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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at All Saint's Subacute & Transitional Care during CMS and state inspections, most recent first.
Incomplete and inaccurate controlled medication records were found for several residents after surveyors reviewed Shipping Manifests, CDRs, and MARs. The MRD and DON could not produce CDRs for multiple controlled medication deliveries, and for one resident the CDR showed oxycodone doses removed that were not documented on the MAR. The facility’s consultant pharmacist summary did not note any scheduled medication accountability problems.
Unlicensed OM Served as Administrator: The facility failed to ensure a licensed NHA was overseeing operations when OM acted as the administrator for more than 11 months. State records showed OM did not hold an active NHA license, yet facility reports, resident council documentation, grievance records, and a contractor agreement identified OM as the administrator and showed OM signing and handling administrator duties, while the DON confirmed OM served in that role during the period reviewed.
Tracheostomy care was deficient for two residents. One resident with TBI, persistent vegetative state, and a trach had a care plan calling for suctioning, but no physician order for suctioning was in the chart and RT documentation did not show the times suctioning was performed. Another resident with respiratory failure, trach status, ventilator dependence, and pneumonia had a manual resuscitator bag left unlabeled and uncovered on top of an O2 cylinder near the bathroom, with tubing touching the floor instead of being stored with the resident’s emergency respiratory supplies.
A resident with TBI, post traumatic seizures, G-tube status, persistent vegetative state, and an indwelling catheter had physician-ordered I&O monitoring each shift and a nightly 24-hour total. The MAR did not show PM shift I&O monitoring or the 24-hour I&O total, and the DON confirmed the licensed nurse did not implement or document the ordered hydration monitoring.
Incomplete MAR Documentation for Administered Medications: A resident with TBI, post traumatic seizures, gastrostomy status, and persistent vegetative state had meds documented in the progress notes as given by an LPN at 0500, but the MAR did not reflect the administration. RN confirmed another nurse gave the meds, and the DON verified the MAR was missing documentation for valproic acid and propranolol, which were scheduled for 0600 and could be given up to one hour early.
Failure to Use Required Gown During Contact Precautions Cleaning: A resident on contact precautions for MRSA wounds and with a tracheostomy was in the room while a housekeeper cleaned an unoccupied bed and other room surfaces wearing gloves but no isolation gown. The housekeeper moved in and out of the room, handled supplies, removed privacy curtains, and discarded used towels without the required gown, despite the facility policy and the IP's statement that gown and gloves were required for cleaning the entire room environment.
A resident with Type 2 DM and a G-tube, who was cognitively intact and care planned for imbalanced nutrition and risk of unstable blood glucose, did not receive ordered blood glucose monitoring and Humalog insulin per sliding scale at a scheduled time. The resident and responsible party reported missed blood sugar checks and insulin doses on multiple occasions, including one specific evening. Review of the MAR confirmed that the blood sugar was not checked and insulin was not administered at the ordered time, and no justification was documented by the nurse, contrary to facility policies requiring adherence to provider orders and timely medication administration.
Staff failed to follow PPE and hand hygiene requirements for two residents on contact precautions. One resident with diabetes and a G-tube had a housekeeper enter the room, clean the bathroom, and handle trash without PPE or hand hygiene, despite posted contact precaution signage and facility policy. An RN also entered this resident’s room without PPE, administered G-tube medication, checked blood sugar, and gave insulin, then left the room without performing hand hygiene, later acknowledging that PPE and hand hygiene were required but citing an empty PPE rack at the door. Another resident with a tracheostomy, G-tube, and ventilator-associated pneumonia had a CNA empty a urinary drainage bag while wearing a gown and gloves, then exit the room, remove the gown in the hallway, keep the soiled gloves on while walking to the nurse’s station, and touch clean gowns without performing hand hygiene, again in conflict with the posted "5 Moments for Hand Hygiene" and the facility’s hand hygiene policy.
Three residents did not receive necessary care as required by their care plans and facility policy. Two residents, both fully dependent on staff for oral hygiene due to complex medical conditions, were observed with significant oral debris and dryness, indicating oral care was not performed as required each shift. Another resident, who was comatose and dependent for toileting, was found by a family member lying on a urine-saturated draw sheet, with facility records showing a lapse in required two-hour safety checks and repositioning. Staff interviews confirmed inconsistencies in care delivery.
