Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 College Oak Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Provide Written Bed Hold Notice After Emergency Transfer: A resident was sent to an acute care hospital via 911 for an emergency transfer, but the RP was notified by phone only and did not receive written notice of the facility’s bed hold policy. The DON and ABOM confirmed no written bed hold notification was sent, despite facility policy requiring written notice to residents or representatives within 24 hours of an emergency transfer.
Food was found improperly stored in the freezer, including unsealed bags of biscuits, enchiladas, and sausage patties that were exposed to the air and available for use. A heavy black residue was also observed around the inside door frame and piping area of the walk-in refrigerator, and staff including the DS, DA, MS, and RD stated they had not noticed the discoloration; facility policy required frozen foods to be stored in airtight moisture-resistant wrappers and refrigeration equipment to be routinely cleaned.
A resident with intact cognition was moved into another resident's room without a clear explanation, consent, or documentation of the reason for the transfer. Staff and leadership confirmed there was no record that either resident or the responsible party was notified, and the room change assessment and transfer form were not completed.
Failure to provide timely ordered pain medication affected two residents who reported significant pain. One resident with epididymitis waited hours after requesting oxyCODONE and described severe testicular pain that limited mobility, while another resident with breast cancer missed a PRN hydrocodone-acetaminophen dose overnight because staff said it was not available even though it was in the e-kit. The DON stated residents should be assessed and given ordered pain meds without waiting hours.
Improper Storage of OTC Medication: Surveyors found seven cough drops on a med cart stored in a clear plastic cup instead of the original package. An LPN confirmed the finding and stated there were no expiration dates on the cough drops. Another LPN and the DON stated OTC meds must be kept in their original packaging, and the facility policy required medications to remain in the packaging in which they were received.
A resident with anxiety disorder and bipolar disorder had a physician order for PRN Valium 5 mg. Nursing staff signed the medication out on the CDR but did not document the administration on the MAR, and the DON confirmed the MAR was inaccurate. The NS stated controlled drugs were expected to be documented in both the CDR and MAR when administered.
A resident with a hx of right femur fracture, VTE/embolism, edema, CKD, and high rehospitalization risk was discharged after returning from LOA when staff decided she had overstayed the LOA and treated it as an AMA discharge. The record lacked documentation that the resident wanted to leave AMA, that risks/benefits were reviewed, or that other placement options were offered, and the resident stated she was told she could not return, her belongings were packed, and she was discharged to her car despite being homeless. The SSD and MD both acknowledged AMA is resident-initiated and that discharging her to the street/car was not appropriate.
A resident who was cognitively intact and had diagnoses including a femur fracture, venous thrombosis history, embolism, edema, and CKD was discharged after returning from LOA, but the DON/SSD did not provide the required written Notice of Transfer or Discharge, appeal rights, or Ombudsman notification. The resident stated she did not want to leave, was unexpectedly discharged to her car, and was unaware of how to appeal or obtain support; the record also lacked documentation that she had requested discharge or understood the reason for it.
The facility failed to accurately account for controlled medications, leading to discrepancies between the Controlled Drug Record and medication blister cards for several residents. A resident's morphine sulfate solution was also improperly reconciled, with more liquid observed than recorded. The facility's policy on reporting discrepancies was not followed.
A facility failed to maintain a medication error rate below 5%, with errors observed in three residents. A resident received an incorrect mixture of ArgiMent AT, another did not have their pulse checked before medication administration and did not consume the full Glycolax dose, and a third received the wrong form of aspirin. These actions were contrary to the facility's policies on medication administration.
The facility failed to properly store and label medications, including an insulin pen without an open date, methadone tablets outside their original packaging, and a morphine sulfate solution in a mismatched box. These actions could lead to medication errors and resident exposure to expired medications.
The facility failed to maintain food safety and sanitation standards, as evidenced by debris on stove burners and improper food handling by a dietary staff member. The staff member used bare hands to handle parsley and continued plating food after scratching her back without washing her hands, increasing the risk of infection spread.
