Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alameda Healthcare & Wellness Center during CMS and state inspections, most recent first.
During a COVID-19 outbreak, the facility did not notify the state health department or post required signage at the entrance. Staff, including a receptionist, CNA, and RNA, were observed wearing N95 masks incorrectly, and others wore surgical masks instead of N95s in hallways. Residents with cognitive and immune vulnerabilities were present, and one resident reported inconsistent mask use by staff. Facility leadership confirmed the outbreak and acknowledged lapses in reporting and signage.
Offensive urine and feces odors were repeatedly observed throughout the facility, including in resident care areas and bathrooms, and a RP reported waiting for staff to clean urine from the floor near a resident room. Staff and a resident reported ongoing shortages of clean linens, towels, and washcloths, with some supplies stained or ripped and resident care delayed. Dusty fans were also observed in the laundry room and at a nursing station, and the MTD acknowledged they needed cleaning.
Multiple residents did not receive medications according to physician orders and care plans due to insufficient nursing staff, resulting in late administration of critical medications and a significant medication error involving a narcotic overdose. Nurses were assigned to pass medications to over 25 residents per shift, leading to delays, errors, and inaccurate documentation, with staff reporting frequent interruptions and lack of support.
Multiple residents did not receive medications as ordered, including late administration of seizure, blood pressure, anticoagulant, and pain medications, and one resident received a fivefold overdose of methadone due to staff distraction and workload. Nursing staff cited high resident loads and lack of assistance as reasons for delays, and medication records did not always accurately reflect administration times.
A resident with a history of heart failure and dementia received five times the prescribed dose of methadone when an RN, distracted during medication preparation, administered 25 mg instead of 5 mg. The error was discovered during a narcotics count the following day, after the resident had also received hydromorphone and subsequently experienced vomiting and over-sedation.
Surveyors found that a medication room with a number-coded lock could be opened without a code, and a refrigerator inside containing an e-kit with lorazepam was left unlocked. A nurse supervisor confirmed the storage should have been locked, and the DON stated all medication storage must be secured at all times. Facility policy requires controlled medications to be double-locked and accessible only to authorized personnel.
The facility's QAPI committee did not fully implement or monitor its program to reduce medication errors and late medication administration, resulting in multiple instances where residents received medications late or in incorrect doses. These included late administration of seizure, blood pressure, anticoagulant, and pain medications, as well as a significant dosing error with methadone. Nurses cited high workloads, lack of support, and distractions as contributing factors, while audits and oversight were inconsistently performed.
A facility failed to ensure that a staff member alleged of abuse completed required abuse prevention re-training before returning to work with a resident who had complex medical needs, including cognitive and respiratory deficits. The staff member resumed duties without completing or acknowledging the mandated training, contrary to facility policy.
A resident with significant medical needs did not receive timely podiatry care after a toenail avulsion and fungal infection, despite physician orders and nursing staff requests. The Social Services Coordinator was unaware of the order for an outpatient podiatry referral, and no appointment was arranged, resulting in the resident not being seen by a podiatrist until the next scheduled in-house visit several months later.
A long-term care facility failed to maintain proper infection control practices, affecting nine residents. Staff did not adhere to hand hygiene protocols during incontinent care and failed to follow PPE protocols for residents on enhanced barrier precautions. Additionally, a resident's urinal was found unclean and not replaced, indicating lapses in sanitation practices.
The facility failed to ensure appropriate use of bed rails for three non-ambulatory residents, increasing the risk of entrapment or injury. Despite facility policy, bed rails were used for residents who could not benefit from them due to their medical conditions, as confirmed by the DON.
A long-term care facility failed to administer medications according to physician orders for multiple residents, resulting in improper documentation, missed doses, and late administration. Staff cited heavy workloads as a reason for delays, and interviews revealed inconsistencies in adherence to facility policies on medication timing and error reporting.
The facility failed to manage waste disposal properly, with trash bags on the ground, overfilled dumpsters, and lids propped open. The Dietary Supervisor confirmed the area was not well maintained and acknowledged the improper state of the dumpster lids.
The facility failed to maintain the dignity and privacy of three residents by displaying signs with personal medical information above their beds. One resident, who was cognitively intact, had a sign with dietary needs and feeding instructions. Another resident, severely impaired, had signs for feeding and seizure precautions. A third resident, also cognitively intact, had signs for feeding status, fall risk, and aspiration precautions. The DON confirmed that this information should not be publicly displayed.
Two residents were found with medications at their bedside without the necessary assessments, physician's orders, or care plans. One resident with COPD had an inhaler without documentation, while another with end-stage renal disease had tablets left by an LVN. Both cases lacked the required self-administration assessments and approvals.
A resident with dementia and Alzheimer's disease was observed receiving peri care with the door open, compromising privacy. Despite the privacy curtain being drawn, the resident's legs were visible from outside the room. Staff interviews revealed differing understandings of privacy protocols, with some believing curtain use was sufficient, while others emphasized the need to close the door. The facility's policy mandates privacy and confidentiality, which was not maintained in this case.