A facility failed to follow infection control recommendations from public health authorities, including halting new admissions and resident transfers, submitting required monitoring logs, and ensuring staff adherence to hand hygiene and PPE protocols. Direct care staff were observed entering rooms of residents on contact precautions without proper hand hygiene or PPE, and staff caring for infected and non-infected residents were not separated. These failures led to the spread of multi-drug resistant organisms and carbapenem-resistant organisms among numerous residents, many with complex medical conditions.
Four residents with complex medical conditions and confirmed NDM infection did not have individualized care plans addressing their antibiotic-resistant infection. The facility focused on isolation procedures rather than creating person-centered care plans specific to each resident's infection, contrary to facility policy and best practices.
The facility failed to accurately document controlled substances for two residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). For one resident, alprazolam was not recorded on the MAR, and for another, morphine orders were inconsistently documented. Additionally, the medication cart was found unlocked twice, contrary to facility policy requiring it to be locked when out of view.
The facility failed to properly store and label medications, including acetylcysteine without open dates, an insulin pen stored outside the refrigerator, and oral medications mixed with eye drops. Additionally, eye drops were labeled only with room numbers, risking administration errors.
The facility's kitchen staff demonstrated incompetence in essential procedures, including incorrect thermometer calibration, improper sanitizer testing, and misuse of sanitizing solutions, risking contamination for 22 residents.
The facility failed to follow food safety standards by using expired seasonings and maintaining unclean kitchen equipment. Eight seasonings were found expired or beyond use-by dates, and a tabletop can opener had residue build-up. The Registered Dietician confirmed these issues, which put 22 residents at risk for foodborne illnesses.
Two residents in an LTC facility, both with significant medical conditions and total dependence on staff for personal hygiene, were observed with long, thick facial hair, indicating a failure to provide necessary grooming assistance. A CNA was unsure of her responsibilities, and the DON acknowledged the risk of skin irritation and compromised dignity. Facility policy requires assistance for residents unable to perform ADLs.
A resident with a tracheostomy and ventilator dependence did not receive proper care as their tracheostomy tie was not changed daily as ordered by the physician. The tie, last changed nearly a month prior, posed risks of skin irritation and infection. Discrepancies were noted between the facility's practice and the physician's order, with staff acknowledging the oversight.
A facility failed to implement a consultant pharmacist's recommendations for a resident's medication regimen. The resident continued to receive quetiapine without the correct indication documented, despite recommendations to update the diagnosis to 'dementia with behaviors - biting'. The facility's policy requires action on such recommendations within 30 days, which was not followed.
The facility did not meet the required 80 square feet of space per resident for 13 residents in 6 multi-bed rooms, with space per bed ranging from 72.87 to 79.75 square feet. Despite this, care provision was not hindered, and residents had adequate personal space and privacy, with no complaints or negative consequences reported.
Incomplete and inaccurate controlled medication records
Penalty
Summary
The facility failed to maintain complete and accurate controlled medication accountability records for Residents 3, 4, 6, and 7. During interviews, the MRD and DON described the process for receiving, filing, and destroying controlled medications, including use of Shipping Manifests, Controlled Drug Records (CDRs), MARs, and destruction documentation. When surveyors requested Shipping Manifests from 9/1/22 through 12/31/22, the MRD identified several controlled medication deliveries for residents including oxycodone and hydrocodone/APAP, but the corresponding CDRs for Resident 3, Resident 4, and Resident 6 could not be located. The DON also reviewed the facility’s policy, which required an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed. For Resident 7, the DON reviewed CDR 4821618.01 for oxycodone 5 mg tablets and found doses documented as removed on 1/11/23, 1/25/23, 1/31/23, 2/1/23, and 2/4/24, but those doses were not documented on the resident’s MAR. The DON stated the facility was unable to provide the missing CDRs for the identified controlled medications, and the Executive Quarterly Summary of the Consultant Pharmacist’s Medication Regimen Review did not document scheduled medication accountability problems. The report also states the facility did not have complete records and did not have accurate records.
