Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Ahmc Seton Medical Center during CMS and state inspections, most recent first.
Failure to Raise Bed Rail During Care Led to Resident Fall and Femur Fracture. A resident with dementia, impaired cognition, and total dependence for ADLs fell out of bed during ADL care after two CNAs left the bedside without raising the side rail. The resident later had pain, grimacing with movement, and x-ray findings of a non-displaced impacted fracture through the right femur; RN and DON interviews confirmed the rail should have been up when the resident was in bed.
The facility failed to ensure adequate dietary oversight when the Interim Dietary Director, who oversaw the kitchen, did not ensure auditing of dish machine and cooling logs. Review showed repeated dish machine final rinse temperatures below the required range and missing temperature documentation, along with multiple cooling log entries where foods such as porridge, gravy, tomato soup, and rice were not cooled and rechecked within required timeframes. The Interim Dietary Director and a Diet Clerk both acknowledged there was no supervisor auditing the logs and that cooling procedures were not being followed.
QAPI oversight was not demonstrated when the facility's meeting minutes only noted "Continue with POC" and did not show how the plan of action was being implemented to address identified deficiencies. The CCQO stated the DON and Manager of the Subacute were responsible for implementation, while an RN stated staff were not made aware of the approved POC and did not know what had been added to it. The facility's QAPI plan stated the Governing Body has ultimate responsibility for the QAPI plan and care provided, and that the Quality, Risk, Safety, and Compliance Dept maintains oversight of the organization-wide QAPI program.
The facility failed to carry out its QAPI process to address multiple deficiencies, including late reporting and incomplete investigation of an abuse allegation involving a resident, delayed reporting of investigation results for abuse allegations involving multiple residents, and lack of follow-through after a resident had significant weight loss. The facility also had incomplete POLST documentation for a resident, failed to complete hand hygiene audit logs as stated, and did not follow its belongings inventory process, with undated or unsigned belongings records for some residents.
Kitchen staff failed to maintain safe food storage and sanitation practices. Unlabeled and expired butter was found in the refrigerator, expired lasagna was stored in the kitchen, and ice cream was kept in a freezer at 35 F and was not frozen hard. Dishmachine logs showed multiple days when the final rinse did not reach 180 F and other days with no temperature documentation, and cooling logs showed cooked foods were not cooled per procedure, with delayed checks and incomplete entries.
A resident with moderate cognitive impairment and vascular dementia had a cellphone, documented on their belongings inventory, go missing. Despite the facility's policy requiring replacement of inventoried items, the cellphone was not replaced after staff were unable to locate it, and the Social Worker did not arrange for a replacement as required.
Incomplete and conflicting POLST documentation was found for two residents. One resident with dementia and other cognitive diagnoses had no advance directive in the chart, while the active order listed FULL CODE - DNR - Comfort Focused Treatment and the POLST was undated and showed DNR and Selective Treatment, creating inconsistent code status documentation. A second resident with PVD, stroke, and functional quadriplegia had an undated POLST missing required resident, MD/NP, and legally recognized decision maker information, and RN confirmed the form was not fully completed.
Failure to Thoroughly Investigate Alleged Abuse: A resident who was cognitively intact and required 2-person assistance reported that a CNA awakened her, complained about her care, and tagged, pushed, and grabbed her while another CNA present did not intervene. SSD documentation noted the resident said the CNA held her tightly and appeared mad, while the DON said she checked the resident's hand and found nothing. The facility's investigation summary showed the MD was notified and ordered monitoring for the resident's upset feelings, but the order was not carried out and monitoring was not started.
Late Significant Change in Status Assessment: A resident with stroke, G-tube status, HTN, kidney disease, osteoarthritis, and adult failure to thrive had a significant change in status after readmission with a G-tube. The MDS SCSA was completed 4 days late, and the MDSC confirmed it should have been completed within the required 14-day timeframe after the IDT determined the resident met SCSA criteria.
Inaccurate MDS omitted osteopenia after fracture event. A resident’s MDS did not include osteopenia even though imaging after a fall out of bed showed a right femur fracture and osteopenia. The MDSC acknowledged the omission and stated osteopenia is significant because the resident is at risk for injury and fracture.
A resident with dementia, DM, and HTN fell out of bed and sustained a right femur fracture; imaging also showed osteopenia. The MDS did not identify osteopenia, and the MDSC acknowledged there was no comprehensive care plan addressing the condition, despite the facility policy requiring individualized care planning based on nursing assessment and physician notes.
A resident with CHF, schizophrenia, schizoaffective disorder, dyskinesia, and dementia had repeated meal refusals and self-imposed fasting, with documented significant weight loss. The facility did not complete a change of condition report, did not develop a care plan for the weight loss, did not follow its weekly weight monitoring policy, and had no documented RD follow-up assessment or interventions.
An LVN failed to perform hand hygiene between glove changes during med pass. While preparing meds in a resident room, the LVN removed gloves, checked the computer, and donned a new pair of gloves without cleaning her hands. The LVN acknowledged she forgot hand hygiene and knew it should be done before putting on new gloves. The facility’s hand hygiene policy required hand sanitation before and after med prep/admin, before gloves, and after glove removal.
Failure to Timely Report Abuse Allegation: A resident developed a reddish discoloration under the left eye that the son questioned as possible abuse. Staff began investigating, but the allegation was not reported right away and was instead delayed until later documentation and reporting. The NM acknowledged the report should have been made within 2 hours, and an RN stated it was not reported because the son was satisfied with the plan of care.