The facility failed to properly dispose of garbage and refuse, with a large amount of cardboard and miscellaneous items found around dumpsters. Despite regular pest control and garbage collection, maintenance did not keep the area clean, as observed over two days. The maintenance log showed several dates where the trash area was not marked as cleaned, contrary to facility policy.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including inadequate TB screening, lack of Enhanced Barrier Precautions for residents with wounds, improper storage of medical equipment, and insufficient hand hygiene. These lapses increased the risk of infection spread among residents.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with multiple diagnoses including muscle weakness, had her call light on the floor, while another resident with severely impaired cognition had the call light wrapped under the bedrail. Both residents expressed difficulty in calling for help, and their care plans indicated the need for accessible call lights. The DON confirmed the importance of call light accessibility to prevent distress.
A facility failed to submit a discharge MDS for a resident within the required timeframe, as mandated by federal regulations. The MDS Coordinator confirmed the delay, acknowledging the need to adhere to submission deadlines. The facility's policy requires compliance with federal and state timeframes, as outlined in the RAI Manual, which specifies a seven-day submission period.
A resident with dementia, dependent on staff for care, was not assisted to participate in daily activities as outlined in their care plan. Observations showed the resident remained in bed, and staff confirmed the lack of documented activities or refusals, posing a risk to the resident's well-being.
A resident with obstructive and reflux uropathy had a Foley catheter without an active physician's order, as required by facility policy. Despite the presence of the catheter, no order was documented in the resident's records, confirmed by a licensed nurse. The Director of Nursing stated that an order should include care instructions and a diagnosis, but this was not present, placing the resident at risk for inadequate care.
A resident with Type 2 Diabetes and dysphagia was served a disliked food item, fish, despite documented preferences. This was confirmed by a CNA and the Dietary Supervisor, who acknowledged the oversight. The facility's policy emphasizes considering resident wishes, but it was not followed, potentially impacting the resident's nutritional status.
A resident in a long-term care facility, admitted for rehabilitation after hip and knee surgery, experienced severe pain rated at 8 out of 10. Despite a physician's order to administer two tablets of oxycodone 5 mg for severe pain, the LN on duty only provided one tablet. The DON confirmed the failure to follow the physician's order, as corroborated by the resident's MAR and care plan interventions.
Failure to Provide Written Bed Hold Notice After Emergency Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy when Resident 1 was transferred to an acute care hospital. Resident 1 was sent to the hospital via 911 as an emergency transfer on 5/11/26, and the resident’s responsible party was notified by phone of the transfer. The transfer/discharge notice documented that the responsible party did not give consent for bed hold by phone, and it did not include a signature from the responsible party or indicate that written notice had been sent. During interviews, the DON stated that the facility did not send a written notification of bed hold for Resident 1’s transfer and that the bed hold was communicated by phone only. The ABOM stated that the business office is responsible for sending bed hold policy notifications to residents or their families and confirmed that the facility did not send a written notice of the bed hold policy to Resident 1’s responsible party for the transfer. Facility policy required written notice of bed-hold and return policies within 24 hours of an emergency transfer, and also stated that residents and/or representatives are informed in writing of the facility and state bed-hold policies at least twice, including at the time of transfer or within 24 hours if the transfer is an emergency.
Food Storage and Refrigerator Cleanliness Deficiencies
Penalty
Summary
Food was not stored and the kitchen environment was not maintained in a sanitary manner for a census of 112. During a concurrent observation and interview in the facility kitchen, three food items were found in the freezer in unsealed plastic bags: a plastic bag of 216 biscuits that was about one-third full, a large bag of 144 enchiladas in an open box, and a partial bag of 107 sausage patties. The Dietary Supervisor verified that the bags were unsealed and available for use. During observation of the walk-in refrigerator, a heavy black residue was seen around the inside door frame, with heavier residue toward the bottom and blackish residue on the putty around a pipe containing electrical wiring in the left corner of the refrigerator window. Dietary staff and the Dietary Supervisor stated they had not noticed the residue, and the Maintenance Supervisor verified the black colored residue around the door jam and pipes. The Registered Dietician stated she inspects the walk-in refrigerator monthly and had never seen the black discoloration, and facility policy stated frozen foods should be stored in airtight moisture resistant wrappers and refrigeration equipment should be routinely cleaned.
