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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at All Saint's Maubert during CMS and state inspections, most recent first.
Missing DON Coverage: The facility failed to have a DON for more than 5 months. Interviews with the FDON, HR, and the Administrator showed the FDON was not the facility's designated DON, had been hired full time as DON at another facility, and had no oversight or responsibility for the facility's licensed nurses. A facility coverage log indicated there was no DON starting on 3/15/25, and there was no DON job posting on the facility careers page.
Improper storage of tube feeding formulas was observed in central supply when the items were kept less than 6 inches above the floor. The RD stated this created a risk for contamination from pests and could alter food temperature, and the facility P&P required dry storage food to be kept at least 6 inches off the floor.
Incomplete Care Plans for Psychotropic Medication Use: The facility failed to develop comprehensive care plans for three residents whose orders included psychotropic medications and behavior-related indications. One resident had antidepressant and antianxiety meds for sadness and inability to relax, another had antidepressant and PRN lorazepam for hopelessness, sadness, and anxiety, and a third had modafinil for sleep cycle. During record review, the ADON stated there were no care plans addressing the residents' target behaviors, despite the facility policy requiring measurable, person-centered care plans.
A facility failed to monitor target behaviors for three residents receiving psychotropic medications. One resident with anxiety, PTSD, and depression received Lorazepam, Bupropion, and Buspirone via NG tube; another resident with a mental disorder received PRN Lorazepam via PEG tube; and a third resident received Modafinil via PEG tube for sleep cycle. The MARs showed the medications were administered, but behavior monitoring was not documented, despite MRR recommendations for behavior and side effect monitoring.
Medication administration errors occurred when an LPN failed to use two resident identifiers for three residents during med pass and gave a resident fludrocortisone acetate despite a mismatch between the MAR and the bubble pack label. The label included hold parameters for BP and HR, while the MD order did not, and the pharmacist stated the directions should have been clarified. Facility staff also noted the medication had been held on several days and no care plan for the drug was found in the resident’s chart.
A resident with tracheostomy status had a soft wrist restraint applied to the left hand under a physician order to prevent pulling out medical tubes and devices. The ADON stated the restraint was used because of a history of pulling out the trach tube, but the MAR and progress notes did not document monitoring for tube-pulling, and the ongoing re-evaluation for the need for the restraint was not documented as required by policy.
PASRR Level II was not completed for a resident with paranoid schizophrenia after a positive PASRR Level I screening. The MDS Resource, MDSC, and ADON each stated the Level II evaluation was not done after the resident transferred from another facility, and the facility’s PASRR policy required screening and evaluation for residents identified with a mental disorder or ID.
Failure to provide grooming and nail care: A dependent resident with anoxic brain damage, a trach, and a respirator was observed with long thick toenails and unshaven facial hair. Staff confirmed the nails needed trimming, noted the resident was not diabetic, and stated grooming was expected to be provided by CNAs; the resident appeared unkempt during observation, and the podiatry referral process had only recently been initiated.
A facility failed to follow infection prevention protocols, including maintaining accurate infection tracking, timely reporting to public health authorities, and proper staff separation between infected and non-infected residents. These failures led to the spread of highly drug-resistant organisms among multiple residents, with staff working across two facilities and providing care to both infected and non-infected individuals.
A facility failed to designate a qualified Infection Preventionist (IP) solely responsible for its infection prevention and control program, instead sharing one IP between two separately licensed buildings. Despite the IP's warnings, staff were scheduled to work in both facilities during an outbreak, resulting in the spread of carbapenemase-resistant organisms (CPOs) among residents with complex medical needs, including those with tracheostomies and ventilator dependence. This cross-contamination was linked to inadequate infection control oversight and staffing practices.
Two residents with complex medical conditions and confirmed KPC infections did not have individualized care plans addressing their infection. The DON stated that the facility focused on isolation procedures rather than creating person-centered care plans for each infection, despite facility policy requiring comprehensive, updated plans for all residents.