A resident with significant cognitive and physical impairments experienced four falls, including one resulting in multiple toe fractures, due to the facility's failure to consistently investigate fall causes, conduct required fall risk assessments, and ensure proper use and evaluation of fall prevention devices. Staff did not always implement care plan interventions, and documentation regarding the use and function of alarms was unclear or missing.
The facility did not provide written bed hold notices to four residents or their responsible parties when the residents were transferred to a hospital. Instead, notifications were either verbal or not given, and there was no documentation in the EHR to show that written notices were provided. The residents had various diagnoses, and their responsible parties reported not receiving information about bed hold rights or the option to return after hospitalization.
A resident's grievance regarding tube feeding administration was not thoroughly investigated. The facility failed to recognize that the ordered feeding rate exceeded the pump's maximum capacity, did not clarify unclear physician orders, and did not measure the actual amount of formula delivered. Staff were unaware of the pump's error rate, and the facility did not provide required follow-up or written notification to the complainant or ombudsman, resulting in unresolved concerns.
A resident assessed as high risk for pressure ulcers developed a Stage 2 ulcer due to the facility's failure to implement necessary interventions, such as timely provision of a low air loss mattress and appropriate offloading measures. The resident's condition worsened due to lack of communication and timely reporting of skin condition changes.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. One resident experienced side effects from Haldol without a dosage reduction, another was given Citalopram without a clinical indication, and a third was administered Risperdal without a proper diagnosis. Additionally, PRN orders for Ativan lacked stop dates and specific frequencies.
Facility staff failed to treat three residents with dignity by not responding to their call lights in a timely manner. Residents reported waiting 30-45 minutes for assistance, and staff interviews confirmed that the facility had issues with staffing and timely response to call lights.
The facility failed to inform residents about the grievance process and did not ensure grievances were resolved appropriately. Seven residents were unaware of the grievance process, and one resident reported missing personal items with no satisfactory resolution provided by the facility.
The facility failed to ensure accurate MDS assessments for three residents. One resident's dental status was incorrectly recorded, another's hemodialysis treatment was not documented, and a third resident's pressure ulcers were inaccurately coded. These errors were confirmed by staff interviews and record reviews.
The facility failed to develop comprehensive care plans for seven residents, leading to unmet nursing needs and goals. Issues included unfit dentures, use of medications like Lovenox and Zolpidem, undocumented use of gloves and alarms, unaddressed planned weight loss, unaddressed extreme fear, and inaccurate dialysis access documentation.
The facility failed to provide preventive treatment and services to maintain and improve ROM for four residents when the physician's order for ROM exercises was not implemented. Observations and record reviews revealed inconsistent documentation and performance of ROM exercises, leading to potential complications such as contractures.
The facility failed to maintain a sanitary environment by not properly cleaning a fixed kettle between uses and having uncovered drainage holes encrusted with food particles on prep tables. Dietary staff admitted to insufficient cleaning practices, contrary to the facility's policy.
The facility failed to provide community dining and activity areas on the 4th, 5th, and 7th floors, confining residents to their rooms for meals. Observations showed no common areas on these floors, and the shared room on the 9th floor was insufficient for the residents' needs. Interviews indicated no current plans for additional dining areas.
The facility failed to ensure a shower area was clean after use and that two window screens were properly maintained. The shower room was found with hair, empty bottles, a safety razor, an opened body wash bottle, and used gloves. Additionally, two rooms had missing window screens, which the RN acknowledged and stated would be fixed by maintenance.
The facility failed to act on the pharmacy consultant's recommendation regarding the use of psychotropic medication for a resident with mood disorder and major depressive disorder. Despite identified irregularities in the medication regimen review, no corrective action was taken by the physician or nursing staff, potentially exposing the resident to unnecessary medications and adverse health consequences.
The facility failed to maintain accurate records for three residents, leading to potential mismanagement of their care. Staff did not accurately document fluid intake for a resident with unplanned weight loss and another on fluid restriction. Additionally, the target behavior for a resident with bipolar disorder was incorrectly documented.
The facility failed to document vaccine education and follow-up for two residents, resulting in missing records of pneumovax vaccine administration, refusal, and education. An RN confirmed the absence of this information during a review.
The facility failed to document COVID-19 vaccine education and follow-up or refusals for two residents. One resident had no documentation of COVID-19 vaccine administration, refusal, or education, while another had no documentation for both COVID-19 and pneumovax vaccines. An RN confirmed the missing information during a record review.
An emergency cart's red plastic lock tag did not match the log book entry, and the facility's policy failed to address the responsibility of floor staff in documenting these checks, potentially compromising emergency readiness.
The facility failed to have a secure handrail in their corridor. During an initial tour, a handrail outside a room was found not secured properly to the wall. This observation was confirmed with an RN, who stated she would inform maintenance. The lack of a secure handrail did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall.
Failure to Raise Bed Rail During Care Led to Resident Fall and Femur Fracture
Penalty
Summary
The facility failed to ensure that a resident’s bed/side rail was raised while the resident was in bed. Resident 97 had diagnoses including dementia, diabetes, and hypertension, and the MDS indicated moderately impaired cognition with poor decision-making and supervision required. The resident was dependent for all ADLs, including bed mobility and transfers. The care plan identified the resident as at risk for falls or injury and included interventions to keep the bed/side rails up when the resident was in bed and to anticipate the resident’s needs. The facility also had informed consent for bedrail use on file. During the investigation of a fall event, the IDT notes indicated that Resident 97 fell out of bed during ADL care because two CNAs did not put the side rail up when they left the bedside. The facility investigation stated the CNAs heard a thump while in the bathroom and found the resident on the floor, then transferred the resident back to bed and continued care. The resident later complained of pain and was sent to the ED. The investigation further documented grimacing with leg movement and when the right hip was touched, and x-ray results showed a non-displaced impacted fracture through the right femur and osteopenia. RN and DON interviews confirmed that the side rails should have been raised when the resident was in bed.
