Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Atterdag Care Center during CMS and state inspections, most recent first.
A resident with dementia, gait abnormalities, and other psychiatric and cognitive diagnoses experienced multiple falls over time. Post Fall Evaluations were completed after each event, documenting existing fall risk factors and interventions such as neuro checks, vital sign monitoring, pain assessment, and MD/POA notification. However, the care plan that had been initiated earlier was not revised to update the focus, goals, or interventions after these repeated falls. The DON confirmed that no changes were made to the care plan despite the additional falls, contrary to facility policies requiring reassessment, IDT review, and updating of the fall care plan and overall care plan when new problems or condition changes are identified.
A resident with dementia-related diagnoses and an order for PRN lorazepam for moderate to severe anxiety received a dose of lorazepam, but staff did not document the reason for administration in the MAR or medical record. The DON acknowledged the absence of this required documentation. Facility policy required that when a PRN medication is given, the nurse must document the reason, route, date, and time, which did not occur in this case.
A resident with Alzheimer's disease, dementia with mood disturbance, major depressive disorder, and anxiety disorder had a PRN lorazepam order for anxiety manifested by frantic searching. The order had no end date, and the DON verified that PRN psychotropic medication orders should be renewed every 14 days, but the clinical record did not contain documented justification for extending the order beyond that timeframe.
Care plan interventions were not properly implemented or documented for two residents. One resident with dementia and high wandering risk had a care plan for a wander alert/wander guard, but the order was placed on the TAR instead of the EMAR and daily documentation was missing. Another resident with a pacemaker had a care plan to monitor and document signs of altered cardiac output or pacemaker malfunction, but the DON could not produce documentation showing the intervention was transcribed or carried out in the TAR or EMAR.
A resident’s care plan was not revised after MDS assessments and remained inaccurate. The CP still listed Ativan for hospice comfort care and Remeron for depression, while the MDS and OS showed no anxiety or depression diagnoses and no active orders for antianxiety or antidepressant meds. The DON acknowledged the CP was not updated to reflect the resident’s status.
A resident with dementia missed multiple doses of an ordered psychotropic medication, and the record did not show physician notification or nursing follow-up. Another resident with COPD had inconsistent O2 sat documentation despite needing supplemental O2, and was observed without oxygen while stating they could not breathe. A third resident with a heel pressure ulcer and skin issues was documented as receiving Calmoseptine to the coccyx without a physician order.
Failure to obtain monthly weights for a resident. During record review and interview, the DON confirmed the resident’s last monthly weight was months earlier and there was no nursing or dietary documentation explaining why weights were not completed. The resident stated she had not refused weighing and had no problem being weighed in a sling. Facility policy required monthly weights after admission and stabilization.
Delayed physician response to changes in condition. Two residents had changes in condition that were reported to the MD, but treatment was not provided in a timely manner. One resident with Parkinson's disease, dementia, and diabetes developed worsening blisters and did not receive physician direction until days later, after which a dermatology visit led to new orders. Another resident with a suprapubic catheter had signs of UTI, abnormal urine testing, and culture results, but an antibiotic order was not documented until weeks after the first MD notification.
A resident’s controlled drug record showed Hydrocodone-Acetaminophen was administered, but there was no licensed staff signature documenting the dose. During review with an LPN, the nurse confirmed the record should have been signed by the administering nurse. The facility policy required the licensed nurse to immediately enter a signature on the accountability record when a controlled med is given.
Expired wound care supplies were found on a wound treatment cart during an observation with an LPN at the nurse's station. Two one-ounce bottles of Stomahesive powder were observed past their expiration date, and the LPN stated that staff are responsible for removing expired supplies and that the items should have been destroyed. Facility policy stated that outdated medication should be removed for proper disposal.
Food safety practices were not followed when two DAs were observed in the food prep area with hair restraints that did not fully cover their hair. Dietary staff also did not follow the facility's cleaning and sanitizing process for work surfaces, with staff using wet cloths and no observed sanitizing step, while staff gave inconsistent statements about sanitizer contact time. In dry storage, an unopened box of dressings with wet cardboard and a squash with white spots were observed, and the DNS stated these items should have been removed.