Unlicensed OM Served as Administrator
Penalty
Summary
The facility failed to ensure that a state-licensed Nursing Home Administrator was overseeing facility operations when the unlicensed Operations Manager (OM) assumed the role of administrator for more than 11 months. State licensing records showed OM did not hold a nursing home administrator license, and the state nursing home database listed ADM 2 and later ADM 3 as the reported administrators during the relevant period, while OM was not listed as a former administrator. Facility financial self-reports, resident council documentation, grievance forms, and a contract all identified OM as the administrator and showed OM signing or being assigned duties in that role. Records reviewed included a resident council response form dated 10/1/22 signed by OM as Administrator, a grievance for Resident 9 about the facility environment that was attended by OM as Administrator along with the DON, SSD, and maintenance manager, and a grievance for Resident 10 about contractors entering the room without announcement that was assigned to OM as administrator and documented a meeting attended by OM as Administrator. A contractor services agreement dated 9/22/22 was also signed by OM as administrator. During interview, the DON stated OM was the facility administrator for the period reflected in the facility document reviewed. State law and regulation reviewed indicated that a person may not act as an administrator without an active nursing home administrator license, and that an administrator is a person licensed by the California Board of Examiners of Nursing Home Administrators.
Tracheostomy suctioning lacked order and time documentation; emergency respiratory equipment was improperly stored
Penalty
Summary
Resident 1, who was admitted with traumatic brain injury, persistent vegetative state, and tracheostomy, had a care plan initiated for tracheostomy care that stated the resident required suctioning for airway clearance as per physician order and as needed for emergency care. However, the Order Summary Report did not include an order for tracheostomy suctioning. The Respiratory Therapy Airway Assessment documented that suctioning was provided every two hours and as needed, but it did not include time-specific documentation showing when each suctioning intervention was performed. During interview, the RN assigned to Resident 1 stated she documented the suctioning she provided in the RT notes, but those notes did not identify the times suctioning occurred. The RT Manager stated tracheostomy suctioning was treated as standard practice for residents with tracheostomies even without a physician order, and that staff determined when to suction based on endorsement rather than a scheduled time. The RT Manager also stated he did not believe documenting the time suctioning was performed was necessary as long as respiratory care was being provided. The Infection Preventionist stated suctioning required a physician order because it was invasive and that if suctioning was required every two hours, staff were expected to follow the schedule and document the time it was performed. Resident 2 was admitted with respiratory failure, tracheostomy status, ventilator dependence, and pneumonia. During observation, the resident was sleeping in bed connected to the ventilator, and the emergency respiratory supplies at bedside did not include a manual resuscitator bag. An unlabeled manual resuscitator bag was found outside the bathroom door, stored without a protective covering on top of a portable oxygen cylinder, with the attached tubing touching the floor. The LVN stated the bag belonged to Resident 2, should not have been left there, had already been exposed to dirt, and should have been stored in a protective bag. The RT Manager stated the bag was used by the resident when going to the bathroom but remained the designated emergency bag and should have been stored properly in a protective bag and kept readily accessible.
Failure to Document Ordered I&O Monitoring
Penalty
Summary
The facility failed to ensure hydration monitoring was implemented for one resident who had orders for intake and output monitoring each shift and for a total 24-hour I&O calculation every night shift. The resident’s record showed diagnoses including traumatic brain injury, post traumatic seizures, gastrostomy status, and persistent vegetative state. The care plan identified the resident as at risk for dehydration or electrolyte imbalance related to enteral nutrition and also noted an indwelling catheter related to neurogenic bladder, with intake and output monitoring listed as an intervention for both care plans. The physician order summary directed staff to monitor I&O each shift, calculate the total 24-hour I&O by combining the previous AM and PM shifts, and report significant changes in fluid balance to the physician. However, the MAR for the month did not reflect PM shift I&O monitoring or the calculated 24-hour I&O for the identified date. During interview and record review, the DON confirmed the PM shift I&O monitoring and the 24-hour total were not implemented or recorded, and stated the licensed nurse should have provided and documented the monitoring to determine the resident’s hydration status. The facility’s policies for measuring and recording intake and output described recording the amount consumed and output in a 24-hour period.