The facility failed to separate clean and dirty items in the laundry room, improperly stored personal items with clean linens, and used the same mop head for both clean and dirty areas. Additionally, biohazardous waste was improperly stored, and there was no water management program to monitor Legionella, despite having a policy in place.
A facility failed to protect a resident's clothing from loss or theft. A family member reported missing clothing items after laundering. Observations revealed a bin of unlabeled items in the Laundry Department, which could not be returned to their owners. Interviews confirmed the lack of labeling, contrary to the facility's policy requiring inventory and labeling of residents' belongings.
A resident with chronic osteomyelitis and Stage IV pressure ulcers received inadequate wound care due to inaccurate documentation and improper hygiene practices by nursing staff. The RN misclassified wound stages and failed to measure wound depth, while the CNA used the same gauze for cleaning different areas, risking infection. The DON confirmed these actions were inconsistent with facility policy and NPUAP guidelines.
A resident with chronic osteomyelitis and Stage 4 pressure ulcers received inadequate wound care due to nursing staff's lack of competency. RN 1 incorrectly assessed the wound stages and failed to measure wound depth, while CNA 1 improperly used the same gauze for cleaning different areas, violating infection control practices. The DON confirmed these errors, highlighting a failure to follow NPUAP guidelines and facility protocols.
The facility failed to prevent food contamination during preparation and storage. Two kitchen staff did not wear hair nets, violating policy. Undated canned goods were found in storage, and bloody meat in the refrigerator had an incorrect date, exceeding the recommended thawing period. These issues risked residents consuming outdated food and developing foodborne illnesses.
The facility failed to maintain a safe environment due to nonoperational hallway lights, identified during an observation with the IP and MHD. The DON confirmed the broken lighting posed a safety risk, as nurses relied on these lights to read medication labels. Facility policies required immediate replacement of defective lights to ensure safety and well-being.
The facility breached privacy by displaying personal care information on signage above two residents' beds, visible to unauthorized individuals. This led to one resident feeling exposed and another's responsible party expressing disrespect. The DON acknowledged the signs should have been covered to maintain privacy.
A resident with chronic osteomyelitis and stage 4 pressure ulcers experienced ongoing pain and anxiety during wound treatments due to the facility's failure to update and implement a comprehensive care plan. Despite the resident's ability to communicate his needs, the care plan did not address his pain and breathing difficulties, and he did not receive pain medication for three days. The facility's policy to identify situations where pain might increase was not followed.
A resident with significant medical needs, including anoxic brain damage and hemiplegia, was found without prescribed foam boots for pressure injury prevention. Despite a physician's order and care plan requiring daily application of foam boots, observations showed the resident without them, highlighting a lapse in care by the nursing staff.
A resident with chronic osteomyelitis and pressure ulcers did not receive adequate pain management during wound care procedures. Despite expressing significant pain and requesting medication, the resident was not administered pain relief, leading to recurrent pain and anxiety. The facility's care plans and documentation failed to address and record the resident's pain complaints, and the staff did not follow the facility's pain management policy.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06%. One resident was given a multi-vitamin tablet instead of the prescribed liquid form, and another resident did not receive erythromycin ointment in both eyes as ordered. These errors were observed during medication administration by an RN, highlighting non-compliance with the facility's medication administration policy.
A facility failed to offer a COVID-19 vaccine to a resident, despite having a policy to do so. The resident, who was admitted with chronic osteomyelitis and pressure ulcers, was assessed to have intact mental abilities and was dependent on staff for care. The Infection Preventionist could not provide documentation that the resident was offered the vaccine, indicating a lapse in following the facility's vaccination policy.