A resident with Alzheimer's disease, dementia with mood disturbance, major depressive disorder, and anxiety disorder had an informed consent for lorazepam/Ativan that did not match the physician's order. The order summary listed 1 mg PO every 12 hours PRN for anxiety, while the signed consent documented 1 mg PO BID PRN. The DON acknowledged the discrepancy, and the facility policy required records to be accurately documented.
Laundry water temperatures were documented below the facility’s minimum infection-control requirement, and the IPN’s monthly surveillance review did not detect the unacceptable readings. In addition, PPE was not readily available at the point of care for residents on EBP; although EBP signs were posted, PPE was kept in resident closets or a locked clean utility closet, and a CNA assisted a resident without donning a gown while PPE was not visible outside the room.
Missing SSD Documentation for Abuse Allegation Follow-Up: A resident with dementia, psychiatric diagnoses, weakness, tremor, vision impairment, and a history of falls had abuse allegations known to the SSD. The SSD attempted to speak with the resident, who was dismissive and gave no feedback, then observed the resident’s normal routine but did not document the follow-up in the chart, despite facility policy requiring timely progress notes in the medical record.
A resident's personal property inventory list was not updated when new clothing was brought in, despite facility policy requiring staff to label new items and update the inventory. Staff interviews confirmed the expectation to maintain current inventory records, but a review showed the list had not been updated since admission.
The facility failed to ensure food safety standards were met, as the dish machine did not reach required temperatures, and staff did not follow proper glove use protocols. The dish machine consistently showed lower temperatures than required, and there was no mechanism to verify these temperatures. Additionally, an employee used the same gloves to handle raw and cooked meat, violating FDA guidelines. These deficiencies could lead to foodborne illness for the 49 residents consuming food from the kitchen.
A facility failed to ensure proper pharmaceutical services for a resident by not obtaining a physician's order for blood pressure monitoring and medication administration. The resident received Coreg without specific parameters, and a nurse revised the medication record without physician direction. The facility lacked a policy to identify hypotension, leading to multiple hypotensive episodes during medication administration.
The facility failed to monitor the medication refrigerator temperature twice daily, as required by policy, resulting in temperatures falling below the acceptable range. The DON confirmed that influenza vaccines were stored in this refrigerator, and no corrective actions were documented for the out-of-range temperatures.
The facility failed to provide residents with diets that matched their physician-prescribed orders, leading to potential nutritional deficits. Discrepancies were found between the PointClickCare (PCC) diet orders and meal ticket reports for several residents, as confirmed by the Registered Dietitian (RD). The facility's policy required a Dietary Communication form for diet changes, but inconsistencies persisted, indicating a lapse in ensuring accurate dietary information.
The facility failed to adhere to menu portion sizes, resulting in incorrect servings for residents on specific diets. On two occasions, residents received incorrect portion sizes due to staff using the wrong scoops, which was confirmed by the Director of Dietary Services and the RD. This inconsistency in portion sizes could potentially impact residents' nutritional needs.
A facility failed to ensure that a resident's POLST matched the EMR, leading to a potential risk of incorrect life-sustaining treatment administration. The resident, with senile degeneration of the brain, had a POLST indicating DNR, but the EMR showed a CPR order. The MDS Coordinator acknowledged the records did not match, as the EMR was not updated to reflect the resident's current wishes.
A facility failed to develop a care plan for RNA services for a resident with muscle weakness, gait abnormalities, and repeated falls. Despite an order for range of motion exercises, no care plan was documented. The MDS Coordinator confirmed the absence of a care plan, contrary to the facility's policy requiring updates as changes occur.
A resident in the facility had an elevated pulse of 103 beats per minute, flagged by the computer system as tachycardia. The nurse did not recheck the pulse or take any preventative actions, and the issue persisted with a pulse of 106 the next day. The DON confirmed that the elevated pulse was not addressed for two days, failing to meet professional standards of care.
The facility's dishwashing machine failed to reach the required temperatures for sanitization, as observed by the DDS and confirmed by a Vendor Technician. The temperature gauges were not functioning, and the facility's policy for checking gauge accuracy was not effectively implemented.
Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s care plan following multiple falls. The resident, an older male admitted on 8/26/24, had diagnoses including senile degeneration of the brain, Alzheimer’s disease, adjustment disorder with mixed anxiety and depressed mood, and abnormalities of gait and mobility. Record review showed that the comprehensive care plan for this resident was initiated on 9/6/24. Post Fall Evaluations (PFEs) documented that the resident experienced an unwitnessed fall on 2/17/26 at 3:45 p.m., with a care plan focus noting an actual fall and multiple risk factors such as lower body weakness, gait and balance difficulties, cognitive impairment, and other listed conditions. The PFE included goals and interventions such as neuro checks, monitoring vital signs every shift for 72 hours, monitoring for pain, and notifying the MD and POA of changes or complications. Subsequent PFEs dated 3/4/26 and 3/10/26 documented additional falls, including another unwitnessed fall, but indicated that the care plan focus, goals, and interventions remained unchanged from the initial PFE on 2/17/26. During an interview and concurrent record review on 3/20/26 at 12:40 p.m., the DON confirmed that the resident’s care plan, initiated on 9/6/24, had no focus, goals, or interventions revised after the three documented falls. Review of the facility’s “Fall Prevention Program” policy stated that after any fall, the licensed nurse will reassess fall risk, complete a PFE, and the IDT will review the fall within 72 hours and add all interventions to the fall care plan. The “Care Planning” policy further stated that newly identified problems and condition changes are to be care planned, and that licensed staff should update the care plan weekly with new interventions and resident responses. Despite these policies, no revisions were made to the resident’s care plan following the falls on 2/17/26, 3/4/26, and 3/10/26.
Failure to Document Reason for PRN Lorazepam Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical record contained required documentation for the administration of a PRN medication. A male resident with diagnoses including senile degeneration of the brain, Alzheimer’s disease, and adjustment disorder with mixed anxiety and depressed mood had a physician’s order for lorazepam 1 mg by mouth every 2 hours as needed for moderate to severe anxiety manifested by vomiting, shortness of breath, or restlessness. Review of the Medication Administration Record (MAR) for the month showed that a dose of lorazepam was administered on 3/17/26 at 5:57 a.m. However, the MAR and the resident’s medical record did not contain any documentation of the reason the PRN lorazepam was given at that time. During an interview, the DON confirmed that the MAR for this resident lacked documentation of the reason for the PRN medication administration on that date and time. The facility’s Medication Administration policy, revised 10/8/24, required that when a PRN medication is given, the nurse must document the reason given, route of administration, date, and time, which was not done in this instance.
Missing Justification for Extended PRN Psychotropic Order
Penalty
Summary
The facility failed to document justification for extending a PRN psychotropic medication order beyond 14 days for one of three sampled residents, Resident 8. Resident 8 was admitted on 1/8/26 and had diagnoses including Alzheimer's disease, dementia with mood disturbance, major depressive disorder, and an anxiety disorder. Her Order Summary Report showed an order for lorazepam 1 mg by mouth every 12 hours as needed for anxiety manifested by frantic searching, and the order had been written on 12/18/2025 with no end date. During a concurrent interview and record review on 1/8/26 at 2:40 p.m., the DON reviewed Resident 8's clinical record and verified that the lorazepam order had no end date. The DON acknowledged that PRN psychotropic medication orders should be renewed every 14 days based on regulatory requirements. Further review of the clinical record did not show documented justification to support not renewing the medication order every 14 days.
Care Plan Monitoring Not Documented for Wander Guard and Pacemaker
Penalty
Summary
Care plan interventions were not properly implemented or documented for two residents. One resident with Alzheimer’s disease, dementia with mood disturbance, major depressive disorder, and anxiety disorder had repeated wandering risk assessments showing high risk scores, and the care plan identified the resident as an elopement risk/wanderer with a wander alert worn on the ankle and monitored on the EMAR for placement and function. A physician order dated 12/22/25 directed staff to check the wander guard for placement and function every day shift, but the DON confirmed the order was transcribed to the TAR instead of the EMAR as indicated in the care plan, and review of the November and December 2025 TARs showed no daily staff documentation for the order. A second resident with paroxysmal atrial fibrillation, old myocardial infarction, ischemic cardiomyopathy, and a cardiac pacemaker had a care plan stating the resident has a pacemaker and directing staff to monitor, document, and report as needed signs and symptoms of altered cardiac output or pacemaker malfunction, including pulse rate lower than the programmed rate and lower than baseline blood pressure. During interview and record review, the DON was unable to provide staff documentation showing the pacemaker monitoring intervention was implemented, and determined the intervention had not been transcribed into either the TAR or EMAR for proper tracking and oversight. The facility policy on care planning stated that resident needs are to be care planned with corresponding measurable objectives and adequate interventions.