The facility failed to maintain air conditioning filters in the subacute unit, affecting 21 residents, including 11 on ventilators. Observations revealed thick, gray film on the filters, and the Maintenance Supervisor admitted they were last cleaned in July 2024. No system was in place to track regular maintenance.
A resident, cognitively intact with a BIMS score of 14, reported rough treatment by a CNA during care. The facility's policy requires abuse allegations to be reported within two hours, but the report to the SSA was delayed, as confirmed by the Administrator.
A facility failed to provide timely written notification to a resident, their representative, and the Ombudsman regarding a hospital transfer. A resident was transferred due to gastrointestinal bleeding, but the required notification to the Ombudsman was not documented. The Social Services staff responsible for notifications could not locate the necessary documentation, leading to a deficiency in communication as per facility policy.
The facility failed to provide bed hold notifications to two residents within 24 hours of their hospital transfers, as required by policy. Despite claims from Social Services that notifications were given, the Administrator confirmed the Admissions Coordinator did not provide them. This oversight was identified through EMR reviews, which showed no notifications for residents with chronic conditions transferred for medical emergencies.
A facility failed to transmit a resident's MDS assessment in a timely manner. The resident, admitted with a femur fracture, spinal stenosis, and chronic kidney disease, had their discharge assessment completed but not transmitted as required by CMS guidelines. An interview confirmed the oversight.
The facility failed to maintain accurate care plans for two residents and did not invite a cognitively intact resident to care conferences. One resident's care plan incorrectly included splint usage, while another's included smoking cessation resources despite being in a vegetative state. Additionally, a resident was not invited to care conferences, contrary to facility policy.
A facility failed to create a person-centered discharge plan for a resident who expressed a desire to return home. Despite being cognitively intact, the resident was not involved in discharge planning discussions. Social services staff did not engage with the resident regarding discharge preferences, and the Social Services Director was unaware of this oversight.
A resident requiring cataract surgery did not receive an ophthalmologist referral order due to the facility's failure to follow up on a referral sent nearly a year prior. The resident's appointments were repeatedly canceled, and staff interviews revealed a lack of awareness about the referral. The facility's policy on coordinating medical services was not followed.
A resident with chronic respiratory failure did not receive prescribed enteral feeding due to staff oversight, missing 15% of their daily nutritional intake. The feeding pump was not turned on at the scheduled time, as confirmed by the resident's spouse and a nurse, who cited time constraints as the reason for the delay.
A facility failed to complete dialysis communication sheets for a resident with end-stage renal disease, missing documentation on 17 occasions over 94 days. The facility's policy requires nursing staff to communicate vital signs, weight, and condition changes to the dialysis provider, and for the provider to report back any issues. Interviews confirmed the deficiency, with the DON expecting nurses to complete pre- and post-dialysis documentation, which was not done.
A resident with a traumatic brain injury and schizophrenia expressed suicidal thoughts during an assessment, prompting a referral to a psychiatrist. However, the facility failed to follow up on the referral, and the resident was not seen by a psychologist. Interviews revealed a lack of a system to ensure psychiatric consultations were completed, leading to the resident being severely depressed.
Expired medications and supplies were found in the Sub-Acute Medication Room, including Erythromycin, Famotidine, and Oseltamivir Phosphate, as well as Calamine Lotion, Silver Nitrate Applicators, and a Dextrose IV bag. The DON acknowledged the issue and mentioned previous efforts to remove expired items.
A facility failed to establish a contract with a dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy requires maintaining signed service agreements with all providers, but a review revealed the absence of such a contract with the dialysis center. This was confirmed by the Administrator, placing residents receiving dialysis at potential risk.
A resident with complex medical needs did not receive podiatry services for a year, leading to excessive toenail growth and a wound on the right great toe. The wound became severely infected, resulting in osteomyelitis and requiring hospitalization and antibiotic treatment. The facility's failure to ensure timely podiatry care contributed to the resident's deteriorating foot health and subsequent medical complications.
A resident with significant medical conditions was vaccinated for COVID-19 without consent from their responsible party, despite prior instructions not to vaccinate due to a compromised immune system. This resulted in swelling and probable pain in the resident's arm. The facility's policy required obtaining consent, which was not adhered to in this case.
Failure to Report COVID-19 Outbreak and Enforce Proper Mask Use
Penalty
Summary
The facility failed to follow infection control practices during a COVID-19 outbreak. Specifically, the facility did not notify the California Department of Public Health about the outbreak and did not post signs at the front entrance to inform visitors, residents, or staff of the outbreak. Observations revealed that staff, including a receptionist, a CNA, and a Restorative Nursing Assistant, were not wearing their N95 masks correctly, with masks worn below the nose. Additionally, a Certified Nursing Assistant and a Laundry Aid were observed wearing surgical masks instead of N95 respirators in resident hallways, contrary to facility policy during the outbreak. Interviews confirmed that staff were aware of the requirement to wear N95 masks and the importance of proper mask usage, but these protocols were not consistently followed. Resident records reviewed included individuals with significant medical vulnerabilities, such as cognitive communication deficits and immunodeficiency, as well as a resident admitted for COVID-19 screening. One resident reported that staff did not always wear their masks correctly. Facility leadership, including the DON and Administrator, acknowledged the outbreak and the need for N95 masks and signage, but confirmed that the outbreak had not been reported to the state health department and that required signage was not in place at the time of the survey.