Dietary Oversight and Food Safety Log Failures
Penalty
Summary
The facility failed to ensure the Interim Dietary Director, who is also the registered dietitian and oversees the kitchen, was fully sufficient when auditing of dish machine logs and cooling logs was not being done in the kitchen. During observation and interview, the dish machine was reviewed with the Interim Dietary Director, who stated the machine was a high-temperature dishwasher and that the wash temperature should be at least 160 F and the final rinse temperature should be at least 180 F. Review of the DISHMACHINE TEMPERATURES logs showed multiple dates in June 2025 and August 2025 when the final rinse temperature did not reach 180 F, and additional dates when wash and rinse temperatures were not documented at all. The Interim Dietary Director acknowledged that the temperatures did not reach the required level and stated there was no supervisor below her to audit the logs. Review of the facility’s FOOD SAFETY STANDARDS and IC 8-F: INFECTION CONTROL-NUTRITION AND FOOD SERVICES policies showed the dishmachine final rinse was required to be 180 F to 195 F and that wash and rinse temperatures should be checked for adequacy before use. The organizational chart showed a food service supervisor should be under the Interim Dietary Director, but interviews with the Interim Dietary Director and Diet Clerk II confirmed there was no supervisor in place to audit the logs. Diet Clerk II stated nobody was auditing the DISHMACHINE TEMPERATURES or COOKING AND COOLING LOG to verify that kitchen staff were checking the correct temperatures. The COOKING AND COOLING LOGS reviewed in July and August 2025 showed multiple instances where cooling procedures were not followed. Several foods, including porridge, gravy, tomato soup, and rice, were not checked within the required timeframes, and temperatures remained above the required cooling thresholds during the documented checks. The Interim Dietary Director acknowledged that the kitchen staff did not follow cooling procedures, that the instructions on the cooling log were not correct, and that the logs were confusing. She also stated that the dish machine not reaching the required final rinse temperature could spread infection to the entire facility.
QAPI Oversight Not Demonstrated
Penalty
Summary
The facility failed to ensure governing body oversight of its QAPI program and activities when the plan of action to correct identified deficiencies was not implemented and maintained. Review of the QAPI Meeting Minutes from September 2025 through November 2025 indicated only, "Continue with POC," and the minutes did not show any oversight of how the plan of action was being implemented to address the identified deficiencies. During an interview on 12/10/25 at 4:40 PM, the CCQO stated that the DON and Manager of the Subacute were responsible for implementing the plan of correction. During an interview on 12/11/25 at 11:37 AM, RN 2 stated that staff were not made aware of the facility's approved plan of correction and did not know what needed to be implemented in the POC, stating, "I don't know what was added in the POC." The facility's revised QAPI plan stated that the Governing Body has ultimate responsibility for the QAPI plan and the care provided, and that the Quality, Risk, Safety, and Compliance Department maintains oversight of the ongoing organization-wide QAPI program.
Failure to Implement QAPI and Correct Multiple Deficiencies
Penalty
Summary
The facility failed to identify ongoing systemic issues and failed to develop, implement, and evaluate its plan of action to correct multiple cited deficiencies. The report states that the facility did not report an alleged abuse incident involving Resident J within the required 2-hour timeframe and did not conduct a thorough investigation of that allegation. It also did not report the results of investigation within five working days for two abuse allegations involving Resident J, Resident L, and Resident M. During interview, the DON stated the allegation was not reported on time because Resident J's allegation was not clear to her, and later confirmed that the investigation result was not completed and faxed to CDPH within the required timeframe. The facility also failed to evaluate, develop, and implement interventions after Resident A was identified with significant weight loss. Review of Resident A's record showed no documentation of a change of condition, nutritional assessment, or care plan after the weight loss on 10/7/25. RN 1 confirmed that although there was a care plan for risk for altered nutrition status, none of the interventions addressed the resident's actual weight loss, and that a change of condition, care plan update, and weekly weights should have been completed. Additional deficiencies involved incomplete or inaccurate documentation and failure to follow stated audit processes. The facility did not ensure a valid copy of Resident 5's POLST contained complete and accurate information; the DON confirmed the physician/nurse practitioner/physician assistant signature and date, as well as the legally recognized decision maker's signature and mailing address, were blank. The facility also failed to ensure hand hygiene was performed between resident care, and audit logs were not completed as stated in the plan of correction. In the belongings review, the facility did not follow its own process for resident valuables: the ADON stated staff checked resident rooms rather than reviewing the belongings inventory as instructed, and Resident E and Resident F had undated belongings records without signatures from the resident/responsible party and witness. Residents D, E, and F stated they did not have copies of their belongings records.