Inaccurate care plan not updated after MDS assessments
Penalty
Summary
The facility failed to revise Resident 36’s care plan after MDS assessments, resulting in a care plan that did not match the resident’s current status. Resident 36 was admitted with diagnoses including chronic pain, a stage 2 pressure ulcer of the left heel, palliative care, and sepsis. The care plan dated 2/27/25 identified the resident as using Ativan related to end-stage disease and hospice care, and the care plan dated 5/20/25 identified the resident as using Remeron related to depression. However, the comprehensive MDS and quarterly MDS assessments dated 5/27/25, 8/18/25, and 11/10/25 indicated the resident did not have anxiety or depression diagnoses and was not taking antianxiety or antidepressant medications. The order summary dated 1/8/26 showed no active orders for Ativan, Remeron, or any other antianxiety or antidepressant medication; Lorazepam had been ordered and discontinued in March 2025, and Remeron 7.5 mg at bedtime for depression was ordered on 5/19/25 and discontinued on 5/20/25. During interview, the DON acknowledged the resident’s care plan was inaccurate and was not updated to reflect the resident’s status at the time of the MDS assessments.
Missed medication follow-up, inconsistent oxygen monitoring, and wound treatment without an order
Penalty
Summary
Resident 8, a female with Alzheimer’s disease, dementia with mood disturbance, major depressive disorder, and anxiety disorder, had an order for Quetiapine Fumarate 100 mg by mouth at bedtime for frantic and fearful statements and pacing. Review of the MARs for November and December 2025 showed the medication was missed on multiple occasions, with 20 of 30 days missed in November and 17 of 31 days missed in December. The documented reason for the missed doses was that the resident was sleeping at the time of administration. The resident’s clinical record did not show documentation that the physician was notified or that nursing staff followed up after the missed doses. During interview, the DON verified that staff should have followed up with the resident after each missed dose and should have informed the IDT so discussions could occur regarding medication timing and frequency. The facility’s psychotherapeutic medication policy required medications to be given as ordered, monitored for effectiveness, and the physician notified if ineffective. Resident 45, admitted with panlobular emphysema, was observed eating lunch on oxygen and later observed without oxygen while self-propelling in a wheelchair and stating, "I can't breathe, I can't breathe. I need my oxygen." The resident’s order was for supplemental oxygen at 2 liters as needed for O2 less than 88%, but the hospice/comfort care progress notes showed oxygen saturations were not consistently documented across the reviewed period. The DON stated oxygen saturations should have been documented every shift so nursing staff could assess breathing status and determine the resident’s need for oxygen. Resident 36, admitted with a left heel pressure ulcer and pre-existing skin integrity issues, had admission nursing documentation stating Calmoseptine ointment was applied to the coccyx area, but the order summary contained no physician order for wound treatment or for Calmoseptine to the coccyx area.
Failure to Obtain Monthly Weights
Penalty
Summary
The facility failed to obtain monthly weights for one of four sampled residents, Resident 4. During a concurrent interview and record review with the DON, Resident 4’s current vital signs showed that the last monthly weight had been obtained on 8/27/24. The DON stated that monthly weights should be obtained for every resident and that the chart should include a notation explaining why a monthly weight was not obtained, but confirmed there were no nursing notes or dietary notes in Resident 4’s record explaining why the monthly weights were not done. During interview, Resident 4 stated the facility can weigh her, that she has not refused, and that she has no problem being weighed in a sling. The facility policy stated residents are to be weighed upon admission, weekly for four weeks or until stable, and monthly thereafter.