Unsanitary odors, linen shortages, and dirty fans
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when offensive urine and feces odors were repeatedly observed throughout the building on multiple occasions. During observations and tours, the facility smelled like urine and feces in all stations, and a foul odor was noted in a station 3 bathroom and in a station 2 shower. A maintenance director acknowledged that it was important for the facility not to have foul odors and that the facility should smell good. A responsible party also reported frustration while waiting for staff to clean urine from the floor near a resident room and stated housekeeping and maintenance did not respond fast enough or at all. The facility also did not provide enough clean linens and towels to meet resident needs. A CNA stated there were not enough linens and towels most of the time and that staff arrived early to gather needed linen before other CNAs did the same. Multiple staff members reported that linen and towel shortages had been ongoing for months, that supplies were often stained, ripped, or not stocked adequately, and that shortages delayed resident care. A resident stated they had gone three days without a washcloth because linen was gone by breakfast, and that many linens, gowns, towels, and clothes were stained. The resident said the lack of adequate linens and towels made them feel forgotten and worried about things that should be unlimited. The facility also failed to keep fans clean in the laundry room and nursing station 2. Observations showed grey dusty matter throughout the fan in the laundry room and later in the fan at nursing station 2. The maintenance director stated the fans were the responsibility of the maintenance team, that fans should be cleaned as needed during routine rounds, and acknowledged that the fan in nursing station 2 needed to be cleaned. Facility policies stated that staff were to maintain pleasant, neutral scents, keep enough linens for at least three complete bed changes per licensed bed, maintain adequate housekeeping supplies, and clean air vents and report dirt or corrosion on fans or ducts.
Insufficient Nursing Staff Leads to Delayed and Incorrect Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely and accurate medication administration for multiple residents, as evidenced by direct observations, interviews, and record reviews. Several licensed nurses were responsible for administering medications to a high number of residents per shift, resulting in significant delays and errors. For example, one nurse was observed administering 12 medications late to a resident with epilepsy, including a seizure medication, and left the medications unattended on the bedside table for several hours. The resident was not capable of self-administering medications, and the medication administration record did not accurately reflect the times medications were given. Another incident involved a registered nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. The nurse attributed the error to being distracted by the needs of another resident and rushing through the medication pass. The error was only discovered during a subsequent narcotics count. Additional residents experienced late administration of critical medications, such as blood pressure medications and anticoagulants, with documentation and interviews confirming that these medications were often given hours after their scheduled times. Staff interviews revealed that nurses were frequently assigned to pass medications to 25 or more residents per shift, leading to delays and increased risk of errors. Nurses reported difficulty finding assistance and being interrupted by other resident care needs, which further contributed to late medication passes. The facility's own policy required medications to be administered within one hour of the scheduled time, but this standard was not met. The Director of Nursing acknowledged that current staffing levels were insufficient to allow for safe and timely medication administration.
Failure to Administer Medications According to Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and resident care plans for five of eight sampled residents. Staff did not administer medications as prescribed, resulting in late administration of critical medications and, in one case, a significant medication error involving a narcotic overdose. For example, one resident with epilepsy and supraventricular tachycardia did not receive seizure medication on time, as the nurse left the medications at the bedside for several hours before administration, despite the resident not being capable of self-administration and having no such order. The medication administration record did not accurately reflect the timing of administration. Another resident received a fivefold overdose of methadone when a registered nurse, distracted by another resident's needs, mistakenly administered five tablets instead of one. The error was only discovered during a subsequent narcotics count, and the nurse acknowledged the mistake. Additional residents experienced late administration of medications for blood pressure, anticoagulation, and pain management, with staff citing high resident loads, frequent interruptions, and lack of available assistance as reasons for the delays. Medication administration records showed that medications were often given hours after their scheduled times. Interviews with nursing staff and leadership confirmed that medication passes were frequently delayed due to staffing shortages and competing resident care demands. Staff reported that they were unable to administer medications within the facility's policy timeframe, and some residents noted that their medications were routinely given late, with documentation not always reflecting the actual time of administration. The facility's policy required medications to be administered within one hour of the scheduled time, but this standard was not met in multiple observed instances.