Missing DON Coverage
Penalty
Summary
The facility failed to have a director of nursing for more than 5 months. During an interview on 8/18/25, the different Facility's Director of Nursing (FDON) stated they were not the facility's designated director of nursing and had only assisted in collaboration with the Assistant Director of Nursing (ADON) with duties requiring a registered nurse. During a concurrent interview and record review on 8/19/25, Human Resources reviewed FDON's acceptance letter to another facility, dated 4/4/25, and stated FDON had been hired full time as the director of nursing at another facility. During an internet search of the facility careers page on 8/19/25, there was no job posting for a director of nursing. During an interview on 8/19/25, the Administrator stated the facility did not have a director of nursing and had been attempting to hire one but was unable to find a suitable candidate. During an interview on 8/22/25, the FDON stated they did not have oversight or responsibility over the licensed nurses at the facility and had been hired as the full time director of nursing at a different facility. A handwritten facility document listing DON coverage from 9/3/23 to 8/22/25 indicated the facility did not have a DON starting on 3/15/25.
Improper Storage of Tube Feeding Formulas
Penalty
Summary
Food was not stored in accordance with professional standards when tube feeding formulas were observed in central supply stored less than six inches above the floor. During the survey observation on 8/18/25 at 3:09 p.m., surveyors found the food items stored below the required height. During an interview on 8/21/25 at 10:39 a.m., the Registered Dietician stated that food stored less than six inches above the floor was at risk for contamination from pests, could have altered food temperature, and had the potential to cause resident sickness. Review of the facility policy and procedure titled "Food Receiving and Storage," dated 2001, showed that food in designated dry storage areas is to be kept at least six inches off the floor.
Incomplete Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three sampled residents when their care plans did not address the use of psychotropic medications and related behavioral manifestations. Resident 2 had physician orders for bupropion for depression manifested by feeling sad, buspirone for anxiety manifested by inability to relax, and lorazepam as needed for anxiety manifested by restlessness and inability to relax. Resident 15 had orders for mirtazapine for depression manifested by feelings of hopelessness, sertraline for depression manifested by persistent sadness in response to prognosis, and lorazepam as needed for anxiety manifested by inability to relax. Resident 16 had an order for modafinil for sleep cycle. During interview and record review, the Assistant Director of Nursing searched the electronic health record for care plans addressing psychotropic medications and behavior manifestations for these residents and stated that the facility did not have care plans to address the residents' target behaviors. The facility's policy for comprehensive person-centered care plans stated that each resident is to have a care plan with measurable objectives and timetables to meet physical, psychological, and functional needs.
Failure to Monitor Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents receiving psychotropic medications were monitored for their target behaviors. Resident 2 had diagnoses including anxiety disorder, post-traumatic stress disorder, and depression, and was receiving Lorazepam PRN for anxiety, Bupropion for depression, and Buspirone for anxiety via NG tube. The record showed these medications were being administered, but there was no monitoring documented for the target behaviors associated with each medication. Resident 15 had a diagnosis of mental disorder, not otherwise specified, and was receiving Lorazepam PRN via PEG tube for anxiety manifested by inability to relax. The MAR showed the medication was administered, but there was no monitoring of the target behavior. Resident 16 was prescribed Modafinil via PEG tube for sleep cycle, and the MAR showed it was being given, but there was no monitoring documented for the target behavior related to sleep cycle. During interview and record review, the ADON stated the consultant pharmacist’s MRR recommended behavior monitoring and side effect monitoring, but behavior monitoring orders were not added and behaviors were not being monitored or documented for the three residents. The ADON also stated there were no care plans for the target behaviors for Residents 2, 15, and 16 and acknowledged that monitoring was important to determine whether the medications were effective and whether the residents still needed them.