Delayed Physician Response to Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician consultation or treatment when residents experienced a change in condition. The report states that this deficient practice affected two of five sampled residents, Residents 23 and 28, and resulted in a delay in care and treatment to meet their immediate care needs. The facility policy on Change of Condition required prompt notification of the attending physician and follow-up nursing assessments and monitoring until the condition stabilized. Resident 23 was admitted with diagnoses including Parkinson's disease, dementia, and Type 2 diabetes mellitus with diabetic peripheral angiopathy. The resident developed a fluid-filled blister on the right outer index finger, and the physician and responsible party were notified the same day. Over the following days, additional blisters developed on the resident's right hand fingers and right plantar foot, and some blisters opened. Progress notes documented that staff were awaiting physician response on multiple dates. The physician did not call the facility until 10 days after the initial notification, at which time instructions were given to make an urgent dermatologist appointment. The resident was then seen by a dermatologist and returned with new medication orders for doxycycline, mupirocin, and prednisone. The DON acknowledged that the resident had a change in condition and that staff should have pursued daily physician notifications to ensure timely care. Resident 28 was admitted with a diagnosis including presence of urogenital implants and had an indwelling suprapubic catheter for neurogenic bladder. The care plan directed staff to monitor, record, and report signs and symptoms of UTI to the MD. The resident had restless behavior, a urinalysis positive for nitrites and leukocytes, thick white catheter tubing, and subsequent urine testing and culture results were faxed to the physician. The physician did not provide treatment until 22 days after the first MD notification, when an order for Bactrim was documented for acute cystitis. The DON acknowledged that the physician provided treatment recommendation 22 days after the first MD notification and stated staff should have pursued daily physician notifications to ensure timely care.
Controlled Drug Record Not Signed After Administration
Penalty
Summary
The facility failed to ensure nursing staff signed the controlled drug record after administering medication. During a concurrent interview and record review with Licensed Nurse 1, Resident 24’s Controlled Drug Record dated 1/6/26 was reviewed and showed that Hydrocodone-Acetaminophen was administered at 8:55 p.m. There was no licensed staff signature on the record to indicate the medication had been administered. Licensed Nurse 1 stated that the controlled drug record should have been signed by the nurse who gave the medication. The facility policy titled Medication Administration Controlled Substance stated that when a controlled medication is administered, the licensed nurse administering the dose must immediately enter the nurse’s signature on the accountability record.
Expired Supplies Found on Wound Treatment Cart
Penalty
Summary
Expired medical supplies were found on a wound treatment cart during a concurrent observation and interview with LN1 at the nurse's station. Two one-ounce bottles of Stomahesive powder were observed with an expiration date of [DATE]. LN1 stated that all staff are responsible for ensuring expired supplies are removed from the cart and that these supplies should have been destroyed. A review of the facility's policy and procedure titled Medication Administration, dated [DATE], stated that if medication is discontinued or outdated, it should be removed for proper disposal.
Food Safety Deficiencies in Dietary Area
Penalty
Summary
Food safety requirements were not met when two dietary aides were observed in the food preparation area with hair restraints that did not completely cover their hair. During the observation, the Director of Nutrition Services confirmed the hair restraints were not properly covering the hair area. The facility policy titled Hair Restraints stated that hair restraints, hats, and beard covers are to be worn in the food production area by all staff to prevent hair from falling into food. Dietary staff also did not follow the facility's cleaning and sanitizing procedure for kitchen surfaces. The facility policy for cleaning work tables and counters required scrubbing with hot soapy water, rinsing with hot water, and sanitizing with no-rinse multi-surface food grade sanitizing wipes left to air dry. Instead, staff were observed wiping food preparation surfaces with a wet cloth, and no sanitizing step was observed. Staff statements about the required contact time for the sanitizer varied, and the manufacturer's instructions for the sanitizing wipes indicated that non-porous surfaces must remain visibly wet for five minutes. In addition, in the dry storage area, an unopened box of dressings with wet cardboard packaging and a squash with white spots were observed, and the Director of Nutrition Services stated these items should have been removed and placed on the return cart.
Inaccurate informed consent for psychotropic medication
Penalty
Summary
The facility failed to ensure that the informed consent for a psychotropic medication contained accurate information for one resident. Resident 8 was admitted with diagnoses including Alzheimer's disease, dementia with mood disturbance, major depressive disorder, and an anxiety disorder. The resident's order summary listed lorazepam 1 mg by mouth every 12 hours as needed for anxiety manifested by frantic searching, with the order dated 12/18/2025 and no end date. The resident's informed consent for an anxiolytic, signed by the resident's daughter, documented Ativan increased from 0.5 mg to 1 mg PO BID PRN. During record review and interview with the DON, the medication frequency on the order summary, every 12 hours, was compared with the informed consent, twice a day, and the DON acknowledged the discrepancy. The facility policy required medical records to be accurately documented.