Incomplete MAR Documentation for Administered Medications
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for one sampled resident when a licensed nurse documented in the progress notes that medications were administered at 5:00 a.m. on 6/16/26, but those medications were not documented on the resident’s MAR. The resident’s admission record showed a history of traumatic brain injury, post traumatic seizures, gastrostomy status, and persistent vegetative state. The progress notes for the night shift indicated medication administration at 0500 per orders, but the MAR for 6/1/26 through 6/30/26 did not reflect that administration. During interviews, RN 1 stated another licensed nurse was assigned to administer the resident’s medications and that the nurse confirmed the medications were given at 5:00 a.m. The DON reviewed the record and confirmed the MAR did not show the medications administered at that time. The DON identified the medications as valproic acid and propranolol, both scheduled for 6:00 a.m., and stated the nurse was permitted to administer them up to one hour early. The DON stated the medications should have been documented on the MAR and noted that the missing documentation could have negatively impacted adherence to the five rights of medication administration.
Failure to Use Required Gown During Contact Precautions Cleaning
Penalty
Summary
The facility failed to ensure staff followed its infection control policies for one sampled resident who was on contact precautions for MRSA associated with wounds to the left foot and left leg. The resident had been admitted with a tracheostomy and, according to the physician's order, remained on contact precautions related to MRSA. During observation, a Contact Precautions sign was posted on the outside of the resident's room door, and the resident was in bed near the door while a housekeeper was inside the room cleaning an unoccupied bed with a moist towel while wearing gloves but no isolation gown. The housekeeper moved in and out of the room multiple times to get cleaning supplies, continued wiping the bed, climbed a ladder with gloved hands, removed used privacy curtains, and stepped out of the room to discard used towels, all without wearing the required gown. In interview, the housekeeper stated a gown and gloves were required when cleaning surfaces in a Contact Precautions room, even if the bed was unoccupied. The Infection Preventionist stated housekeepers were required to wear an isolation gown and gloves when cleaning the environment in a room where a resident was on Contact Precautions, because the whole room was considered contaminated. The facility's Contact Precautions policy stated staff wear a disposable gown upon entering the room and remove it before leaving the room.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a resident with Type 2 Diabetes Mellitus and a G-tube did not have blood glucose monitoring and insulin administration performed as ordered. The resident’s admission record showed diagnoses including Type 2 Diabetes Mellitus with hyperglycemia and gastrostomy status, and the MDS assessment documented intact cognition with a BIMS score of 15 and a diagnosis of Diabetes Mellitus. The resident’s care plan, initiated in April 2023, identified imbalanced nutrition related to insulin resistance and risk for complications such as unstable blood glucose and cardiovascular disease, with an intervention specifying diabetes medication as ordered by the physician. During an interview with the resident and the resident’s responsible party, both reported that the resident’s blood sugar was not checked and insulin was not administered on multiple occasions, including a specific evening. Review of the MAR for that date and time confirmed that the resident’s blood sugar was not checked and Humalog insulin, ordered every six hours per sliding scale, was not given at the scheduled 6:00 p.m. dose, and the licensed nurse did not document any justification for the missed insulin administration. The facility’s policies on diabetes care and medication administration required following provider orders for blood glucose monitoring, assisting with the prescribed medication regimen, and administering medications safely, timely, and in accordance with prescriber orders within one hour of the prescribed time, which was not followed in this instance.