Medication Administration Errors and Identification Failures
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with four errors observed in 33 medication pass opportunities for four of five sampled residents, resulting in a 12.12 percent medication error rate. During the medication pass observation, LVN 1 did not use the required minimum of two resident identifiers before administering medications to three residents, including Resident 10, Resident 16, and Resident 17. In interview, LVN 1 acknowledged she did not verify the residents’ identities and stated she knew them but should have checked the ID band and photo. During the same observation, LVN 1 administered fludrocortisone acetate 0.1 mg via PEG tube to Resident 9. The bubble pack label directed the medication to be held for BP less than 100 and HR less than 55, but the physician order for Resident 9 did not include those parameters. LVN 1 stated she did not hold the medication because the doctor’s order did not give parameters, and she was unsure whether the medication was for hypotension or hypertension. The pharmacist stated the medication is typically ordered for low blood pressure and that the hold parameters on the label did not make sense, and the original order had parameters that should have been clarified with the doctor. Record review and interviews showed the label and order did not match, and no clarification was documented. The ADON stated the nurse should have notified the pharmacy to update the bubble pack label and that a sticker should have been placed on the instructions to indicate no parameters on the current order. The ADON also stated the medication had been held on several days in July 2025 and that no care plan for fludrocortisone acetate could be found in Resident 9’s chart. The facility policy required the medication label and MAR to be compared before administration and for a direction change sticker to be applied if directions had changed from the current label.
Failure to Document Ongoing Need for Left Wrist Restraint
Penalty
Summary
The facility failed to adequately monitor and document the necessity of a soft wrist restraint for one resident with tracheostomy status. The resident was admitted in August 2025 with a diagnosis of tracheostomy status and was observed lying in bed with a soft wrist restraint on the left hand. The resident’s physician ordered that a soft wrist restraint may be applied to the left hand as clinically indicated to prevent the resident from pulling out medical tubes and devices to ensure safety and help achieve the optimum health outcome. During record review, the Assistant Director of Nursing stated the resident’s reason for the left wrist restraint was a history of pulling out the tracheostomy tube. However, the resident’s records from 8/16/25 through 8/19/25 did not document monitoring of pulling out medical tubes in the MAR or progress notes, and the ongoing re-evaluation for the need for restraints was not documented as required by the facility’s restraint policy. The restraint remained applied on the left wrist during the reviewed period.
PASRR Level II Not Completed for Resident With Schizophrenia
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for one sampled resident with paranoid schizophrenia was completed and coded accurately. The resident’s admission record showed a diagnosis of paranoid schizophrenia, a severe mental disorder characterized by hallucinations and delusions, and the resident had been admitted from another facility. During interview and record review, the MDS Resource stated the resident’s PASRR Level I screening was positive and required a PASRR Level II evaluation, but the Level II was not completed because the resident had been discharged from another facility and transferred to the current facility, and another submission was needed. The MDS Coordinator stated she did not receive a PASRR for the resident from admissions or the business office, and the ADON stated the PASRR II was not completed even though it needed to be rescheduled. The facility policy stated residents must be screened for a mental disorder or intellectual disability prior to admission and those identified must be evaluated and receive care and services in the most integrated setting appropriate to their needs.
Failure to Provide Grooming and Nail Care
Penalty
Summary
The facility failed to ensure one of two sampled residents received good grooming when Resident 6 had long, thick toenails and facial hair. Resident 6 was readmitted on [DATE] and originally admitted on [DATE] with diagnoses including anoxic brain damage, and was dependent on a respirator and tracheostomy. The Minimum Data Set dated 8/8/25 indicated Resident 6 was dependent on staff for hygiene. During an observation on 8/19/25, a CNA confirmed Resident 6's toenails needed trimming and stated she was new and it was her first time working with him. On 8/20/25, an LVN stated nurses cut nails for non-diabetic residents and that diabetic residents are referred to a podiatrist, and later stated Resident 6 was not diabetic and she did not know how long the toenails had been long. On 8/21/25, Resident 6 was observed lying in bed with gray facial hair above the lips and below the nose, around the cheeks and chin, unshaven and appearing unkempt. An LVN confirmed Resident 6 needed shaving and stated the CNA was supposed to shave him. The ADON stated it was not okay for Resident 6's nails to be long and acknowledged the facial hair, stating the expectation was for CNAs to groom residents. The SSD stated referrals to the podiatrist are sent within 24 to 48 hours when notified by nursing, and that Resident 6 had just been added to the podiatry list on 8/19/25.