Laundry Water Temperature and PPE Availability on EBP
Penalty
Summary
The facility failed to ensure infection control practices were implemented when laundry washing machine water temperatures were documented below the minimum required level for infection control. Review of the Laundry Water Temperature Logs for September, October, November, and December 2025 showed multiple entries below 140 degrees, including 13 days in September, October, and November that were not within the acceptable range. During interview and record review, the EVS Supervisor acknowledged the recorded temperatures were unacceptable, and laundry staff stated the logs did not specify whether white or colored laundry was being washed even though the logs showed temperatures below the facility’s minimum requirement. The facility’s policy titled Laundry Procedures, dated 12/2025, stated that water temperature during the wash cycle should be checked and recorded, and that appropriate temperatures for infection control should range between 140 and 160 degrees. The Infection Prevention Nurse stated the laundry temperature logs were reviewed monthly through the Infection Control Surveillance-Laundry form, which asked whether the washing machine wash temperature was maintained at a minimum of 140 degrees. Review of those surveillance forms showed mixed documentation, including one entry noting occasional 130-degree readings recorded before water/clean started and another entry noting 146-152 degrees. The IPN acknowledged that unacceptable wash temperatures in September, November, and December were not detected during monthly infection surveillance review. The facility also failed to ensure PPE was readily available for residents on Enhanced Barrier Precautions. During observations, EBP signs were posted outside the rooms of four residents, but no PPE was visibly available near the rooms or down the hall other than hand sanitizer. Staff stated PPE was obtained from a locked clean utility closet or from residents’ closets, and the DON and IPN stated PPE was kept inside resident rooms to maintain a homelike environment. During an observation in one resident’s room, a CNA assisted the resident back to bed while wearing gloves but did not don a gown, and no PPE was visible outside the room or in the room at the time. The IP later located gowns on a bottom shelf behind incontinence briefs in the resident’s closet.
Missing SSD Documentation for Abuse Allegation Follow-Up
Penalty
Summary
The facility failed to ensure that Social Services Designee documentation was completed in the medical record for one sampled resident regarding allegations of abuse. During record review, Resident 1’s admission record showed the resident was 94 years old and had diagnoses including senile degeneration of the brain, generalized anxiety disorder, schizoaffective disorder bipolar type, weakness, vascular dementia, unspecified lack of coordination, cognitive communication deficit, muscle weakness, essential tremor, mild cognitive impairment, macular degeneration, cerebral ischemia, drug induced secondary parkinsonism, type 2 diabetes mellitus, and a history of falling. During interview, the SSD stated awareness of abuse allegations involving Resident 1 and reported attempting to speak with the resident, but the resident was challenging, dismissed the SSD, and did not provide feedback. The SSD stated the resident was observed for the rest of the day and went about a normal routine, and because there was no feedback, no note was made; the SSD acknowledged that a note should have been completed. The facility’s job description for the SSD required documenting social service needs in medical charts, and the facility’s progress notes policy required each discipline to document progress notes in the appropriate section of the chart in a timely manner and maintain them in the resident’s medical record.
Failure to Update Resident Personal Property Inventory
Penalty
Summary
The facility failed to ensure that a resident's personal property inventory list was updated when new belongings were brought in. The resident reported being unable to locate a pair of pants she had purchased, prompting staff to assist in finding the item, which was eventually located and identified with the resident's name tag. Interviews with social services staff, a licensed nurse, and a certified nursing assistant confirmed that facility protocol requires staff to label new clothing and update the inventory list when new items are added. However, a review of the resident's inventory list revealed it had not been updated since admission, and the Director of Nursing acknowledged the list was outdated and should have been updated when the new pants were labeled. The facility's policy requires recording additional belongings on the clothing list as they are brought in or removed.
Deficiencies in Dishwashing and Glove Use Protocols
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. The high-temperature dish machine was not reaching the required temperatures of 150 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle. The facility lacked a mechanism to verify the plate-level temperature was reached according to their policy and procedure. Observations and interviews revealed that the dish machine consistently showed lower temperatures than required, and the facility did not have a way to verify these temperatures accurately. The Director of Dietary Services and the Maintenance Engineer were unaware of the issue until it was brought to their attention by the surveyor, and the Registered Dietitian was not conducting regular inspections to verify the dish machine's performance. Additionally, the facility's staff failed to follow proper glove use protocols, which is critical in preventing cross-contamination. An employee was observed using the same gloves to handle raw meat and then touching other items, including cooked meat and utensils. This practice is against the FDA Food Code, which requires single-use gloves to be used for only one task and discarded when switching tasks or when they become soiled. The Registered Dietitian acknowledged the expectation for staff to change gloves after handling raw meat but noted that staff might have a false sense of security when wearing gloves. The deficiencies in the dishwashing process and glove use had the potential to result in the growth of microorganisms, which could cause foodborne illness for the 49 residents eating food from the kitchen. The facility's failure to adhere to its policies and procedures for dishwashing and glove use, as well as the lack of regular inspections and monitoring, contributed to these deficiencies.