Significant Medication Error: Overdose of Methadone Administered
Penalty
Summary
A registered nurse (RN) administered a significant medication error to a resident who had been admitted with acute heart failure, dementia, and failure to thrive. The resident had physician orders for methadone 5 mg orally twice daily and hydromorphone as needed for pain. On one occasion, the RN, while distracted and rushing due to the needs of another resident, mistakenly administered five tablets of methadone 5 mg (totaling 25 mg) instead of the prescribed single 5 mg tablet. The error was not immediately recognized and was only discovered the following day during a narcotics count. Following the administration of the incorrect methadone dose, the resident received additional doses of hydromorphone both before and after the error. The resident subsequently experienced vomiting and was observed to be over-sedated. Facility documentation and interviews confirmed the medication error, the circumstances leading to it, and the resident's adverse reaction. The facility's policy required nursing staff to adhere to the seven rights of medication administration, including the right amount and right time, which was not followed in this instance.
Failure to Secure Medication Room and Controlled Substances
Penalty
Summary
A deficiency was identified when the medication room in the sub-acute area was found to be unsecured during an observation. The door to the medication room, which was supposed to be secured with a number-coded lock, could be opened without entering a code. Inside the medication room, a refrigerator containing an emergency kit (e-kit) with a vial of lorazepam, a controlled medication, was also found to be unlocked, with the keyed padlock hanging on a hinge. These observations were made in the presence of a nurse supervisor, who confirmed that the e-kits were supposed to be stored in a locked refrigerator and acknowledged that a mechanism keeping the door unlocked had been engaged. Further interviews with facility staff, including the DON, confirmed that all medication rooms and medication storage areas were required to be locked at all times to prevent unauthorized access. A review of the facility's policy indicated that medication supplies should only be accessible to authorized personnel and that controlled medications must be stored in a double-locked compartment. The failure to secure both the medication room and the refrigerator containing controlled substances constituted a breach of these policies.
Failure to Implement Effective QAPI Program for Medication Administration
Penalty
Summary
The facility's quality assurance committee failed to effectively implement its QAPI program aimed at reducing medication errors and preventing late medication administration. Despite having a QAPI project in place, the committee did not fully implement the interventions, did not adequately investigate the causes of late medication administration and errors, and failed to monitor or reassess the program when issues persisted. This resulted in continued medication errors and late administration for five of eight sampled residents, with the potential to affect all residents in the facility. Specific incidents included a nurse administering 12 medications late to a resident with epilepsy, including a seizure medication, and another nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. Additional cases involved late administration of blood pressure and anticoagulant medications to residents with significant cardiovascular and neurological conditions, as well as late administration of pain medications to a resident with chronic pain syndrome. Observations and interviews revealed that nurses were often delayed due to high workloads, lack of assistance, and frequent distractions, with some nurses admitting to documenting medications as given on time even when they were late. Record reviews showed that the facility's QAPI program relied on self-reporting of errors by nursing staff and limited audits by the DON, which were not consistently performed as outlined in the program. The pharmacy consultant was not fully integrated into the QAPI process and was unaware of recent medication errors or related QAPI plans. The facility's policy required ongoing evaluation and monitoring of the QAPI program, but these steps were not adequately carried out, contributing to the persistence of medication administration issues.
Failure to Ensure Abuse Prevention Re-Training for Staff After Allegation
Penalty
Summary
The facility failed to develop and implement written policies and procedures that ensured re-training and re-education of staff alleged of abuse or mistreatment before allowing them to return to work with residents. Specifically, after an allegation of mistreatment involving a registered nurse, the nurse was suspended pending investigation but was permitted to resume resident care duties without completing required abuse prevention re-training or signing an acknowledgment of training completion. The facility's policy required such re-training after suspension for abuse allegations, but this was not followed in this instance. The resident involved was admitted with significant medical needs, including bed confinement, cognitive communication deficits, sepsis, dependence on a respirator, and acute and chronic respiratory failure. Interviews with facility leadership confirmed that, contrary to policy, the only education provided to the nurse was to have another staff member present during certain care activities, and this education was not focused on the nature of the abuse allegation. The required abuse prevention training was not completed prior to the nurse's return to resident care.
Failure to Provide Timely Podiatry Services for Resident with Fungal Toenail Infection
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bed confinement, cognitive communication deficit, sepsis, and respiratory failure, did not receive timely podiatry services after experiencing toenail avulsion and fungal infection. The resident had a physician's order for podiatry services as clinically indicated, and specific orders were in place to monitor and care for avulsed toenails. Despite these orders, after the resident's left great toenail came off due to fungal infection, there was no documentation that an outpatient podiatry appointment was arranged as ordered by the physician. The in-house podiatrist, who visits every 61 days, did not return to the facility until several months later, and the resident was not seen by a podiatrist in the interim. Interviews with staff revealed that the Social Services Coordinator was unaware of the physician's order for an outpatient podiatry referral and did not arrange for the service, instead waiting for the next scheduled in-house podiatry visit. Documentation showed that the need for podiatry care was recognized by nursing staff and communicated to Social Services, but the referral process was not completed. The facility's policy required coordination between nursing and social services to ensure physician orders for outside referrals were documented and acted upon, but this did not occur, resulting in a lack of timely podiatry care for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices for nine residents, leading to potential risks of infection and spread. Observations revealed that staff did not adhere to hand hygiene protocols during incontinent care for several residents, including not washing hands between glove changes and failing to clean between the labia. This was confirmed by staff interviews, where they acknowledged the lapses in hand hygiene and the need for glove changes during care. Additionally, the facility did not follow proper personal protective equipment (PPE) protocols for residents on enhanced barrier precautions (EBP). Staff were observed wearing gowns outside of resident rooms and not changing them between different residents, which is against the facility's policy. In some cases, staff were unaware of the EBP status of certain rooms and did not don the necessary PPE, further compromising infection control measures. The facility also failed to maintain sanitary conditions for resident equipment, as evidenced by a resident's urinal that was found to be unclean and not replaced as required. Interviews with staff confirmed that the urinal should have been cleaned or replaced, highlighting a lack of adherence to the facility's sanitation policies. These deficiencies indicate a systemic issue with infection prevention and control practices within the facility.