Failure to Implement Infection Control Practices Resulting in CRO Outbreak
Penalty
Summary
Facility 1 failed to implement and follow proper infection prevention and control practices, resulting in the spread of Carbapenemase-Resistant Organisms (CROs) among residents. The facility did not maintain an accurate and updated line list for tracking infections, as evidenced by missing laboratory test dates and incomplete records for several residents who became infected. This lack of documentation made it difficult to determine when infections were identified and to monitor the progression of the outbreak. Additionally, the facility had only one Infection Preventionist (IP) shared between two separately licensed facilities, contrary to regulatory requirements, and the administrator was unaware that each facility should have its own IP. The facility also failed to notify the California Department of Public Health (CDPH) in a timely manner about the outbreak. The IP admitted to forgetting to report new cases and was unclear about the reporting requirements, despite facility policies stating that even a single case of a highly communicable infection should be reported. This delay in notification hindered appropriate public health response and oversight during the outbreak. Furthermore, direct care staff were not properly separated between infected and non-infected residents, nor between the two facilities. Staff were scheduled to work in both facilities on the same day, including providing care to residents on contact precautions for KPC and then to residents not on precautions. The scheduling coordinator and DON acknowledged that staff should not have been shared between facilities, especially during an outbreak, and that this practice contributed to the transmission of CROs. Observations confirmed that staff worked double shifts across both facilities, increasing the risk of cross-contamination and further spread of infection among residents.
Failure to Designate a Qualified Infection Preventionist Led to CPO Outbreak
Penalty
Summary
Facility 1 failed to ensure that a qualified and designated Infection Preventionist (IP) was responsible for adequately assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program (IPCP). Instead, one IP was assigned to cover both Facility 1 and Facility 2, which are separate entities operating under different licenses. The IP reported that she was required to work across both facilities, averaging 45 hours per week, and stated that each facility required a full-time IP to effectively manage infection control. Despite the IP's instructions to prevent staff from working in both facilities during an outbreak, the scheduling coordinator continued to assign direct care staff to work double shifts in both locations, contributing to the spread of infection. A review of facility records and laboratory reports revealed an increase in Carbapenemase-Resistant Organism (CPO) infections in Facility 1, including cases of Klebsiella Pneumoniae Carbapenemase (KPC), New Delhi Metallo-β-lactamase (NDM), and Carbapenem-Resistant Pseudomonas aeruginosa (CRPA). The affected residents had complex medical histories, including conditions such as encephalopathy, acute respiratory failure, tracheostomy status, ventilator dependence, traumatic brain injury, spastic quadriplegic cerebral palsy, and myotonic muscular dystrophy. The cross-contamination and transmission of these infections to non-infected residents were linked to the failure to implement effective infection control measures and the sharing of staff between the two facilities during an outbreak. Interviews with the IP and the facility administrator confirmed that there was only one shared IP for both facilities, and the administrator was unaware of the regulatory requirement for each facility to have its own IP. The facility's policy stated that the IP should be employed on-site and scheduled with enough time to properly manage the IPCP, but this was not followed. The lack of a dedicated IP for Facility 1 and the continued sharing of staff between facilities during an outbreak directly contributed to the increase and transmission of multi-drug resistant organism infections.
Failure to Develop Comprehensive Care Plans for Residents with KPC Infection
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who tested positive for Klebsiella Pneumoniae Carbapenemase (KPC), a highly drug-resistant infection. Both residents had complex medical conditions, including encephalopathy, acute respiratory failure, tracheostomy status, and, for one resident, ventilator dependence. Laboratory reports confirmed the presence of the KPC gene in both individuals. Despite these findings, a review of their care plans revealed that neither resident had a care plan addressing their KPC infection. During interviews, the DON acknowledged that care plans should have been created for all residents with infections, especially during an outbreak, but admitted that the facility focused only on isolation types rather than individualized plans for specific infections. The facility's policy required individualized, comprehensive care plans with measurable objectives and timetables for each resident, incorporating identified problems and risk factors, and updating plans as residents' conditions changed. However, these requirements were not met for the two residents with KPC infections.