Failure to Notify Residents and Complete Room Transfer Assessment
Penalty
Summary
The facility failed to notify two residents of a room change and failed to complete a room transfer assessment after moving Resident 127 into Resident 32's room. Resident 127 was admitted with diagnoses including Type II diabetes with neuropathy and asthma, and her record showed she had capacity to understand choices and make health care decisions, with a BIMS score of 14 out of 15 indicating intact cognition. During interview, Resident 127 stated she was moved from her previous room without a clear explanation, was told only that the room needed cleaning and she would return afterward, and said she did not want to move. She also stated nursing staff and CNAs did not provide additional information, and she was later told the room had been reassigned for short-term residents. The ADON stated residents must consent before being moved and must be informed of the reason for any transfer, but she was unaware of the reason for Resident 127's room change. The SSD confirmed Resident 127 was relocated and that the room change assessment section was not completed, with no documentation of the reason for the transfer or evidence of consent, and she could not identify who initiated the move. Resident 32, who had diagnoses including epilepsy and Type II diabetes, stated she remembered Resident 127 moving into her room and was not informed by staff. The SSD verified there was no documentation that Resident 32's RP was notified, no record that Resident 32 was informed of the transfer, and the transfer form had not been initiated. The ADM confirmed the transfer occurred but could not provide who authorized it or why it happened.
Failure to Provide Timely Ordered Pain Medication
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for two residents who reported significant pain and did not receive their ordered pain medication when requested. Resident 3 was admitted with epididymitis and had a BIMS score of 15, indicating no cognitive deficits. His order was for oxyCODONE 10 mg by mouth every 6 hours as needed for pain. The MAR showed his last dose was given at 5:22 a.m. on 4/6/26, making the next dose due by 11:22 a.m. During interview, Resident 3 stated he requested his oxycodone before lunch but did not receive it until 1:59 p.m., two to three hours later. He described severe pain, saying it felt like someone was hitting him with a hammer on his testicle, and said the pain made it very difficult to move around and limited his mobility and independence. Resident 136 was admitted with breast cancer and had an order for hydrocodone-acetaminophen 5-325 mg by mouth every 4 hours as needed for pain management, with a hold parameter if respirations were less than 12. The MAR showed her last dose was given at 1:44 a.m. on 4/5/26. During interview, Resident 136 stated she requested pain medication during the night but was told it was not available, and she reported she did not sleep well and was in pain because the dose was missed. LN 2 confirmed that the resident did not receive the medication even though it was due and available in the e-kit, and stated nursing staff should have ensured pain medications did not run out and should have called pharmacy before running out to maintain adequate pain management. The DON stated that residents reporting pain should be assessed and given ordered pain medication without waiting hours, and if medication was not in the cart, staff should have obtained it from the e-kit and requested a refill from pharmacy.
Improper Storage of OTC Medication
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted professional principles and current standard of practice. During a concurrent observation and interview on the south medication cart, seven cough drops were found in a clear plastic cup and not in their original packaging. The Licensed Nurse present confirmed the cough drops were not in their original packaging and stated there were no expiration dates on them and that they should have been stored in the original package. During interviews, another Licensed Nurse stated over the counter cough drops needed to be stored in their original package and that if they were not, they could potentially be expired and not safe for residents. The Director of Nursing stated the expectation was for nursing staff to store all medications, including over the counter medications, in their original packaging, and that medications not stored in their original packaging and without expiration dates could potentially be expired and have reduced potency. The facility policy titled Medication Labeling and Storage stated medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received, and that only the issuing pharmacy is authorized to transfer medications between containers.
Inaccurate Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one of 13 sampled residents when Resident 12’s Medication Administration Record (MAR) was inconsistent with the Controlled Drug Record (CDR). Resident 12 was admitted in March 2026 with multiple diagnoses including anxiety disorder and bipolar disorder. A physician’s order dated 4/7/26 directed Valium (Diazepam) 5 mg by mouth every 6 hours as needed for anxiety. A review of Resident 12’s MAR and CDR for March and April 2026 showed that nursing staff did not document Valium administration on the MAR when the medication was signed out from the CDR on 4/1/26 at 5:30 p.m. During a concurrent interview and record review, the DON confirmed the Valium use was not accurately documented on the MAR. The NS stated the expectation was for nursing staff to document in both the CDR and MAR when a controlled drug was administered, and that inaccurate documenting could potentially result in residents not getting accurate dosage of medication per physician’s order.