Failure to Ensure Proper Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident by not obtaining a physician's order for blood pressure monitoring and medication administration. The resident was prescribed Coreg, a blood pressure medication, without specific parameters for blood pressure or pulse monitoring. Despite the absence of these parameters, the resident continued to receive the medication from September 12, 2024, to October 13, 2024, without the nursing staff consulting the resident's physician for clarification. On October 13, 2024, a nurse independently revised the resident's medication administration record to include daily blood pressure and pulse recordings without physician direction. The facility also lacked a policy and procedure to identify hypotension, which contributed to the oversight. The resident experienced multiple hypotensive episodes from October 13, 2024, to January 23, 2025, during which the blood pressure medication was administered despite low blood pressure readings. This oversight had the potential to cause severe hypotension, risking the resident's health by potentially leading to organ failure and shock.
Failure to Monitor Medication Refrigerator Temperature
Penalty
Summary
The facility failed to adequately monitor and maintain the medication refrigerator temperature within the acceptable range, as required by their policy. The Director of Nursing (DON) confirmed that the temperatures of the refrigerator in the medication storage room were only monitored once a day, contrary to the facility's policy which mandates twice-daily monitoring. During the review of the Medical Room Refrigerator Temperature Monitoring Log (MRRTML) for October, November, and December 2024, it was found that several recorded temperatures were below the accepted range of 36-46 degrees Fahrenheit. Specifically, temperatures as low as 30 degrees Fahrenheit were recorded, and there was no documented evidence of corrective action taken when these out-of-range temperatures were noted. The DON acknowledged that influenza vaccines were stored in the medication room refrigerator, which further emphasizes the importance of maintaining proper storage conditions. The facility's Policy and Procedure on Medication Storage clearly states that medications requiring refrigeration should be kept at temperatures between 36 and 46 degrees Fahrenheit, and the temperature should be monitored and recorded twice daily. The failure to adhere to these guidelines had the potential to result in residents receiving ineffective medications due to improper storage conditions.
Dietary Discrepancies in Resident Meal Orders
Penalty
Summary
The facility failed to ensure that residents were provided with a well-balanced, physician-prescribed diet that met their nutritional needs. This deficiency was identified through observations, record reviews, and interviews, revealing discrepancies between the meal tickets and the diet orders for seven residents. For instance, during a lunch meal service, a resident's meal ticket indicated a puree small portion diet with a #6 scoop of lamb, which did not align with the facility's practice of using half portions for small portion diets. Additionally, the Registered Dietitian (RD) confirmed discrepancies between the PointClickCare (PCC) diet orders and the meal ticket reports, indicating inconsistencies in the dietary information provided to the kitchen staff. The facility's policy and procedure for the transmission of diet orders, dated 09/04/2018, required a Dietary Communication form to be completed, dated, signed by a Licensed Nurse, and sent to Dietary upon admission or change of diet order. However, the review of facility documents showed that the diet orders in the PCC system did not match the meal ticket reports for several residents, leading to potential nutritional deficits. The RD acknowledged that diet discrepancies existed between the PCC and the meal ticket reports, which were only reviewed every couple of months, further contributing to the issue.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed correctly, leading to incorrect portion sizes being served to residents on specific diets. On January 22, 2025, during the lunch meal, four residents on puree diets received incorrect portion sizes of meat, potatoes, and zucchini. The facility's Daily Spreadsheet specified that a #6 scoop should be used for meat and a #10 scoop for vegetables, but a #8 scoop was used instead. This discrepancy was confirmed by both the staff member responsible for serving the meals and the Director of Dietary Services. Additionally, on January 21, 2025, a resident on a regular diet received incorrect portion sizes of cod, polenta, and spinach, as the staff used a #12 scoop instead of the required #8 scoop for regular portions. The Registered Dietitian (RD) was not aware that the staff was not following the menu portion sizes and acknowledged that portion sizes were inconsistent from day to day. The RD stated that while they occasionally observe tray accuracy or conduct test trays, these checks are primarily for temperature rather than portion size accuracy. The RD confirmed that the expectation is for kitchen staff to follow the menu daily spreadsheet and adhere to the specified portion sizes. This failure to follow the menu and portion sizes has the potential to result in residents not having their nutritional needs met.
