, who was busy and running behind, failed to verify the medication before application. The resident, who was cognitively intact, reported the burning sensation immediately. The Director of Nursing confirmed the error and lack of documentation, highlighting a failure to follow the facility's medication administration policy.
A resident with a history of amputation and diabetes did not receive prescribed wound care for their left heel and toe, despite documentation indicating otherwise. The DON confirmed the treatments were not completed, and a wound nurse noted unchanged bandages, highlighting a failure to follow physician orders.
A resident with a history of amputation and diabetes had worsening wounds due to a Licensed Nurse falsely documenting wound care as completed. The Director of Nursing confirmed the treatments were not performed, and a Wound Nurse observed unchanged bandages, indicating the care was not provided as ordered.
The facility failed to secure medications when a medication cart was found unlocked and unattended, with multiple people walking by. The ADON confirmed the cart was unlocked and should have been secured to prevent unauthorized access. The DON expected all medication carts to be locked when unattended, as per the facility's policy.
A resident with multiple health conditions, including heart failure and chronic kidney disease, was on a physician-ordered 1500 ml per day fluid restriction. Despite this, the resident was found with a water pitcher in their room, which they had been consuming. Staff interviews revealed a lack of communication and adherence to the fluid restriction policy, as the CNA was unaware of the specific order and did not measure the water provided. The DON confirmed the failure to follow the physician's order and the absence of necessary signage in the resident's room.
Failure to Ensure Proper Thermometer Calibration and Staff Training in Food Safety
Penalty
Summary
The facility failed to ensure that food preparation was conducted in accordance with professional standards for food service safety. During a lunch tray line observation, kitchen staff, including the lead cook and certified dietary manager, were unable to properly demonstrate or verbalize the correct procedure for calibrating food thermometers. Multiple attempts to calibrate digital thermometers using the ice bath method resulted in inconsistent and inaccurate readings, with staff unable to achieve the required 32°F reading. Staff also could not provide a relevant policy for reference during the observation and acknowledged their inability to properly calibrate thermometers. Further review revealed a lack of documented staff education or in-service training on thermometer calibration, with only two sporadic entries on an emergency calibration log and no ongoing monthly temperature data. The facility's written policy required monthly calibration using the ice point method, specifying a 30-second wait time for an accurate reading, which staff did not follow. Both the certified dietary manager and registered dietician confirmed the absence of adequate staff training and documentation related to thermometer calibration, as well as the expectation that staff should be knowledgeable about proper food temperature controls.
Administration of Antidepressant Without Justified Diagnosis or Symptoms
Penalty
Summary
A deficiency occurred when a resident was administered an antidepressant medication, escitalopram, without a corresponding medical diagnosis or documented behavioral symptoms to justify its use. The resident was admitted with a diagnosis of anxiety disorder, but there was no diagnosis of depression documented in the Minimum Data Set (MDS), physician progress notes, or the problem list. The MDS assessment indicated no symptoms or behaviors of depression, and the depression screening was negative. Despite this, a physician's order was written for escitalopram with the indication of depression, citing 'verbalized sadness' as the target behavior, but the Treatment Administration History Record showed that this behavior did not occur during the review period. Further review of the Medication Regimen Review raised concerns about the lack of a documented indication for escitalopram, noting that depression was not listed in the resident's problem list and the history and physical stated the depression screening was negative. Interviews with facility staff, including the MDS Coordinator, a licensed nurse, and the DON, confirmed that the resident did not have a diagnosis of depression and that no target behaviors were observed or documented. The facility's policy on comprehensive care planning was reviewed, but a policy on unnecessary medications was requested and not provided.
Failure to Securely Store Medications and Controlled Substances
Penalty
Summary
Surveyors observed that the facility failed to ensure the secure storage of medications and controlled substances. During an inspection of the medication storage room, the refrigerator containing lorazepam, a controlled substance, was found unlocked and unattended, despite facility policy requiring such items to be double-locked and accessible only to authorized personnel. The Director of Staff Development and the Director of Nursing both confirmed that the refrigerator should have been locked when not in active use to prevent unauthorized access. Additionally, a medication cart was found unlocked and unattended. Licensed nurses present at the time acknowledged that the cart should have been locked when not attended, in accordance with facility policy. Review of the facility's medication storage policy confirmed that all drugs and biologicals must be stored in locked compartments, with controlled substances under double lock, and that medication rooms and carts must be locked or attended by authorized staff.