Improper Use of Bed Rails for Non-Ambulatory Residents
Penalty
Summary
The facility failed to ensure the appropriate use of bed rails for three residents, increasing the risk of entrapment or injury. The facility's policy on bed rails, revised in November 2022, states that bed rails should only be used to treat a resident's medical symptoms and not for staff convenience or as a form of discipline. Despite this, observations and interviews revealed that bed rails were improperly used for residents who could not benefit from them due to their medical conditions. Resident 30, who was non-ambulatory and had bilateral upper extremity contractures, was observed with bilateral half rails on her bed. Her care plan included the use of bedrails for bed mobility, but her bed rail assessment indicated that side rails were not necessary. The Director of Nursing (DON) confirmed that Resident 30 was unable to use the bed rails and that they should not have been present. Similarly, Resident 53, who was in a persistent vegetative state and had contractures, was observed with bilateral enabler bars. Although his care plan and order history included the use of these bars, his assessment showed that he could not use them independently. The DON confirmed the inappropriateness of the enabler bars. Resident 99, also non-ambulatory with contractures, was found with quarter side rails, despite her assessment indicating no need for them. The DON acknowledged that these side rails were unnecessary and should be removed.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for nine residents, leading to potential decreased therapeutic results. The deficiencies included improper documentation, failure to administer medications, and late administration of medications. For instance, Resident 16 did not receive several morning medications due to a heavy medication pass, as confirmed by a registered nurse. Resident 29's medication administration was documented as completed, despite the resident refusing the medications when they were offered late in the afternoon. Several residents experienced late medication administration, which was attributed to staff being busy or having a high number of residents to attend to. Resident 33 received albuterol sulfate late on multiple occasions, and Resident 38 did not receive lorazepam on time. Similarly, Resident 44's medications were administered late, and Resident 45 received critical medications, including insulin and clonidine, hours after the scheduled time. These delays were confirmed through interviews with nursing staff, who cited workload as a reason for the delays. The facility's policies on medication administration and error reporting were not adhered to, as evidenced by the lack of timely documentation and notification to physicians about late or missed medications. Interviews with the medical director, pharmacist, and nursing staff revealed discrepancies in expectations for medication administration timing, with some staff unaware of the ongoing issues. The facility's administrator and director of nursing acknowledged that medication reviews were part of quality assurance meetings, but did not indicate that late administration was a current concern.
Improper Waste Management in Dumpster Area
Penalty
Summary
The facility failed to properly manage waste disposal in the dumpster area located behind the building. Observations on two consecutive days revealed several deficiencies: bags of trash were found on the ground, a stack of wooden pallets and broken-down cardboard boxes were present, and the blue dumpster was overfilled, preventing its lid from closing properly. Additionally, the large green dumpster had its lid propped open by a white plastic pipe. These conditions were confirmed by the Dietary Supervisor, who acknowledged that the area was not well maintained during the initial days of the survey and that the dumpster lids should not be propped open.