Kitchen Food Storage, Dishwashing, and Cooling Failures
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food service practices in the kitchen. During observation, multiple small packs of butter were found in a black container in the refrigerator with no expiration dates, and additional butter packs in a stainless-steel container were labeled with a Use By date of 7/26/25 even though the date had passed. Staff acknowledged that the butter was expired and should not be used. In the kitchen storage room, six packs of MY OWN MEAL FLORENTINE LASAGNA were found with a Best By date of 07/2025, and staff acknowledged that all six packs were expired and should not be used. The kitchen’s ice cream freezer was observed at 35 F, and the ice cream inside was not frozen hard. The strawberry and vanilla ice cream packs were soft and squishy, and some leaked when pressed. Staff acknowledged that the freezer temperature was out of range and that the ice cream was not frozen. The facility’s policies reviewed during the investigation stated that frozen foods and ice cream should be held at 0 F or less, and that food should be labeled and dated. The dish machine temperature logs showed multiple days in June and August 2025 when the final rinse temperature did not reach 180 F, and additional days in June 2025 when wash and rinse temperatures were not documented at all. Staff and the interim dietary director acknowledged that the dish machine temperatures were below the required range on the documented dates and that the machine should not be used until proper temperatures were reached. Cooling logs also showed that cooked foods, including porridge, gravy, tomato soup, and rice, were not cooled according to the facility’s cooling procedures on multiple dates in July and August 2025. The logs showed delayed temperature checks, temperatures remaining above the required limits, and blank follow-up entries, and the interim dietary director acknowledged that the kitchen staff did not follow cooling procedures and that the instructions on the cooling log were not correct.
Failure to Safeguard and Replace Resident's Personal Property
Penalty
Summary
The facility failed to safeguard the personal property of a resident with moderate cognitive impairment and vascular dementia, resulting in the loss of the resident's cellphone. The cellphone, which was documented on the resident's belongings inventory at admission, was discovered missing during routine rounds. Staff searched the resident's closet, bag, drawer, and dresser but were unable to locate the cellphone. The loss was reported to the police and appropriate state agencies, and the value of the cellphone was confirmed by the resident's former student. Despite the facility's Theft and Loss Policy, which requires the Social Worker to arrange for replacement of missing items listed in the inventory, the resident's cellphone was not replaced. Interviews with the Director of Nursing and the Social Worker confirmed that the missing cellphone was documented in the inventory, but no replacement was provided. The facility's policy and procedure on theft and loss specifically state that the Social Worker is responsible for arranging replacement if needed, but this step was not taken in this case.
Incomplete and Conflicting POLST Documentation
Penalty
Summary
The facility failed to ensure that POLST forms for two residents were complete and accurate. One resident was admitted with diagnoses including dementia, drug induced subacute dyskinesia, anxiety, and mild neurocognitive disorder due to a known physiological condition with behavioral disturbance. The resident's record contained no advance directive, and the active physician order listed FULL CODE - DNR - Comfort Focused Treatment - No artificial nutrition, including feeding tubes. However, the resident's POLST was undated and indicated Do Not Attempt Resuscitation/DNR, Selective Treatment, and no artificial means of nutrition, including feeding tubes, creating inconsistent documentation regarding code status. The POLST was signed by the NP and the legally recognized decision maker, and the DON confirmed that FULL CODE and DNR are conflicting orders. A second resident was admitted with diagnoses including PVD, stroke, and functional quadriplegia. During review, the resident's POLST was found to be undated and missing required information for the legally recognized decision maker, including signature and mailing address. The second page of the POLST also lacked required identifying information, including the resident's name, date of birth, gender, the physician's name, the additional contact's name and phone number, and the preparer's name and phone number. RN 2 stated the form was not fully completed. The facility policy stated that a POLST must be completed based on the patient's expressed treatment preferences and, when completed with a surrogate decision maker, must be consistent with the known desires of and in the best interests of the patient.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical and emotional abuse involving a cognitively intact resident who required extensive physical assistance from two staff for dressing, mobility, and transfers. The resident reported that a CNA awakened her with a loud voice, complained repeatedly about how she had been dressed, and tagged, pushed, and grabbed her while providing care. The resident stated she asked the CNA to stop and later asked that the CNA not care for her any further. She also stated that a second CNA who was assisting during the incident did not intervene. The Social Services Director stated the allegation was brought to her attention several days later and documented that the resident said the CNA held her tightly and quickly while providing care and appeared mad. The DON stated she had multiple interviews with the resident and checked the resident's left hand, finding nothing. The facility investigation summary indicated the physician was notified and ordered monitoring for the resident's upset feelings, but the ADON stated that the order was not carried out and monitoring was not started. The facility policy required staff to report alleged abuse, protect the resident immediately if witnessed, complete an event report with details, and for physical abuse, complete a physical assessment and request physician assessment.
Late Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for one of 26 sampled residents, Resident 56, after the resident had a significant change in status related to readmission with a gastrostomy tube. Resident 56’s admission record showed diagnoses including stroke, gastrostomy status, high blood pressure, kidney disease, osteoarthritis, and adult failure to thrive. The MDS indicated that the resident had an SCSA with an ARD of 1/28/25, and the assessment was signed as complete by the RN Assessment Coordinator on 2/14/25. During interview and record review, the MDS Coordinator stated that Resident 56 was determined to have had a significant change in status when he was readmitted with a G-tube and that the SCSA should have been completed on 2/10/25. The MDS Coordinator confirmed the assessment was completed on 2/14/25, four days late, and stated that a significant change in status assessment should be completed 14 days after the significant change in status was determined. The report also cited the LTC Facility Resident Assessment Instrument 3.0 User’s Manual, which states that the ARD must be no later than 14 days after the IDT determines the criteria for an SCSA are met.