Infection Control Deficiencies in Laundry and Waste Management
Penalty
Summary
The facility failed to implement effective infection control and prevention policies, as evidenced by several observations. In the laundry room, clean items such as mop heads, cleaning cloths, and Restorative Nurses Aids (RNA) slings were stored in the same area as dirty laundry, with no clear separation. Personal items belonging to a staff member, including a sweater, shawl, and a cup of coffee, were found in the area designated for clean resident linens. Additionally, a Laundry Aide mopped both clean and dirty areas with the same mop head and was unaware of the chemicals used in the mopping solution, which was not in compliance with the facility's maintenance policy. In the Soiled Utility Room, used suction canisters were improperly stored with biohazardous sharps containers, contrary to the facility's policy on medical waste segregation. Furthermore, the facility lacked a water management program to monitor and test for Legionella, despite having a policy in place. The Maintenance/Housekeeping Director confirmed the absence of a process to ensure the water system was free of Legionella, which was a requirement according to the facility's Legionella Water Management program.
Failure to Protect Resident's Clothing from Loss
Penalty
Summary
The facility failed to protect a resident's clothing from loss or theft, as observed in the case of one resident among eleven sampled. The deficiency was identified through interviews, observations, and record reviews. A family member reported that the resident had multiple clothing items laundered by the facility that were never returned. During an observation in the facility's Laundry Department, a bin was found containing unlabeled residents' items, including clothing, which could not be returned to their original owners due to the lack of labeling. Interviews with the Maintenance/Housekeeping Director and the Laundry Aide confirmed that the items in the laundry bin were unlabeled, making it impossible to identify their owners. The facility's policy and procedure on personal property indicated that residents' belongings should be inventoried, labeled, and documented upon admission and updated as necessary. However, this procedure was not followed, leading to the loss of the resident's clothing.
Inadequate Wound Care and Documentation
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for Resident 66, who was admitted with chronic osteomyelitis and Stage IV pressure ulcers on both heels and buttocks. The nursing staff inaccurately documented the wound status, with RN 1 incorrectly identifying a Stage IV buttock wound as Stage III and failing to measure the wound depth or tunneling. Additionally, RN 1 misclassified the heel wounds as Stage I, despite them being deep tissue injuries, which should be considered at least Stage II or IV according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. During wound care, RN 1 and CNA 1 did not perform hand hygiene before donning gloves, which is against the Centers for Disease Control (CDC) hand hygiene guidance. CNA 1 improperly cleaned the wound by using the same gauze to clean the anus and then the perimeter of the buttock wound, increasing the risk of infection. The Director of Nursing confirmed these practices were inconsistent with the facility's policy and the NPUAP guidelines. Physician 1, who conducted weekly wound assessments, emphasized the importance of accurate wound assessment and documentation by nursing staff between his visits. He noted that significant changes could occur within the week, and accurate documentation was crucial for effective wound management. The facility's policy required detailed documentation of wound characteristics, which was not adhered to in this case.