Violation of Resident Dignity Due to Display of Medical Information
Penalty
Summary
The facility failed to uphold the dignity and privacy of three residents by displaying signs above their beds containing personal medical information. Resident 21, who was cognitively intact with a BIMS score of 15, had a sign indicating dietary needs and feeding instructions, which was visible during multiple observations. Despite being alert, the resident was noted to be disorganized, and the sign remained in place over several days. Similarly, Resident 77, who was severely impaired with a BIMS score of zero, had signs indicating feeding instructions and seizure precautions. These signs were observed on multiple occasions above the resident's bed and nightstand. Resident 89, who was cognitively intact with a BIMS score of 13, had three signs above the bed detailing feeding status, fall risk, and aspiration precautions. These signs were also observed over several days. The Director of Nursing confirmed that such information should not be publicly displayed and should instead be included in the Kardex.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the necessary assessments, physician's orders, and care plans in place. This deficiency was identified for two residents, R44 and R73, who were observed with medications at their bedside without the required documentation and approvals. The facility's policy mandates that residents must be assessed by the interdisciplinary team and have a physician's order before they can self-administer medications, which was not adhered to in these cases. Resident R73, who was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), was observed with an albuterol sulfate inhaler on her overbed table. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status score of 15 out of 15, there was no evidence of a physician's order, self-administration assessment, or care plan for the inhaler in her electronic medical record. The Director of Nursing confirmed that R73 should not have had the inhaler at her bedside without the necessary documentation and approval. Resident R44, with a primary diagnosis of end-stage renal disease, was also found with medications at her bedside. She had a medication cup with sevelamer carbonate tablets, which were left by an LVN who stated that R44 preferred to take her pills with meals. However, R44 did not have a self-administration assessment, and her care plan did not include self-administration of medications. The Director of Nursing confirmed that R44 should have had an assessment if medications were to be left at her bedside.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to ensure privacy during care for a resident, identified as R108, who was moderately impaired for decision-making with a BIMS score of eight out of 15. R108 was admitted with multiple diagnoses, including unspecified dementia and Alzheimer's disease. During an observation, a Certified Nurse Aide (CNA) was seen providing peri care to R108 with the door open, despite the resident being in a three-person room. Although the privacy curtain was drawn, R108's legs were visible from outside the room, compromising the resident's privacy. Interviews with staff revealed inconsistencies in understanding the facility's privacy policy. CNA5 believed that drawing the curtains was sufficient, while the Regional Quality Management Consultant and another CNA stated that best practice involves closing the door and drawing the curtains. The Director of Nurses expected either the curtains to be fully drawn or the door to be closed during such care. The facility's policy on Resident's Rights emphasized the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Maintain Air Conditioning Filters in Subacute Unit
Penalty
Summary
The facility failed to maintain air conditioning filters in one of its four residential units, specifically affecting the subacute unit where 21 residents reside, 11 of whom are on ventilators. During an observation, it was noted that the portable air conditioner at the end of the subacute resident hall had three filters with a thick, gray film caked on them. The facility's policy on Heating and Air Conditioning System Inspection, revised on 01/01/12, assigns the responsibility of inspections to the Maintenance Department to protect the health and safety of residents, visitors, and staff. However, during an interview, the Maintenance Supervisor admitted that the filters were last cleaned in July 2024 and acknowledged that they needed cleaning again. The Maintenance Supervisor also stated that there was no log or system in place to track items requiring regular maintenance.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State survey agency (SSA) within the required timeframe. The facility's policy mandates that any allegations of abuse must be reported to law enforcement and relevant agencies within two hours. However, in this case, the report was not sent to the SSA until later in the evening, resulting in a delay. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident reported that a Certified Nursing Assistant (CNA) was rough during care, which was brought to the attention of the Director of Nursing by a surveyor. Despite the facility's policy, the report to the SSA was confirmed to be late by the Administrator, highlighting a failure in adhering to the established reporting procedures.
Failure to Notify Ombudsman and Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their representative, and the Ombudsman regarding a transfer to the hospital. Specifically, the facility did not ensure that a written notice was given to one of the three residents reviewed for hospitalization, identified as Resident 30, prior to or as soon as practical following their transfer to the hospital. The facility's policy requires that upon transfer to an acute hospital, the resident or their representative should be given an opportunity to execute a Bed Hold and be provided with a Notice of Proposed Transfer and Discharge document. However, there was no documentation indicating that the Ombudsman was notified of the transfer for Resident 30. Resident 30 was admitted to the facility and had a quarterly Minimum Data Set assessment that did not include a Brief Interview for Mental Status due to the resident's inability to participate. The resident was discharged to the hospital due to gastrointestinal bleeding and later returned to the facility. The Social Services staff member responsible for sending out transfer and discharge notifications acknowledged during an interview that she could not locate the Ombudsman notification for Resident 30's hospitalization. This oversight created the potential for residents or their responsible parties to lack the necessary information to understand the transfer to the hospital.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to two residents, R30 and R100, within 24 hours of their emergent transfers to the hospital. According to the facility's policy, residents or their representatives should be notified in writing about the bed hold option whenever a resident is transferred to an acute care hospital. However, upon review of the electronic medical records (EMR) for both residents, no bed hold notifications were found. R30, who was diagnosed with chronic respiratory failure with hypoxia, was transferred to the hospital due to gastrointestinal bleeding. Similarly, R100, with a primary diagnosis of type two diabetes mellitus with diabetic chronic kidney disease, was transferred due to fever, coughing, and wheezing. Interviews conducted during the investigation revealed that the Social Services staff member claimed to have provided bed hold notifications, but the Administrator confirmed that the Admissions Coordinator failed to do so for both residents. This oversight increased the potential for residents to be unaware of their right to request a bed hold, which could affect their ability to return to the facility. The absence of documented notifications in the EMR for both residents highlights a lapse in adherence to the facility's policy and regulatory requirements.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure timely transmission of a Minimum Data Set (MDS) assessment for one resident, identified as Resident 86, out of 47 sampled residents. According to the Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, the MDS completion date should be no later than 14 calendar days after the discharge date, and the transmission date should be no later than 14 calendar days after the MDS completion date. Resident 86 was admitted to the facility with diagnoses including a fracture of the neck of the right femur, spinal stenosis, and chronic kidney disease. The discharge assessment for this resident, with an Assessment Reference Date (ARD) of March 1, 2024, was completed on March 9, 2024, but there was no evidence of it being transmitted. An interview with MDS1 confirmed that the assessment was not transmitted after completion.