Inaccurate MDS omitted osteopenia after fracture event
Penalty
Summary
The facility failed to ensure that Resident 97’s MDS included osteopenia, resulting in an inaccurate assessment of the resident’s current health status. The record review showed that the physician progress notes dated 4/24/25 listed dementia, diabetes, and hypertension as diagnoses for Resident 97. The facility reported incident dated 5/4/25 indicated that on 4/25/25, Resident 97 fell out of bed and sustained a fracture through the right femur. The same incident report and imaging completed on 4/25/25 indicated that Resident 97 had osteopenia. The MDS dated 7/29/25 did not indicate osteopenia for Resident 97. During an interview on 8/15/25, the MDS Coordinator reviewed the electronic record and acknowledged that osteopenia was not entered in the MDS. The MDS Coordinator stated that addressing osteopenia is significant because the resident is at risk for injury and fracture. The facility policy titled, Assessment - MDS and CAA, stated that residents are reassessed following a significant change in condition and/or as needed, and at regularly scheduled times.
Care Plan Missing for Osteopenia
Penalty
Summary
Failure to develop and implement a comprehensive care plan for Resident 97 addressed osteopenia, despite the resident’s documented fall and fracture history. Physician progress notes dated 4/24/25 listed diagnoses of dementia, diabetes, and hypertension. A facility-reported incident dated 5/4/25 stated that on 4/25/25 Resident 97 fell out of bed and sustained a fracture through the right femur. The same incident report also stated that imaging completed on 4/25/25 showed osteopenia. The MDS dated 7/29/25 did not indicate osteopenia for Resident 97. During an interview on 8/15/25, the MDS Coordinator reviewed the electronic record and acknowledged there was no comprehensive care plan completed to address osteopenia, stating that osteopenia is significant because the resident is at risk for injury and fracture. The MDS Coordinator also stated that nurses are responsible for completing residents’ care plans and that the MDS reviews the completed care plan. The facility policy titled Nursing Process, Plan of Care and Documentation stated that the plan of care is individualized for each resident based on information gathered through the nursing process and that nurses must review physician progress notes to become familiar with the medical treatment plan and any changes in condition.
Failure to Address Resident Weight Loss and Nutritional Decline
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was cited after the facility failed to effectively assess, evaluate, and implement interventions for Resident A's nutritional decline. Resident A was admitted with congestive heart failure, schizophrenia, schizoaffective disorder, drug induced subacute dyskinesia, and unspecified dementia. The record showed episodes of refusing meals, mostly breakfast or lunch, and intermittently refusing medications for several days, with the resident reporting that he was fasting for religious and personal reasons. An SBAR note documented the meal refusal pattern and that the medical doctor was notified and ordered a multivitamin with minerals, with a recommendation to consult RD for further guidance. The facility did not initiate a change of condition report after Resident A's 7.8-pound weight loss was identified, did not develop a care plan to address the weight loss, and did not implement weekly weight evaluations in accordance with facility policy. The Nutrition/Dietary note documented significant weight loss of 11.3% in 6 months, including 4.8% in 1 month and 5.4% in 3 months, and noted that the resident continued to refuse meals despite RD efforts to encourage intake and obtain food preferences. There was no documented follow-up assessment, actions, or interventions by the RD to address the weight loss.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure staff followed its infection control policy and procedure when an LVN did not perform hand hygiene between glove changes during medication administration. During observation of medication administration in a resident room, the LVN was preparing medications while wearing gloves, then removed the gloves, checked the computer, and put on a new pair of gloves without performing hand hygiene. During interview, the LVN acknowledged forgetting to do hand hygiene before putting on the new gloves and stated she knew hand hygiene should be performed first. Review of the facility’s hand hygiene policy, dated 5/2019, showed hand sanitation should be performed before and after preparing and administering medications, before putting on gloves, and after removing gloves.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported immediately, and no later than two hours after the allegation was made, for Resident 77. The record review showed that on 4/26/2025 the resident had a reddish discoloration under the left eye, described as a bruise with skin intact and no swelling, after the resident's son noticed the area and asked, "who punched my mom?" The nurses' notes dated 5/6/2025 documented that the incident was reported to law enforcement and that the social worker was informed the IDT team decided to report the incident and that a care conference was needed regarding the incident. The SOC 341 form was completed on 5/6/2025, listing the incident date as 4/26/2025 and describing the discoloration under the left eye as abuse resulting in other injury. During interviews, the Nurse Manager stated the facility had made a wrong judgment about the incident and knew it should have been reported within 2 hours, and an RN stated the nurse supervisor began to investigate after the son saw the bruise or discoloration, but it was not reported because the son was satisfied with the plan of care, although it should have been reported right away.