Improper Disposal and Storage of Kitchen Grease and Refuse
Penalty
Summary
The facility failed to maintain sanitary conditions in both indoor and outdoor refuse areas, as observed during multiple kitchen tours. In the Receiving Room, a one-gallon uncovered silver pot, half-filled with thick yellow liquid from the kitchen stove's grease trap, was found on the floor near a garbage can. Additionally, outside dumpsters were found with their doors open, and a green rigid plastic receptacle bin was observed with its lid open. Large amounts of old, dried, and wet yellow grease and food particles were adhered to the grated opening of the bin. On a subsequent observation, the same bin was again found with its lid open, and the silver pot was turned upside down over the grated opening. During interviews, the Certified Dietary Manager (CDM) confirmed that the silver pot was used to collect grease from the kitchen and was stored in the Receiving Room for convenience before being disposed of in the outside receptacle. The CDM acknowledged that staff had not received in-service training related to grease or garbage disposal or pest avoidance, and there was uncertainty regarding the facility's garbage/refuse disposal policy. The facility's policy and procedure required containers to have tight-fitting lids and to be maintained in a sanitary manner, which was not followed in these instances.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of a resident who eloped from the building. The resident, who had diagnoses including toxic encephalopathy and congestive heart failure, was admitted with a diet order for pureed texture and mildly thick liquids. On the day of the incident, a CNA notified a nurse that the resident was missing. A thorough search of the resident's room, the building, and staff rooms was conducted, but the resident could not be located. Facility management reviewed surveillance cameras and confirmed that the resident had left the building and was seen heading east. The resident was later found inside a local restaurant approximately 0.4 miles from the facility by the Administrator in Training. The restaurant staff had contacted emergency services due to the resident appearing confused. Upon return to the facility, the resident was medically assessed, including for aspiration risk due to consumption of non-thickened liquids. The Director of Nursing confirmed that the resident was not their own responsible party and reiterated the resident's dietary restrictions. The facility's policy states that residents have the right to a safe environment, but the lack of adequate supervision allowed the resident to leave the premises unsupervised.
Improper Food Storage in Resident Room Refrigerators
Penalty
Summary
The facility failed to safely store food for two residents, as food was found in room refrigerators labeled as coolers, which were not monitored for safe food temperatures. Resident 2, admitted with multiple diagnoses including metabolic encephalopathy and hemiplegia, had an open cup of applesauce and a container of chocolate pudding in their room refrigerator. Similarly, Resident 5, who had undergone orthopedic aftercare following an amputation and had other health issues, had a container of fruit salad in their room refrigerator. Both refrigerators had signs indicating they were for drinks only, and no food storage was permitted. Interviews with staff revealed inconsistencies in the understanding and enforcement of food storage policies. A CNA mentioned that room refrigerators were not used for outside food except for protein shakes, and snacks were to be discarded after one day if opened. However, the housekeeper stated that she did not discard items unless the resident was discharged. The DON confirmed that room refrigerators were meant only for beverages and that any outside food should be stored in the gym refrigerator, which was monitored for temperature. Despite this, some staff, including LN 2 and LN 3, were unaware of these guidelines and believed snacks could be stored in room refrigerators. The facility's policies on food storage and handling from outside sources were not effectively implemented. The policy indicated that food should be stored at appropriate temperatures to prevent contamination, and food from outside sources should be monitored and stored correctly. However, there was no policy for monitoring room refrigerator temperatures, as they were not intended for food storage. This lack of monitoring and enforcement of food storage policies led to the deficiency, as food was improperly stored in room refrigerators, posing a risk of food-borne illness to residents.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed-hold to a resident's responsible party (RP) at the time of the resident's transfer to a hospital. This deficiency was identified for one of the three sampled residents. The resident, who was admitted to the facility with hypertensive heart disease and generalized weakness, was transferred to the hospital due to low oxygen levels. Despite the transfer, there was no documented evidence that the resident's RP was informed in writing about the bed-hold policy, which is a requirement according to the facility's policy. Interviews with the resident's RP and facility staff, including the Director of Nursing (DON) and the Admission Coordinator (AC), confirmed that the RP did not receive any written notice or information regarding the bed-hold options. The AC, who was responsible for notifying residents or their RPs about bed-hold notices, admitted that the RP was neither called nor offered a bed-hold. The facility's policy mandates that the RP should be notified about the bed-hold option when a resident is transferred to acute care, but this procedure was not followed in this case.