Care Plan Inaccuracies and Resident Exclusion from Conferences
Penalty
Summary
The facility failed to ensure accurate and regularly updated care plans for two residents, R4 and R99, and did not invite resident R101 to participate in care conferences. For R4, the care plan inaccurately included the use of splints, despite no orders or observations supporting their use. The Director of Nurses confirmed that R4 did not wear splints and that the care plan was incorrect. Similarly, R99's care plan erroneously included smoking cessation resources, although R99 was in a vegetative state and not a smoker. The Director of Nursing acknowledged this error and the need for an update. Additionally, the facility did not invite R101, who was cognitively intact, to care conferences, despite the facility's policy requiring such invitations. R101 expressed a desire to attend these meetings, and the Social Services Director confirmed that all cognitively intact residents should be invited, regardless of their responsible party status. This oversight increased the risk of excluding residents' preferences and concerns from their care plans.
Failure to Develop Person-Centered Discharge Plan
Penalty
Summary
The facility failed to develop and implement a person-centered discharge plan for one resident, identified as R101, who was reviewed for discharge planning. According to the facility's policy, discharge planning should begin upon a resident's admission, with the attending physician reviewing the resident's progress to determine a possible discharge date. However, R101, who was cognitively intact with a BIMS score of 15 out of 15, expressed a desire to know the plan for returning home but had not attended any meetings to discuss discharge planning. Interviews revealed that the facility's social services staff did not engage with R101 regarding discharge preferences. Social Services (SS1) stated that R101 did not have a discharge plan because R101 was considered a long-term care resident, defined as anyone remaining in the facility past 90 days. The Social Services Director (SSD) confirmed that all residents should be asked about their discharge goals and desires but was unaware that SS1 had not spoken with R101 about discharge preferences. This lack of communication and planning led to the deficiency in discharge planning for R101.
Failure to Facilitate Ophthalmologist Referral for Cataract Surgery
Penalty
Summary
The facility failed to make an ophthalmologist referral order for a resident who required cataract surgery. The resident, who was admitted with diagnoses including diabetes mellitus with diabetic chronic kidney disease, had a Brief Interview for Mental Status (BIMS) score indicating moderate decision-making capacity. Despite a referral form dated nearly a year prior, there was no physician order for the resident to receive cataract surgery. The resident reported that her appointments were repeatedly canceled by the facility staff, and she felt that the staff did not want her to see an eye doctor, resulting in her vision remaining cloudy. Interviews with facility staff revealed a lack of awareness and follow-up regarding the ophthalmologist referral. The receptionist at the ophthalmologist's office confirmed that a referral was sent to the facility's social services department. However, the social services staff, including a new employee and the social services supervisor, did not recall receiving the referral. The facility's policy on referrals to social services indicated that staff should be aware of and coordinate services for residents' medical and psychosocial well-being, which was not adhered to in this case.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to adhere to physician orders for enteral feeding for a resident with chronic respiratory failure and hypoxia, increasing the risk of dehydration and weight loss. The resident, who was unable to participate in a BIMS assessment, had a physician order for enteral feeding with Jevity 1.5 at 60 ml/hr for 20 hours daily, starting at noon and stopping at 8 AM, to provide 1200 calories per day. However, on the specified date, the enteral feeding was not initiated at the scheduled time of 12:00 PM. Observations and interviews revealed that the resident's feeding pump was not turned on as ordered. The resident's spouse confirmed the pump had not been activated since their arrival at the facility at 12:50 PM. Further observation at 2:52 PM confirmed the pump remained off, and the registered nurse acknowledged the oversight, citing a lack of time to turn it on. This resulted in the resident missing three hours of feeding, equating to a 15% loss of the daily nutritional intake prescribed by the physician.
Incomplete Dialysis Communication Sheets for a Resident
Penalty
Summary
The facility failed to ensure that dialysis communication sheets were complete for a resident who required dialysis services. The facility's policy on dialysis care mandates that nursing staff communicate vital signs, weight, and any changes in the resident's condition to the dialysis provider in writing. Additionally, the dialysis provider is expected to communicate any problems encountered and ongoing monitoring requirements back to the facility. However, for one resident with end-stage renal disease, there were 17 instances over a period of 94 days where the dialysis communication sheets were missing, indicating a lapse in the required documentation and communication process. Interviews with the resident, the Administrator, and the Director of Nursing confirmed the deficiency. The resident, who attends dialysis three times a week, acknowledged taking her communication book to the dialysis center. Both the Administrator and the Director of Nursing confirmed that the communication sheets were not completed as expected. The Director of Nursing expressed an expectation that nurses complete the pre-dialysis sheet, send it to the dialysis center, and complete the post-dialysis portion upon the resident's return, which was not adhered to in this case.