Failure to Implement and Evaluate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically in the implementation of its fall prevention program for a resident with multiple risk factors. The facility did not consistently conduct thorough investigations into the primary causes of the resident's falls, nor did it perform fall risk assessments after two of the resident's falls, as required by facility policy. Documentation was unclear or lacking regarding whether fall prevention devices, such as tab alarms and bed alarms, were properly applied or functioning at the time of the falls. Staff also did not consistently implement care plan interventions, such as ensuring alarms were in place and activated. The resident involved had significant cognitive and physical impairments, including dementia, Parkinson's disease, depression, anxiety, osteoarthritis, and movement disorders. She required substantial to maximal assistance with transfers and toileting and had no voluntary control over bowel and bladder functions. Despite being assessed as high risk for falls, the resident experienced four falls within a four-month period, one of which resulted in fractures to all five toes on her right foot. Observations and interviews revealed that the resident was able to unclip her tab alarm unassisted, and staff were aware of this but did not evaluate or implement alternative interventions. Interdisciplinary team (IDT) notes and interviews with facility leadership indicated that post-fall huddles and investigations were inconsistently documented and did not always address whether alarms were used or functioning. In some cases, staff presumed the cause of the fall without direct evidence, and there was no documentation of reminders to staff regarding the application of alarms. The facility's own policy required fall risk assessments after each fall, but these were not completed for at least two incidents. Only one root cause analysis was conducted for the resident's falls, despite multiple incidents.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of bed hold rights to four sampled residents or their responsible parties at the time of transfer to an acute care hospital. In each case, interviews and record reviews confirmed that neither the residents nor their responsible parties received the required written notification regarding the option to request a bed hold during hospitalization or therapeutic leave. Instead, notifications were either given verbally or not at all, and there was no documentation in the electronic health records to indicate that written notices had been provided. The residents involved had various medical conditions, including encephalopathy, urinary tract infection, femoral neck fracture, congestive heart failure, hypertensive heart disease, and acute bronchitis. Responsible parties for these residents reported not receiving any written bed hold notices and were unaware of their rights regarding bed holds and the possibility of returning to the facility after hospitalization. Facility staff interviews further confirmed the absence of written notifications and revealed that the process for providing such notices was inconsistent and not documented as required by facility policy.
Failure to Thoroughly Investigate Tube Feeding Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance regarding the administration of tube feeding formula for a resident who was ordered to receive 325 ml of formula within one hour at four specified times daily. The investigation did not consider the maximum rate of the facility's tube feeding pumps, which was 295 ml/hr, making it impossible to deliver the ordered amount within the specified time using the pump alone. Additionally, the facility did not identify that the physician's order was unclear and unachievable with the available equipment, nor did staff question or clarify the order despite its impracticality. During the investigation, staff did not measure the total amount of tube feeding in the enclosed bag before and after feedings, nor did they verify the amount of formula remaining after the third feeding session. This omission made it difficult to determine if the resident was receiving the prescribed amount. Observations confirmed that after three feedings, significantly more formula remained in the bag than expected, indicating the resident was not receiving the full ordered amount. Furthermore, staff were unaware that the tube feeding pumps had a plus/minus 10% error rate, which could result in under-delivery of the formula. The facility unilaterally declared the grievance resolved without providing follow-up or written notification to the complainant or ombudsman, as required by their own grievance policy. Documentation confirming communication of the investigation's outcome to the complainant and ombudsman was not provided. The lack of a thorough investigation and failure to address the complainant's concerns led to the issue being escalated to the state health department.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer for a resident (Resident 22) who was assessed as high risk for pressure ulcers. Despite being identified as needing extensive assistance with bed mobility and being incontinent, the resident did not have appropriate interventions implemented to prevent skin breakdown. Observations revealed that the resident was often found lying in bed without any device to offload pressure from the coccyx, which is a critical measure to prevent pressure ulcers. The resident developed a Stage 2 pressure ulcer on the coccyx, which was first observed on 8/2/23 and continued to worsen over time due to the lack of appropriate interventions, such as the timely provision of a low air loss (LAL) mattress that was ordered but not delivered promptly. The wound management detail reports indicated a decline in the wound's healing status, with measurements showing an increase in the size of the ulcer and signs of maceration due to prolonged exposure to moisture. The facility's failure to implement the necessary interventions, such as the use of a therapeutic support surface and offloading measures, contributed to the resident's condition worsening. Interviews with nursing staff revealed that there was a lack of communication and timely reporting of changes in the resident's skin condition, which could have prevented the progression of the pressure ulcer. The care plan for the resident included goals and approaches to prevent skin breakdown, but these were not effectively executed, leading to the development and worsening of the pressure ulcer.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 409 experienced side effects from the use of Haldol, an antipsychotic drug, and the facility did not lower the dosage for 96 days after side effects were identified. The resident's aggressive behaviors were linked to smoking restrictions, but non-medication interventions were not adequately implemented. Additionally, the resident was not started on Ingrezza, a medication to counteract Haldol's side effects, until much later, despite the recommendation to lower the Haldol dosage while waiting for approval for Ingrezza. Resident 70 was administered Citalopram, an antidepressant, without a clinical indication for its use. The resident's records did not show a diagnosis of depression, and the medication was administered continuously without proper justification. Furthermore, the PRN order for Ativan, a medication used to treat anxiety, did not have a stop date, which is against the recommended practice for psychotropic medications. Resident 86 was given Risperdal, an antipsychotic medication, without a proper clinical indication. The resident's records indicated diagnoses of stroke and depression, but not a psychotic disorder. Additionally, the PRN order for Ativan did not have a specific frequency and duration, which was identified as an irregularity by the pharmacist but remained uncorrected by the physician.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
Facility staff failed to treat three out of 24 sampled residents with dignity by not responding to their call lights in a timely manner. Resident 6, who had multiple diagnoses including respiratory failure, obesity, kidney failure leading to dialysis, and a wound near the tailbone, had to wait up to 45 minutes for assistance after having a bowel movement. His responsible party reported that staff cited being short-staffed as the reason for the delay. Resident 408, who had diagnoses including paraplegia, depression, respiratory problems, anxiety, chronic pain, and arthritis, also reported waiting 30-45 minutes for assistance and felt that newly transferred residents were treated like second-class citizens. Resident 82, with diagnoses including cancer, malnutrition, breathing problems, and a stomach feeding tube, reported waiting 5-35 minutes for staff to respond to his call light. Interviews with direct care staff confirmed that the facility had issues with staffing and timely response to call lights. A CNA reported that the facility was often short at least three CNAs. An RN stated that the facility was sometimes short of CNAs and LVNs, sometimes by one or two staff members. Another RN mentioned that the facility was usually short of direct care staff two to three days a week. These staffing shortages contributed to the delays in responding to residents' call lights, thereby failing to ensure that residents were treated with dignity and respect.