Inadequate Wound Care Competency in Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and competencies to perform wound care treatments for Resident 66, who was admitted with chronic osteomyelitis and Stage 4 pressure ulcers on both heels and buttocks. During an observation, Registered Nurse 1 (RN 1) incorrectly assessed the stage of the pressure wounds and did not measure the depth or tunneling of the wounds. RN 1 admitted to still learning how to assess pressure wounds, which indicates a lack of competency in wound care assessment and documentation. Additionally, during the wound care procedure, Certified Nursing Assistant 1 (CNA 1) used the same gauze to clean the resident's anus and the perimeter of the buttock wound, which is against proper infection control practices. The Director of Nursing (DON) confirmed that the CNA should not have used the same gauze for both tasks and that gloves should be changed between handling dirty and clean dressings. The DON also confirmed that RN 1's assessment of the wounds was incorrect according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. The physician responsible for Resident 66's weekly wound assessments confirmed that the resident had bilateral Stage IV ischial wounds and deep tissue injury wounds on both heels. The physician emphasized the importance of accurate wound assessment and documentation by nursing staff between his visits, as significant changes could occur. The facility's policy and procedure for pressure injuries also outlined the need for accurate assessment and documentation of wound characteristics, which was not adhered to in this case.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to its policies and procedures designed to prevent food contamination during preparation and storage. During an observation, it was noted that two kitchen staff members, including the Kitchen Manager/Registered Dietitian and a cook, were not wearing hair nets while in the kitchen. This was in violation of the facility's policy, which mandates that dietary staff must wear hair restraints to prevent hair from contacting exposed foods. Additionally, the facility's dry storage room contained several undated cans of food, including diced tomatoes, mandarin oranges, and fruit cocktail, which should have been marked with a use-by date according to the facility's policy. Furthermore, a refrigerator in the facility contained bloody meat in a metal pan, covered with plastic wrap, with a date that was not clearly defined. The meat had been placed in the refrigerator to thaw, but the date on the label was incorrect, and the meat had been in the refrigerator for five days, which exceeded the recommended thawing period. These oversights placed residents at risk of consuming outdated food and developing foodborne illnesses.
Nonoperational Hallway Lights Pose Safety Risk
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment due to nonoperational overhead lights in the hallway of 2-South. This deficiency was identified during an observation and interview conducted on October 24, 2023, at 1:45 p.m., with the Infection Preventionist and the Maintenance/Housekeeping Director. The Director of Nursing and the Administrator confirmed during a subsequent interview that the broken lighting posed a safety risk, as nurses relied on the overhead lights to read medication labels accurately when administering medications. The facility's policy and procedure documents, titled 'Interior General Maintenance' and 'Maintenance Policy & Procedure,' both dated December 31, 2015, were reviewed. These documents indicated that defective light bulbs or buzzers should be replaced immediately and emphasized the importance of maintaining a safe, sanitary, and functional environment to ensure the safety and well-being of residents, staff, and the public. The failure to adhere to these policies placed residents at risk of receiving incorrect medications and increased the risk of falls for residents and visitors.
Privacy Breach Due to Visible Personal Care Signage
Penalty
Summary
The facility failed to respect the privacy rights of two residents by displaying personal care information on signage above their beds, visible to unauthorized individuals. In a shared room, signage above one resident's bed indicated specific care instructions, such as 'Do Not Use Pink Chucks,' while the other resident's signage included instructions like 'Be Careful Turning On Left Side' and 'Only Use Latex Free Condoms.' These signs were visible to any visitors, leading to one resident feeling exposed and the responsible party of the other resident expressing feelings of disrespect. During an interview, the Director of Nursing acknowledged that the signs should have been covered to maintain the residents' privacy and dignity.
Failure to Update Care Plan for Resident's Pain and Anxiety
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced ongoing pain and emotional distress during wound treatments. The resident, admitted with chronic osteomyelitis and stage 4 pressure ulcers on both heels and buttocks, was totally dependent on staff for care and had intact mental abilities. Despite the resident's ability to communicate his needs, the care plan did not address his pain and anxiety during wound treatments, leading to continued suffering. During wound care, the resident reported a pain level of seven out of ten and difficulty breathing when positioned on his right side, a known issue due to a history of a collapsed lung. The resident had repeatedly informed staff of his pain and breathing difficulties, yet the care plan was not updated to reflect these concerns. The Director of Nurses confirmed that the resident had not received pain medication for three days, despite complaints of pain, and there was no documentation of these complaints in the nurse progress notes. The facility's policy required staff to identify situations where pain might increase, such as during wound care, but this was not followed.