Failure to Follow PPE and Hand Hygiene Requirements for Residents on Contact Precautions
Penalty
Summary
The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies, including contact precautions and hand hygiene, for two residents on contact precautions. Resident 1’s admission record showed admission with diagnoses including Type 2 diabetes mellitus with hyperglycemia and gastrostomy status, and a physician’s order placed the resident on contact precautions. Facility signage outside the room directed everyone to clean their hands before entering and when leaving, and directed staff to don gloves and gowns before room entry and discard them before room exit. Despite this, a housekeeper entered Resident 1’s room without any PPE, cleaned and emptied the bathroom and trash bins, then exited the room and did not perform hand hygiene. The housekeeper stated she knew PPE was required when cleaning Resident 1’s room but reported there was no PPE supply available that morning on the rack. Further noncompliance with infection control measures occurred when an RN provided direct care to Resident 1 without PPE and without performing hand hygiene. Resident 1’s physician orders confirmed contact precautions, and the facility’s hand hygiene policy required hand hygiene after contact with blood, body fluids, contaminated surfaces, after touching a resident, after touching the resident’s environment, and immediately after glove removal. During observation and interview, the RN was seen in Resident 1’s room without PPE, then exited without hand hygiene. The RN acknowledged that PPE was supposed to be worn because the resident was on contact precautions and explained that the PPE rack on the door was empty and PPE was stored at the nurse’s station. The RN confirmed having direct contact with Resident 1 by administering medication via G-tube, checking blood sugar, and giving insulin, and acknowledged not performing hand hygiene after this direct care and that this created an increased risk of transmission of infection. Resident 2’s records showed admission with tracheostomy status, gastrostomy status, and ventilator-associated pneumonia, and a physician’s order and care plan placed the resident on contact precautions. The care plan required staff to perform handwashing after completing care and leaving the room and to use PPE. During observation, a CNA was seen at Resident 2’s bedside emptying a urinary drainage bag while wearing a gown and gloves. The CNA then exited the room, removed and discarded the gown in a trash bin located in the hallway outside the room, but did not remove the soiled gloves. The CNA walked toward the nurse’s station while removing the gloves and touched a clean pack of gowns at the station. The CNA stated he removed the gown in the hallway because the garbage bin was outside the room and admitted he did not perform hand hygiene after emptying the urinary bag because he did not think about it. The CNA also reported that the PPE rack on Resident 2’s door was empty and that he had to obtain PPE from the nurse’s station. The facility’s hand hygiene policy and posted "Your 5 Moments for Hand Hygiene" signage required hand hygiene immediately after exposure risk to body fluids, after touching a patient or their surroundings, and immediately after glove removal, which was not followed in this instance.
Failure to Provide Timely Oral and Incontinent Care
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three residents. Two residents, both dependent on staff for oral hygiene due to conditions such as traumatic brain injury, ventilator dependence, and gastrostomy status, did not receive proper oral care. Observations revealed one resident with dried, tan-colored matter on the lips and brown, dry matter at the corners of the mouth, as well as sticky, creamy matter inside the mouth. The other resident was observed with a dry, coated upper lip and a thick, peeling layer of skin. Staff interviews confirmed that oral care was not performed as required every shift, and facility policy stated that oral care should be provided every shift and as needed for residents with special needs. Another resident, who was comatose, dependent for toileting hygiene, and used an external urinary condom catheter, did not receive timely incontinent care. A family member reported finding the resident lying on a draw sheet saturated with dry urine up to the shoulders and upper body, and that nursing staff had not repositioned or changed the soiled linen. Facility records indicated a gap in required two-hour safety checks, with the resident not being checked for over six hours during the night. Staff interviews provided conflicting accounts regarding the resident's condition and care provided during the relevant period. Facility policies required residents who are unable to carry out activities of daily living independently to receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, as well as to be repositioned at least every two hours. The failure to adhere to these policies resulted in residents not receiving the necessary oral and incontinent care as outlined in their care plans and facility procedures.
Failure to Follow Infection Control Practices Resulting in Widespread MDRO and CRO Transmission
Penalty
Summary
Facility 2 failed to implement and follow infection prevention and control practices as recommended by the local public health department (LPHD), resulting in the spread of multi-drug resistant organisms (MDROs) and carbapenem-resistant organisms (CROs) among residents. Despite explicit recommendations from the LPHD to halt new admissions and prevent movement of residents between buildings, the facility continued to admit and transfer residents from another facility under a different license. The facility also did not submit required adherence monitoring logs for hand hygiene, PPE use, and environmental cleaning, nor did it provide complete line lists with laboratory test dates for residents who tested positive for CROs. Additionally, the facility failed to notify the California Department of Public Health about the outbreak in a timely manner and did not provide adequate documentation of outbreak notification and education to residents and families. Direct care staff were observed not following basic infection control protocols, such as performing hand hygiene and donning appropriate PPE before entering rooms of residents on contact precautions. For example, a CNA entered a resident's room without hand hygiene or PPE, embraced the resident, and then exited the building, despite a contact precaution sign being posted. These lapses in infection control were observed during surveyor visits and interviews, and staff confirmed that recommended practices were not consistently followed. The facility also failed to separate staff caring for residents infected with MDROs from those caring for non-infected residents, contributing to cross-contamination. As a result, numerous residents became infected with various MDROs, including carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), and New Delhi metallo-beta-lactamase (NDM) producing organisms. The report details the medical histories and conditions of affected residents, many of whom had complex medical needs such as ventilator dependence, quadriplegia, and chronic respiratory failure. The cumulative failures led to an Immediate Jeopardy situation, as the facility's actions placed residents at significant risk of harm.