Failure to Inform Residents About Grievance Process and Resolve Grievances
Penalty
Summary
The facility failed to inform residents about the grievance process and did not ensure that grievances were resolved appropriately. During a resident council meeting, seven residents stated they were unaware of the facility's grievance process. Additionally, Resident 408 reported missing personal items during her transfer to the facility. The facility claimed that the resident's friend had the missing belongings, but the friend confirmed she only had limited possession of the items. The Director of Nursing (DON) was aware of the issue and filed a Theft & Loss Report but failed to provide proof of follow-up with the resident or her friend to confirm the resolution. The facility's grievance policy, revised in October 2023, requires informing residents of the resolution to ensure their satisfaction. However, the DON was unable to provide evidence that the grievance process was completed or that Resident 408 was satisfied with the resolution. This failure to inform residents about the grievance process and to follow through on grievance resolutions did not ensure that residents' concerns were addressed in a timely and appropriate manner.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three of 24 sampled residents. Resident 4's Minimum Data Set (MDS) dental assessment was inaccurate. During an observation, Resident 4's dentures were seen in a denture cup, and the resident mentioned difficulty chewing with them. The MDS for Resident 4 did not indicate the presence of dentures, which was confirmed by the Social Worker and Director of Nursing, who acknowledged a history of MDS discrepancies in the facility. The facility had stopped reauditing MDS assessments for the past six months due to relocation. Resident 6's MDS assessment inaccurately indicated that he was not on hemodialysis, despite his care plan showing a dialysis care plan initiated earlier. The MDS nurse confirmed the error and stated that a corrected MDS would be uploaded. For Resident 13, the MDS inaccurately recorded three pressure ulcers when there was only one. The MDS nurse admitted the coding error and was unable to explain why the sacral wound was identified incorrectly. These inaccuracies in the MDS assessments could potentially harm the residents by not providing the necessary care and services to maintain their highest level of functioning.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for seven residents, leading to unmet nursing needs and goals. Resident 4 experienced pain due to unfit dentures, which was reported to the nursing staff but not included in the care plan. Similarly, Resident 7's use of the blood-thinning medication Lovenox was not care planned until months after the medication was prescribed. Resident 70's use of Zolpidem for insomnia was also not included in the care plan until several months after the medication was ordered. Resident 78's care plan did not reflect the use of gloves to prevent self-scratching or the use of tab and bed alarms for fall prevention, despite these interventions being in place. Resident 38's planned weight loss was not documented in the care plan, even though the resident's weight had been gradually decreasing. Additionally, Resident 407's care plan did not address the specific target behavior of extreme fear for which Seroquel was prescribed. Finally, Resident 6's dialysis care plan inaccurately documented the dialysis access site, conflicting with other medical records that indicated the correct site. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors, highlighting the facility's failure to develop individualized, person-centered care plans for the residents involved.
Failure to Implement Physician-Ordered ROM Exercises
Penalty
Summary
The facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for four residents when the physician's order for ROM exercises was not implemented. Resident 12, who had diagnoses including dementia, stroke, hemiplegia, and hemiparesis, was observed with contracted lower extremities. The resident's records indicated that ROM exercises were ordered but not consistently documented or performed. Similarly, Resident 22, with severe cognitive impairment and hemiplegia, had an order for ROM exercises that was not consistently followed, as evidenced by incomplete documentation over several months. Resident 38, diagnosed with quadriplegia and stroke, was observed with contractures on both arms. The resident's care plan included ROM exercises, but documentation showed that these exercises were not performed consistently. Interviews with staff confirmed that ROM exercises were often not documented, indicating they were likely not performed. The Director of Nursing (DON) acknowledged that the facility lacked a dedicated Restorative Nursing Assistant (RNA) program, and all Certified Nurse Assistants (CNAs) were responsible for performing ROM exercises. Resident 14, who had multiple diagnoses including heart problems, high blood pressure, stroke, and paralysis, also had orders for ROM exercises that were not consistently documented. The DON confirmed that the standard practice was to document all ROM exercises, and any omissions in documentation indicated that the exercises were not performed. The facility's policy on ROM exercises emphasized the importance of these exercises in preventing contractures and maintaining muscle strength, but the policy was not followed consistently for the residents involved.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly cleaning one of the four fixed kettles between serving porridge and soup for lunch. During a kitchen observation, it was noted that only one of the four large built-in cooking kettles was functioning, and it was not adequately cleaned between uses. Additionally, two kitchen prep tables had uncovered drainage holes encrusted with dried, unidentifiable food particles. Interviews with dietary staff revealed that the cleaning process for the kettles was insufficient, with only occasional scrubbing for 'creamier' items. The facility's policy and procedure for food service equipment safety and sanitation required kettles to be cleaned and sanitized after each use, which was not followed.
Lack of Community Dining and Activity Areas
Penalty
Summary
The facility failed to provide a community dining and activity area on the 4th, 5th, and 7th floors, resulting in residents being confined to their rooms for all meals. During observations, it was noted that there was no common area or dining room on the 7th and 5th floors. Additionally, the room on the 9th floor, which was being used for a singing activity, lacked sufficient chairs and tables and was shared by residents from the 4th, 5th, and 7th floors, leading to limited capacity, especially with residents in wheelchairs accompanied by their CNAs. Interviews with the Director of Dietary and the Director of Admin revealed that there were no current plans for installing dining areas on each floor, and the facility was awaiting insurance estimates for future plans.