Unsafe AMA Discharge and Failure to Provide Appropriate Transfer Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was cognitively intact, had a history of a right femur fracture, venous thrombosis, embolism, localized edema, and chronic kidney disease, and was identified by the NP as high risk for rehospitalization. The resident had been admitted with a discharge plan to transfer from skilled care to custodial care until placement was secured because she was homeless, and her care plan conference notes reflected that plan. Her record also showed skilled PT orders with goals related to transfers and ambulation with moderate independence. On the day in question, the resident left the facility for a leave of absence and returned later that same day. Facility documentation stated that because she had been out more than four hours, staff treated the situation as an AMA discharge. The DON documented that the resident came back at 4 p.m. and was told the MD had discharged her AMA, and a physician order later reflected discharge against medical advice. However, the resident’s record did not contain documentation that she had expressed a desire to leave AMA, that risks and benefits were discussed with her, that alternative locations or options meeting her needs were offered, or that she understood the reason for discharge and her response to it. Interviews with the resident and facility staff showed that the resident said she was not trying to leave AMA and that staff told her she could not return after her LOA. She stated the facility packed her belongings, discharged her to her car, and wanted her to sign an AMA form, which she refused because it was not her decision. The SSD acknowledged the resident did not initiate the AMA discharge and stated the resident was homeless and could not safely be discharged to her car. The MD also stated that an AMA discharge is resident-initiated and that he would not discharge a resident to the street. The report further noted that the resident remained unhoused after discharge and was living in her car.
Failure to Provide Required Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide Resident 1 with the required written discharge notices and appeal information when she was discharged from the facility. Resident 1 was admitted with diagnoses including a right femur fracture, history of venous thrombosis and embolism, localized edema, and chronic kidney disease. Her MDS indicated she was cognitively intact and capable of making her own decisions, and her care plan indicated she would receive verbal and written discharge instructions. The record showed Resident 1’s discharge plan had been discussed as a transfer from skilled to custodial care until placement was secured. However, when Resident 1 returned to the facility after being out on a leave of absence, staff informed her she could not return as a resident and that the medical director had discharged her AMA. Documentation included a voicemail from the SSD stating the facility had decided to discharge her because she had been out for more than four hours, and a social services note stating the NP was notified and agreed with proceeding with discharge. A physician order later documented discharge against medical advice, but nursing notes did not show that Resident 1 had expressed a desire to leave or that she understood the reason for the unexpected discharge or her response to it. Resident 1 stated she was not trying to leave, did not want to leave, and was unexpectedly discharged to her car after staff packed her belongings. She stated she did not receive written notification or discharge instructions and was unaware of her right to appeal or who to contact for support. The SSD confirmed there was no documentation that the Notice of Transfer or Discharge form had been provided prior to or on the day of discharge, and the Ombudsman stated he had not received recent discharge notifications from the facility. The facility policy required written notice at least 30 days before transfer or discharge, including appeal rights, Ombudsman contact information, and bed-hold policy information, and required a copy to be sent to the Ombudsman at the same time.