Failure to Apply Pressure Injury Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure injury reducing devices were applied for a resident, which had the potential to worsen an existing wound and develop a new one. The resident, who was admitted with anoxic brain damage, hemiplegia, moderate protein-calorie malnutrition, muscle wasting, and dependence on a ventilator, was dependent on staff for all aspects of care, including footwear. A physician's order required foam boots to be applied daily for pressure prevention. Observations revealed that the resident was found without foam boots on multiple occasions. On one occasion, a CNA observed the resident without foam boots and subsequently applied them. The Assistant Director of Nursing confirmed that the care plan required the application and removal of foam boots as per routine order, and that nursing staff were responsible for this task. The facility's policy indicated that nursing staff should document and report current treatments, including support surfaces.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 66, who was admitted with chronic osteomyelitis and pressure ulcers on both heels and bilateral ischium. Despite having a care plan that required assessing pain every shift and administering medication as ordered, the facility did not provide pain medication to Resident 66 prior to a painful wound care procedure. During an observation, Resident 66 expressed a pain level of seven out of ten and requested pain medication, but the attending nurse did not administer any medication, instead advising the resident to 'hang in there.' This lack of action resulted in the resident experiencing recurrent pain and anxiety during daily wound treatments. Further investigation revealed that Resident 66 had not received pain medication for three consecutive days, despite complaints of significant pain. The Director of Nurses confirmed that there was no documentation of the resident's pain complaints in the nurse progress notes, and the care plans did not address wound treatments and associated position changes as potential sources of pain. The facility's policy required staff to identify situations where an increase in pain might be anticipated, such as during wound care, but this was not adhered to. The physician responsible for the resident's care expected nurses to conduct pain assessments and medicate as needed, which was not done in this case.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06% during a medication administration observation. This deficiency involved two residents. Resident 8, who was admitted for protein-calorie malnutrition, muscle wasting and atrophy, and dysphagia, was incorrectly administered a multi-vitamin with minerals tablet instead of the prescribed multi-vitamin with minerals liquid 15 mL. The error was identified during a medication pass observation with RN-2, who confirmed that the tablet was given in place of the liquid form, which was not ordered for Resident 8. Additionally, Resident 65 did not receive the prescribed erythromycin ophthalmic ointment in both eyes as ordered by the physician. During the medication pass, RN-2 applied the ointment only to the right eye, despite the order specifying application to both eyes for an eye infection. The facility's policy on administering medications, which requires adherence to prescriber orders and proper documentation, was not followed in these instances, contributing to the medication errors observed.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to implement its COVID-19 Vaccine Policy and Procedure for a resident, identified as Resident 66, among the eleven sampled residents. Resident 66 was admitted to the facility on October 9, 2023, with diagnoses including chronic osteomyelitis and pressure ulcers on both heels and bilateral ischium. The Minimum Data Set (MDS) assessment dated October 13, 2023, indicated that Resident 66 had intact mental abilities, could communicate needs, and was entirely dependent on facility staff for care, including mobility and repositioning. During an interview and record review on October 25, 2023, the Infection Preventionist (IP) was unable to provide documentation that Resident 66 had been offered the opportunity to receive a COVID-19 vaccination. The facility's policy stated that all residents and staff should be offered an approved COVID-19 vaccine unless medically contraindicated. However, there was no evidence that Resident 66 was assessed for eligibility or offered the vaccine, leading to a deficiency in the facility's adherence to its vaccination policy.
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What surveyors actually found near you
We read the 794 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Leandro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| All Saint's Subacute & Transitional Care | 0 mi | ★★★★★ | 2 | 0 |
| Alameda County Medical Center D/p Snf | 0.2 mi | ★★★★★ | 0 | 0 |
| Kaiser Permanente Post-acute Care Center | 1 mi | — | 0 | 0 |
| Washington Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Valley Pointe Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 20 | 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.