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, which compromised their ability to meet the residents' medical, physical, mental, and psychosocial needs. For Resident 32, despite being prescribed Augmentin for a urinary tract infection, there was no care plan developed to monitor the effectiveness of the antibiotic or any potential adverse side effects. This was confirmed by the Minimum Data Set Nurse during a record review. Resident 22's care plan lacked interventions for the management of a PICC line and the use of psychotropic medication, despite having orders for both. Similarly, Resident 186's care plan inaccurately included interventions for tube feedings and IV fluids, which were not part of the resident's treatment. Resident 189's care plan also failed to include necessary interventions for a PICC line, while incorrectly listing tube feedings and IV fluids. Resident 191's care plan did not incorporate the use of multiple psychotropic medications prescribed for schizophrenia and depression. Additionally, Resident 1's comprehensive care plan did not reflect the prescribed Alzheimer's medication, rivastigmine, despite its inclusion in the physician's orders. The Director of Nursing confirmed the omission of this medication from the care plan. The facility's policy mandates that care plans be updated as needed, reflecting changes in conditions, goals, and interventions, which was not adhered to in these cases.
Medication and IV Management Deficiencies
Penalty
Summary
Nursing staff at the facility failed to adhere to professional standards of quality in the administration of medications and management of intravenous lines for four residents. For Resident 26, the nursing staff did not check the heart rate or blood pressure before administering digoxin and midodrine, despite physician orders specifying these parameters. This oversight occurred during a medication pass observation, where the licensed nurse acknowledged the failure to perform the necessary checks. Resident 392 received Lovenox injections without proper site rotation, contrary to the manufacturer's specifications. The nurse administered the injection in the same location on consecutive days, which could lead to bruising or scar tissue formation. The Director of Nursing confirmed that site rotation is essential to prevent these issues and ensure proper medication absorption. For Resident 22, the nursing staff did not obtain necessary physician orders for monitoring and changing the dressing of a PICC line, which is crucial for preventing infection. Similarly, Resident 537's port-a-cath was not flushed as required, and there was no physician order for this procedure. The facility's policy mandates daily flushing of accessed ports, but this was not documented or performed, as confirmed by the nursing staff and the Director of Nursing.
Inaccurate Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accounting of controlled substance medications for a resident, leading to potential misuse or abuse. The Director of Nursing (DON) confirmed that the expectation was for nurses to sign out controlled medications from the Controlled Drug Record (CDR) and document their administration on the Medication Administration Record (MAR). However, discrepancies were found in the records for a resident prescribed hydrocodone/acetaminophen for pain management. On multiple occasions, the CDR indicated that doses were removed from the medication cart, but the MAR either showed late documentation or no documentation at all, indicating a lack of accurate record-keeping by the nursing staff. The specific instances of inaccurate documentation included late entries for doses administered and missing entries for doses removed from the cart. For example, on one occasion, a dose was removed at 1 a.m., but the MAR was not updated until over four hours later. Similarly, another dose was removed at 7:57 p.m., but the MAR was updated over three hours later. The DON acknowledged these inaccuracies and stated that the failure to document at the time of administration could result in harm to the resident if another dose was given without knowledge of the previous administration. The facility's policy required immediate documentation after medication administration, which was not followed in these instances.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have an 18.18% medication error rate during a medication pass observation, which is significantly higher than the acceptable threshold of 5%. The errors involved two residents, with multiple instances of medications not being administered according to the prescriber's orders or manufacturer's specifications. For Resident 26, a licensed nurse (LN 1) administered Macrobid and potassium chloride on an empty stomach, contrary to the requirement to give these medications with food to improve absorption and reduce adverse effects. Additionally, LN 1 failed to remove a lidocaine patch after 12 hours as per the physician's order, risking lidocaine toxicity. For Resident 392, LN 1 administered Lovenox injections in the same site on consecutive days, contrary to the requirement to rotate injection sites to prevent bruising and scar tissue formation. Furthermore, LN 1 did not administer Trelegy Ellipta and Metamucil as they were not available in the medication cart, despite physician's orders for these medications. The Director of Nursing (DON) confirmed that nursing staff were expected to follow the provider's instructions and manufacturer's specifications when administering medications. The report highlights the failure of the nursing staff to adhere to medication administration protocols, which resulted in residents not receiving the full therapeutic effect of their medications. The DON and Pharmacy Consultant emphasized the importance of following special instructions and rotating injection sites to ensure proper medication absorption and prevent adverse effects. The facility's policy and procedure on medication orders also stressed the need for clear and complete orders, which were not followed in these instances.