Failure to Maintain Clean Shower Area and Window Screens
Penalty
Summary
The facility failed to ensure a shower area was clean after use and that two window screens were properly maintained. During an initial tour with the Director of Nursing (DON), the shower room across from a specific room was found used and not cleaned, with strands of hair on the tile floor, a commode container full of empty plastic personal hygiene product bottles, a safety razor on the floor, an opened body wash bottle labeled 211A on the grab bar, and used plastic gloves in the recessed soap dish. The DON stated that staff should not leave the shower in this manner and should clean it after use. Additionally, during a tour with an RN, two rooms were found to have missing window screens, which the RN acknowledged and stated would be fixed by maintenance.
Failure to Act on Pharmacy Consultant's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendation regarding the use of psychotropic medication for Resident 86 was acted upon. Resident 86, who was admitted with diagnoses including mood disorder and major depressive disorder, was prescribed Risperdal for mood disorder. The pharmacy consultant identified irregularities in the medication regimen review (MRR) on two occasions, noting that mood disorder is not an appropriate diagnosis for antipsychotic use and could be viewed as a chemical restraint. Despite these identified irregularities, no corrective action was taken by the physician or nursing staff. Interviews with the pharmacist and the Director of Nursing (DON) revealed that the identified irregularities were communicated to the RN and the physician, but the physician did not act upon them. The DON acknowledged that the irregularities were communicated verbally and documented in the progress notes, but admitted that the physician's inaction was possibly missed. This failure had the potential to expose Resident 86 to unnecessary psychotropic medications and adverse health consequences, negatively impacting the resident's mental, physical, and psychosocial well-being.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to maintain accurate records for three residents, leading to potential mismanagement of their care. For Resident 397, who had multiple diagnoses including diabetes and excessive unplanned weight loss, staff did not accurately document fluid intake. Interviews with direct care staff revealed that they combined meal and fluid intake in their records, contrary to the Registered Dietitian's expectations. This inaccurate documentation could affect the management of the resident's weight loss and overall health condition. For Resident 396, who had diagnoses including anxiety, depression, schizophrenia, and bipolar disorder, the target behavior for bipolar disorder was incorrectly documented as delusion instead of hallucination. RN 8 acknowledged the need to revise this documentation. Additionally, Resident 25, who had conditions such as anemia, high blood pressure, kidney failure requiring dialysis, and diabetes, had inaccurate fluid intake and output records. RN 1 admitted that the intake and output records for January 2024 were not accurate, which is critical for managing the resident's fluid restriction due to dialysis.
Failure to Document Vaccine Education and Follow-Up
Penalty
Summary
The facility failed to ensure that education regarding protective vaccines was documented and that follow-up and/or refusals were recorded in the medical records of two residents. Specifically, for Residents 70 and 88, there was no documentation of the administration of the pneumovax vaccine, no record of refusal, and no evidence of education provided regarding the vaccine. During a concurrent record review and interview with RN 5, it was confirmed that the necessary information was missing from the records, and RN 5 was unable to locate the missing documentation. This failure did not ensure that residents and/or their responsible parties could make informed decisions regarding vaccines, nor did it ensure that residents' healthcare choices were honored.
Failure to Document Vaccine Education and Refusals
Penalty
Summary
The facility failed to ensure that education regarding the COVID-19 vaccine was documented and that follow-up and/or refusals were recorded in the medical records of two of four sampled residents. Specifically, Resident 89 had no documentation of COVID-19 vaccine administration, refusal, or education. Similarly, Resident 13 had no documentation of COVID-19 or pneumovax vaccine administration, refusal, or education. During a concurrent record review and interview with RN 5, it was confirmed that the necessary information was missing from the records, and RN 5 was unable to locate the missing documentation.
Emergency Cart Lock Tag Discrepancy
Penalty
Summary
An emergency cart's red plastic lock tag did not match the lock tag documented on the log, indicating a failure to follow procedure regarding logging lock tags. This discrepancy was observed during initial rounds and confirmed with an RN, who was unable to provide an explanation for the mismatch. The RN explained that once the cart is accessed, it is sent to central supply to be re-stocked, a new red plastic lock tag is installed, and the tag number is entered into the log book. The facility's policy on emergency crash carts, revised in March 2021, states that the carts will be checked every 30 days by pharmacy personnel, and new locks will be applied and documented. However, the policy did not address the responsibility of floor staff in documenting how the red tags are checked and logged. This gap in the policy contributed to the observed deficiency, as the emergency cart's lock tag did not match the log book entry, potentially compromising the availability of emergency devices and supplies.
Unsecured Handrail in Corridor
Penalty
Summary
The facility failed to have a secure handrail in their corridor. During an initial tour on 01/29/2024 at 10:29 AM, a handrail outside room [ROOM NUMBER] was found not secured properly to the wall. This observation was confirmed with RN 6, who stated she would inform maintenance. The lack of a secure handrail did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall.
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.
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What surveyors actually found near you
We read the 831 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Daly City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Heights Healthcare | 0.8 mi | ★★★★★ | 2 | 0 |
| Golden Pavilion Healthcare | 0.8 mi | ★★★★★ | 2 | 0 |
| San Francisco Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Pacifica Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Jewish Home & Rehab Center D/p Snf | 3.9 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.