Discrepancy in POLST and EMR for Resident
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) matched the electronic medical record (EMR) for a resident, which could potentially lead to a delay or incorrect administration of life-sustaining treatments. The discrepancy was identified during a review of the resident's records, where the POLST indicated a 'do not attempt resuscitation' (DNR) status, while the EMR contained a physician order for cardiopulmonary resuscitation (CPR). This inconsistency was acknowledged by the Minimum Data Set Coordinator (MDS 1), who noted that the order in the EMR had not been updated to reflect the resident's current wishes as documented in the POLST. The resident involved was an elderly female with a diagnosis of senile degeneration of the brain, a condition characterized by a progressive decline in cognitive function. The facility's policy and procedure on life-sustaining measures and advanced health care directives required that if a resident desired a DNR status, the physician should review the request with the resident or their surrogate and document the DNR order on the physician's order sheet. However, this procedure was not followed, leading to the mismatch between the POLST and the EMR.
Failure to Develop RNA Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan to address Restorative Nursing Assistant (RNA) services for a resident, identified as Resident 27. This resident was admitted with diagnoses including generalized muscle weakness, abnormalities of gait and mobility, and a history of repeated falls. Despite an order for RNA services, specifically active and passive range of motion exercises for the right upper extremity, there was no documented care plan addressing these RNA services. During an interview and record review, the Minimum Data Set Coordinator confirmed the absence of a care plan for RNA services. The facility's policy and procedure on care plans, dated November 1, 2011, requires all disciplines to have input on the care plan and to update it as changes occur.
Failure to Address Tachycardia in Resident
Penalty
Summary
The facility failed to ensure that standards of practice regarding tachycardic pulses were addressed for a resident, leading to a deficiency. The resident's medical record showed an elevated pulse of 103 beats per minute, which was flagged by the facility's computer system. According to the Fundamentals of Nursing, a pulse above 100 beats per minute in adults is considered tachycardia. Despite this, the elevated pulse was not rechecked by the nurse responsible for the resident's care on the same day, and no interventions were documented to address the elevated pulse. The following day, the resident's pulse was recorded at 106 beats per minute, indicating that the issue persisted. Interviews with the nurse and the Director of Nursing (DON) confirmed that no preventative actions were taken to address the resident's tachycardia over the two-day period. The DON acknowledged that the elevated pulse should have been addressed immediately upon identification, but it was not, resulting in a failure to meet professional standards of quality care.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwashing machine was functioning properly and in safe operating condition, as the temperatures of the wash and rinse cycles did not reach the manufacturer's specified levels. During an observation in the main kitchen, the rinse temperature gauge read 124°F and the wash temperature gauge read 128°F, both below the required temperature for effective sanitization. The Director of Dietary Services (DDS) confirmed that staff relied solely on the display gauges to verify machine temperatures and had no alternative method for temperature validation. Further investigation revealed that the temperature test strips, which should change color at 180°F, did not change when cycled through the dishwashing machine, indicating inadequate temperature levels. However, when submerged in 187°F water, the test strips changed color as expected. A review of the facility's policy indicated that the Director of Food and Nutrition Services should periodically check the accuracy of the gauges using thermal strips and report any discrepancies. A Vendor Technician later confirmed that the temperature gauges were not functioning and recommended their replacement.
What surveyors are citing around you — mapped
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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 20 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Solvang
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lompoc Valley Medical Center Comprehensive Care Ce | 17.9 mi | ★★★★★ | 5 | 0 |
| Lompoc Skilled Nursing & Rehabilitation Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Buena Vista Care Center | 21.9 mi | ★★★★★ | 14 | 1 |
| Channel Islands Post Acute | 24.7 mi | ★★★★★ | 1 | 0 |
| Valle Verde Health Facility | 25.3 mi | ★★★★★ | 7 | 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.