Failure to Develop Comprehensive Care Plans for Residents with NDM Infection
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents who tested positive for an antibiotic-resistant infection known as Carbapenemase-Producing Organisms (CPO), specifically the New Delhi metallo-β-lactamase (NDM) enzyme. Despite laboratory reports confirming NDM infection for these residents, their care plans did not address this specific infection. The residents involved had complex medical histories, including conditions such as anoxic brain damage, acute respiratory failure, cardiac arrest, critical illness myopathy, COPD, tracheostomy status, cervical spine fusion, and ventilator dependence. The absence of individualized care plans for their NDM infection was identified through observation, interview, and record review. During interviews, the DON acknowledged that care plans should have been developed for all residents with infections, especially during an outbreak, but stated that the facility focused only on isolation types rather than the specific infections. Review of the facility's policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and should be updated as residents' conditions change. However, this process was not followed for the residents with NDM infection, resulting in a lack of person-centered care planning for their identified needs.
Controlled Substance Documentation and Security Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances for two residents, leading to potential misuse or diversion of medications. For Resident 49, alprazolam 0.25 mg was recorded on the Controlled Drug Record (CDR) but not on the Medication Administration Record (MAR) on two separate occasions. This discrepancy was confirmed during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), who acknowledged the failure to document the medication on both records. The facility's policy requires that controlled medications be documented on the MAR, which was not adhered to in this case. Additionally, for Resident 15, there was a lack of proper documentation for morphine sulfate prescriptions. The CDR and MAR did not match, with only one CDR sheet available for two different morphine orders. This inconsistency was noted by a Registered Nurse (RN) and the DON, who recognized the risk of medication errors due to the mismatch. Furthermore, the medication cart was observed to be unlocked on two occasions, posing a risk of unauthorized access to medications. The facility's policy mandates that medication carts be locked when out of the nurse's view, which was not followed, as observed by an LVN and confirmed by the DON.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to manufacturer specifications and accepted professional principles. Two containers of acetylcysteine, used for breaking up mucus in lung disease patients, were found without an open date in the medication refrigerator for two residents. This oversight was confirmed by an LVN, who acknowledged the risk of administering ineffective medication if not labeled with an open date. Additionally, an unopened insulin pen was improperly stored in a medication cart instead of the refrigerator, contrary to the facility's policy and manufacturer guidelines, which could lead to reduced effectiveness. Further observations revealed that oral medications were stored in the same compartment as eye drops in a medication cart, increasing the risk of administering medications via the wrong route. Four bottles of artificial tears were labeled only with room numbers, posing a risk of being administered to the wrong resident if room assignments changed. These labeling and storage deficiencies had the potential to result in residents receiving incorrect or expired medications.
Incompetence in Kitchen Staff Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their job duties, leading to potential contamination risks. A cook demonstrated an incorrect method for calibrating a food thermometer by adding hot water to a mixture of cold water and ice, which was not in line with the facility's policy. The Registered Dietician (RD) confirmed that this method was incorrect and could result in inaccurate temperature readings, which are crucial for food safety. Additionally, a dietary aide (DA) incorrectly tested the sanitizer strength in the dish machine by using a chlorine test strip on the bottom of the machine instead of on a wet plate, as required by the facility's policy. The RD confirmed that the method used by the DA was improper and did not comply with the established procedures for ensuring the correct sanitizer concentration. Furthermore, there was confusion among the kitchen staff regarding the preparation and use of sanitizing solutions. A dietary aide used a spray bottle with a sanitizer solution that was not properly labeled and did not know the correct concentration. Another aide prepared the solution but was unsure of its strength, and a Territory Representative confirmed that the solution was too concentrated and not suitable for food contact surfaces. This lack of knowledge and adherence to proper procedures posed a risk of contamination for the 22 residents receiving food from the kitchen.