Failure to Ensure Timely Mental Health Services for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with suicidal ideations, which could potentially contribute to continued suicidal thoughts and self-harm. The resident, who was readmitted with a traumatic brain injury and schizophrenia, expressed suicidal thoughts during a Minimum Data Set assessment in May 2024. Although a referral to a psychiatrist was made, there was no follow-up to ensure the consultation was completed. The resident later expressed feelings of loneliness and sadness, and it was noted that the resident had not been seen by a psychologist. Interviews with the social services staff revealed a lack of a check-and-balance system to ensure psychiatric consultations were completed. The Social Service Supervisor confirmed that a psychological referral was made in May 2024, but no follow-up was conducted. The resident was eventually seen and determined to be severely depressed, highlighting the facility's failure to ensure timely and appropriate mental health services for the resident.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to adhere to its policy on the storage of medications, resulting in the presence of expired medications, treatment supplies, and intravenous supplies in the Sub-Acute Medication Room. During an observation conducted with the Director of Nursing (DON), it was found that several medications, including Erythromycin, Famotidine, and Oseltamivir Phosphate, were expired. The Erythromycin bottle lacked an open or discard date, despite instructions to discard after 35 days of opening. Famotidine had been opened on 05/10/24 and should have been discarded by 06/10/24, but it remained in stock. Similarly, Oseltamivir Phosphate did not have an open or discard date, although it should have been discarded 17 days after opening. In addition to expired medications, the observation revealed expired treatment and intravenous supplies, such as Calamine Lotion, Grafco-Silver Nitrate Applicators, and a Dextrose 10% IV bag. The Calamine Lotion had an expiration date of 02/2024, the Silver Nitrate Applicators expired in April 2019, and the Dextrose IV bag expired in March 2024. During an interview, the DON acknowledged the issue of outdated medications and mentioned that a sweep had been conducted to remove expired items, with plans to implement a routine system for future removal of expired medications.
Failure to Establish Contract with Dialysis Center
Penalty
Summary
The facility failed to ensure a contract was completed with a dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy titled 'Service Agreements' mandates that the Administrator must keep an original signed and dated copy of all service agreements with vendors, consultants, and providers. However, upon review, it was found that the facility did not have a contract with the dialysis center where the resident received treatment. This oversight was confirmed during an interview with the Administrator, who acknowledged the absence of a contract with the dialysis center, thereby placing all residents receiving dialysis at potential risk.
Failure to Provide Timely Podiatry Services Leads to Severe Infection
Penalty
Summary
The facility failed to provide adequate podiatry services for a resident, resulting in a significant health issue. The resident, who had been admitted in 2016 with multiple complex medical conditions including dependency on a ventilator, tracheostomy, and anoxic brain damage, did not receive podiatry services for a year. This neglect led to excessive toenail growth, which subsequently caused a wound on the resident's right great toe when the nails were eventually trimmed. The wound developed a severe infection, progressing to osteomyelitis, and required hospitalization and antibiotic treatments. The deficiency was identified through interviews and record reviews. A podiatrist noted severely thick toenails and trimmed them, but during a subsequent visit, observed bleeding from the resident's right big toe, which had developed into an ulcer. The podiatrist ordered wound care and antibiotics, but the resident was hospitalized due to the severity of the infection. The wound was later diagnosed as osteomyelitis, and the same organism, MRSA, was found to be the causative agent for both the toe wound and a bloodstream infection. The resident's condition required extensive medical intervention, including intravenous antibiotics and multiple hospital visits. Despite these efforts, the resident's right great toe continued to require treatment for infection and dry gangrene. The facility's failure to ensure timely podiatry services directly contributed to the resident's deteriorating foot health and subsequent medical complications.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent from the responsible party (RP 1) before administering a COVID-19 vaccination to Resident 1, who had a history of significant medical conditions including ventilator dependency, tracheostomy, and anoxic brain damage. The responsible party had previously informed the facility in December 2021 not to vaccinate Resident 1 due to their compromised immune system. Despite this, the facility administered a COVID-19 vaccine to Resident 1 on 5/3/22 without obtaining the necessary consent from RP 1. This oversight resulted in Resident 1 experiencing swelling and probable pain in the vaccinated arm, which was noticed by RP 1 during a visit on 5/12/22. The facility's Director of Nursing confirmed awareness of the refusal to vaccinate Resident 1 due to their compromised immune system. The facility's policy required obtaining general consent for vaccinations, which could be given in various forms, but this procedure was not followed in this instance, leading to the deficiency.
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 1,057 citations issued within 25 miles in the last 12 months — including the 1 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 Alameda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay View Rehabilitation Hospital, Llc | 0.6 mi | ★★★★★ | 5 | 0 |
| Alameda Hospital D/p Snf | 0.6 mi | ★★★★★ | 2 | 0 |
| West Shore Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Marina Garden Nursing Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Fruitvale Healthcare Center | 2.2 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.