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they administered expired insulin to one of the sampled residents. During an inspection of a medication cart, it was discovered that insulin lispro and insulin glargine vials for a resident were past their expiration dates. The Licensed Nurse confirmed that the insulins had expired, and a review of the resident's medical record showed that the resident received seven doses of expired insulin lispro and four doses of expired insulin glargine over several days. The Director of Nursing stated that nursing staff are expected to check expiration dates before administering medications, and confirmed that expired insulin would not be effective in controlling blood sugar. The facility's policy and procedure documents also indicated that expired medications should be discarded immediately and replaced. However, these procedures were not followed, leading to the administration of expired insulin to the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during an inspection of medication carts. On Medication Cart 2, a vial of tubersol was found stored outside the refrigerator, contrary to the manufacturer's instructions, which require refrigeration to maintain effectiveness. Additionally, an Evencare G3 vial of test strips was missing an opened date, and two vials of insulin were not discarded after the recommended 28 days. A Breo Ellipta inhaler was also found without an opened date, and several expired medications, including tubersol and Pepto Bismol, were identified. On Medication Cart 3, similar issues were observed, including an Evencare G3 vial of test strips without an opened date and expired control solutions. An Arnuity Ellipta inhaler and a vial of Rocklatan eye drops were found open and unlabeled with opened dates. An albuterol inhaler was found without a pharmacy label or patient name, only marked with a room number, which is inadequate for proper identification. An expired bottle of acetaminophen was also noted. Interviews with the Director of Nursing and the facility's Pharmacy Consultant confirmed that these practices could place residents at risk if expired medications were administered. The facility's policies and procedures require multi-dose vials to be dated upon opening and discarded within specified timeframes, and medications requiring refrigeration to be stored accordingly. However, these protocols were not followed, leading to the deficiencies noted in the report.
Infection Control Lapses in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Licensed Nurse 1 (LN 1) during medication preparation and administration. LN 1 was observed not performing hand hygiene before or after donning gloves while administering medications to two residents. This practice was contrary to the facility's policy, which requires hand hygiene before and after glove use. Interviews with LN 1, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that hand hygiene was expected between residents, before treatment, and before and after glove use. The failure to adhere to these protocols increased the risk of infection spread among residents, visitors, and staff. Additionally, LN 1 did not sanitize or disinfect the pill cutter after use, merely wiping it with a gloved hand before using it again. This action was against the facility's policy, which mandates that equipment for medication administration be thoroughly cleaned and properly stored after each use. The IP and DON both acknowledged that the pill cutter should have been disinfected after each use to prevent potential harm from medication residue. These lapses in infection control practices placed 39 residents at increased risk of infections.
Medication Administration Error Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards when a resident did not receive the prescribed medication, Voltaren Arthritis Pain gel, as ordered by the physician. Instead, a Licensed Nurse (LN) applied Bengay Extra Strength, which was not prescribed for the resident. This error occurred when the LN, who was reportedly busy and running behind, grabbed the wrong cream from the cart without verifying it against the resident's medication order. The resident immediately experienced a burning sensation and reported the issue to the LN, who admitted to not checking the medication properly. The resident, who was cognitively intact and able to communicate effectively, suffered from skin irritation, redness, and sensitivity in the areas where the Bengay was applied. The Director of Nursing (DON) confirmed that there was no medical order for Bengay for this resident and that the application of the wrong medication was not documented in the resident's medical record or the facility's documents. The facility's policy on medication administration, which requires verification of the right patient, drug, dose, dosage form, route, and time, was not followed, leading to this deficiency.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident, resulting in a deficiency related to wound care. The resident, who was admitted with diagnoses including orthopedic aftercare following a right below-knee amputation and diabetes with a foot ulcer, had specific physician orders for wound care on the left lateral heel and left first toe. These orders included cleansing with normal saline, applying a skin protectant barrier, and covering with a foam dressing for the heel, and cleansing with normal saline and painting with betadine for the toe. The orders specified that these treatments should be performed daily and monitored for signs of infection. Despite documentation by a licensed nurse indicating that the treatments were completed on two specific days, an interview with the Director of Nursing confirmed that the treatments were not actually performed on those days. Additionally, a wound nurse reported that the bandages he applied on a previous day remained unchanged when he returned to work, indicating that the treatments had not been conducted as documented. This failure to provide the ordered wound care had the potential to worsen the resident's wounds, as noted in the progress notes when the resident was sent back to the hospital for treatment.