Expired Seasonings and Unclean Equipment in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by storing and using expired seasonings and maintaining unclean kitchen equipment. During an observation in the kitchen, eight different dry seasonings were found to be either expired or beyond their use-by dates. These seasonings, including sweet basil, tarragon, ground cloves, crushed Italian seasoning, Cajun seasoning, ground ginger, ground black pepper, and ground cinnamon, were stored on a wall shelf behind the cooking area. The Registered Dietician (RD) confirmed the expiration and use-by dates and acknowledged that kitchen staff should dispose of seasonings past their expiration dates, as per the facility's food storage chart. Additionally, a tabletop can opener was observed to be unclean, with a white and deep brown residue build-up on its gear and cavity. The RD confirmed that the can opener was dirty and should be cleaned after each use. The facility's policy and procedure on sanitization, dated 2008, requires that all equipment be washed to remove or completely loosen soils. These deficiencies placed 22 residents who received food from the kitchen at risk for foodborne illnesses.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, Resident 40 and Resident 59, who were unable to maintain personal hygiene and grooming due to their medical conditions. Resident 59, who was admitted in March 2024, had diagnoses including encephalopathy and traumatic hemorrhage of the cerebrum, and was totally dependent on staff for personal hygiene. Observations revealed that Resident 59 had long, thick facial hair, and a Certified Nurse Assistant (CNA) from an agency was unsure if shaving was her responsibility. The Licensed Vocational Nurse (LVN) confirmed that CNAs were responsible for maintaining Resident 59's grooming, and the family representative expressed that Resident 59 would have preferred to be shaved occasionally. Similarly, Resident 40, admitted in January 2024 with encephalopathy and acute and chronic respiratory failure with hypoxia, was also totally dependent on staff for personal hygiene. Observations showed that Resident 40 had long, thick facial hair, and the LVN noted that this could lead to skin irritation or breakdown. The Director of Nursing (DON) stated that CNAs were expected to maintain residents' personal hygiene and grooming, and acknowledged the risk of compromised skin integrity and dignity due to long facial hair. The facility's policy indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene.
Failure to Change Tracheostomy Tie as Ordered
Penalty
Summary
The facility failed to provide proper tracheostomy care for a resident, identified as Resident 59, by not changing the tracheostomy tie daily as ordered by the physician. The resident, who was dependent on a ventilator, had a tracheostomy tie that was last changed on 6/14/24, despite the physician's order requiring it to be changed every shift, as needed if soiled or dislodged, and after a shower. This oversight was observed during a survey on 7/9/24, when the tracheostomy tie was found to be dated nearly a month prior. Interviews with the Registered Nurse Supervisor and the Respiratory Therapist Director revealed discrepancies in the facility's practice and the physician's order. The RN Supervisor acknowledged that the tracheostomy ties should be changed daily, while the RT Director stated they should be changed every 2-3 days. Both acknowledged the risk of skin irritation and infection due to the failure to change the tracheostomy tie as required. The facility's policy, dated 2001, also indicated that tracheostomy care should be provided at least once daily for established tracheostomies.
Failure to Implement Pharmacist's Recommendations for Medication Indication
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations regarding the medication regimen of Resident 19, who was receiving quetiapine. The consultant pharmacist's Medication Regimen Review (MRR) for April 2024 recommended updating the diagnosis to 'dementia with behaviors - biting' to justify the use of quetiapine. However, as of July 10, 2024, these recommendations had not been reviewed by the physician, and the resident continued to receive quetiapine without the correct indication documented. During interviews and record reviews, the Director of Nursing (DON) confirmed that the pharmacist's recommendations were not implemented for Resident 19. The facility's policy and procedure for Medication Regimen Review and Reporting requires that recommendations be acted upon within 30 days, but this was not adhered to. The DON acknowledged the importance of having correct indications for medication use to ensure resident safety and prevent unnecessary side effects.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident for 13 residents occupying 6 multi-bed rooms. During an observation, it was noted that the rooms had less than the mandated space per bed, with measurements ranging from 72.87 to 79.75 square feet per bed. Despite this deficiency, there was sufficient space for the provision of care, and no heavy equipment was present that could interfere with residents' care. Residents had adequate personal space and privacy, and there were no complaints or negative consequences reported due to the decreased space.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 Maubert | 0 mi | ★★★★★ | 3 | 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 | ★★★★★ | 1 | 0 |
| Valley Pointe Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 20 | 0 |
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