False Documentation of Wound Care in LTC Facility
Penalty
Summary
The facility failed to ensure accurate clinical records for a resident when a Licensed Nurse (LN 1) falsely documented that she completed the ordered wound care. This deficiency was identified during an investigation into allegations of wound care not being provided as ordered and falsely documented as completed. The resident, who was admitted with diagnoses including orthopedic aftercare following a right below-knee amputation and diabetes with a foot ulcer, had a worsening wound condition that required hospital treatment. Physician orders specified daily wound care for the resident's left lateral heel and left first toe, which included cleansing, applying skin protectant, and monitoring for signs of infection. Despite these orders, LN 1 documented that she completed the wound treatments on two specific dates, although the Director of Nursing confirmed that the treatments were not performed. A Wound Nurse, who was responsible for the resident's wound care on a prior date, noted that the bandages with his initials remained unchanged when he returned to work, indicating that the treatments had not been done. The facility's policy and procedure for patient care required that treatments be delivered as ordered and documented accurately in the medical record at the time of occurrence.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the security of medications for a census of 38 residents when a medication cart was found unlocked and unattended. During an observation on June 7, 2024, at 11:05 a.m., the medication cart was positioned against the wall between two resident rooms, left unattended and unlocked, with multiple people passing by. This was confirmed during a concurrent observation and interview with the Assistant Director of Nursing (ADON) at 11:25 a.m., who acknowledged that the cart containing prescription medications was unlocked and stated that it should have been locked to prevent unauthorized access. Further confirmation came from an interview with the Director of Nursing (DON) at 1:10 p.m. on the same day, who expressed the expectation that all medication carts with prescribed medications should be locked when unattended for safety reasons. A review of the facility's policy titled 'Medication-Storage,' dated September 28, 2022, indicated that medication rooms, carts, and supplies are to be locked or attended by authorized personnel.
Failure to Adhere to Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to professional standards of care for a resident who was on a physician-ordered fluid restriction. The resident, admitted with multiple diagnoses including coronary artery bypass grafting, hypertensive heart, and chronic kidney disease with heart failure, was ordered a 1500 ml per day fluid restriction. Despite this, the resident was found with a water pitcher and a cup filled with clear liquid in his room, which he had been consuming. This was contrary to the facility's policy that patients on fluid restrictions should not have water pitchers in their rooms. Interviews with staff revealed a lack of communication and adherence to the fluid restriction order. A registered nurse confirmed the presence of the water pitcher and acknowledged that the fluid intake documentation would be inaccurate due to the unmeasured liquids. The certified nursing assistant admitted to bringing the water pitcher into the room without measuring the water, and was unaware of the specific fluid restriction order. The director of nursing confirmed that the fluid restriction was not followed as per the physician's order and that the room lacked the necessary signage to indicate the restriction. The facility's policy on fluid restrictions was not followed, as evidenced by the presence of unmeasured fluids at the resident's bedside and the lack of proper communication among staff. The policy stated that no water should be provided at the bedside unless calculated into the daily total fluid restriction, and that both nursing and dietary departments were responsible for documenting fluid intake. The failure to follow these procedures resulted in a deficiency in meeting the professional standards of care for the resident.
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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.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherwood Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Mckinley Park Care Center | 1.7 mi | ★★★★★ | 31 | 0 |
| Mid-town Oaks Post-acute | 1.9 mi | ★★★★★ | 25 | 0 |
| Saylor Lane Healthcare Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Pioneer House | 2.7 mi | ★★★★★ | 22 | 0 |
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