Controlled Medication Accountability Discrepancies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for several residents, leading to discrepancies between the Controlled Drug Record (CDR) and the medication blister card (medcard). During a medication cart check, it was found that Resident 76's CDR for clonazepam and hydrocodone-apap showed more doses than were present in the medcard. Similarly, Resident 151's CDR for methadone hydrochloride and Resident 17's CDR for lacosamide also showed discrepancies. Licensed Nurse 5 confirmed that controlled medications should be signed out in the CDR when taken from the medcard, and the Director of Nursing stated that reconciliation should occur before administering medication. Additionally, a bottle of morphine sulfate solution for Resident 63 was not reconciled properly. The liquid in the bottle was observed to be at 24 ml, while the CDR indicated only 17 ml remained. The Pharmacist/Pharmacy Manager confirmed that manufacturers do not overfill containers, suggesting an error in reconciliation. The facility's policy requires any discrepancy in controlled substance medication counts to be reported immediately to the Director of Nursing, but this was not adhered to, resulting in inaccurate accountability of controlled medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 17.86% during a medication pass observation. This involved five medication errors out of 28 opportunities for three residents. For Resident 7, a Licensed Nurse (LN) prepared an ArgiMent AT packet without measuring the liquid, resulting in a mixture exceeding the recommended amount. The facility's policy required the correct dose preparation, which was not followed. For Resident 204, LN 4 did not check the pulse rate before administering medications, which was necessary according to the resident's orders. Additionally, the resident did not consume the entire Glycolax mixture, leading to an incomplete dose. The facility's policy required verification of vital signs and ensuring the resident consumed all medications. For Resident 351, LN 8 administered the wrong form of aspirin, providing a chewable tablet instead of the prescribed enteric-coated form. The facility's policy required medications to be administered according to prescriber orders, which was not adhered to in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a medication cart check. An insulin pen was found without an open date, which is crucial for tracking its expiration, as confirmed by the Director of Nursing (DON). The facility's policy requires that nursing staff label insulin pens with the date they are opened. Additionally, methadone tablets were improperly stored outside their original packaging, which is necessary to maintain essential information such as the resident's name and expiration date. Furthermore, a bottle of morphine sulfate solution was found in a mismatched box, lacking the correct administration instructions. The medication administration instructions on the label did not match the medical doctor's order, as confirmed by the DON. The facility's policy mandates that medications be stored in their originally received containers to meet legal requirements. These deficiencies in medication storage and labeling could lead to medication diversion, errors, and resident exposure to expired medications.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Thick, black, charcoal-like debris was found between all spokes of the two front gas burners on the facility's industrial stove, which was verified by the Dietary Manager (DM) during an initial tour of the kitchen. This indicates a lack of proper maintenance and cleaning of kitchen equipment, which is essential for ensuring sanitary food preparation. Additionally, a dietary staff member, referred to as [NAME] 2, was observed handling parsley with bare hands and placing it directly on resident plates, contrary to the facility's policy that requires the use of utensils or gloves when handling ready-to-eat food. Furthermore, the same staff member scratched her back and continued plating food without washing her hands, which was confirmed by the DM. The Registered Dietician (RD) also emphasized the importance of wearing gloves and washing hands after contact with clothing. These actions increased the risk of infection spread and compromised the sanitary preparation of food for the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. A large amount of cardboard and miscellaneous items, including milk cartons, straws, sugar packets, plastic gloves, a coffee pot top, soft drink cans, a Christmas tree decoration, Styrofoam pieces, a metal tube, and zip lock bags, were found strewn around and under the garbage dumpsters at the back of the facility. This situation was observed during an interview with the Dietary Assistant Supervisor, who was unsure how long the trash had been there, suggesting it might have been a day or so. The Maintenance Supervisor indicated that pest control services the area once a month and that the dumpsters are emptied daily, with cardboard being collected three times a week. However, the maintenance team is responsible for keeping the area clean. Further observations revealed that the cardboard was still protruding from under the dumpster the following day. The Maintenance Assistant mentioned that they clean the area around 8:45 a.m. daily, provided there are no urgent tasks, and noted that the cardboard should be disposed of in the dumpster with the lid closed. A review of the facility's maintenance log showed several dates where the trash area was not marked as cleaned, and a note indicated that new trash cans were delivered late. The facility's policy and procedure document stated that maintenance is responsible for keeping the grounds free of litter and maintaining a safe and orderly environment around the buildings.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Three residents were not properly screened or tested for tuberculosis (TB) upon admission or annually, as required. Resident 3 had not received a TB test since the initial test in 2021, and there was no documentation of further testing or physician notification. Resident 8's records lacked evidence of a TB test or refusal documentation, and no chest X-ray was ordered to rule out TB. Resident 79 was not annually screened for TB, contrary to the facility's policy. Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds, increasing the risk of infection spread. Resident 9 and Resident 151, both with chronic wounds, did not have EBP signage outside their rooms, and staff did not wear gowns during wound care. The facility's policy required EBP for residents with wounds, but this was not followed, as observed during wound care procedures. Infection control practices were further compromised by improper storage of medical equipment and inadequate hand hygiene. Resident 201's nebulizer mask and the oxygen tubing for Residents 84 and 202 were found on the floor, posing a risk of contamination. Additionally, a Restorative Nursing Assistant (RNA) failed to perform hand hygiene between assisting multiple residents during lunch, and a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) for a resident on droplet precautions. These lapses in infection control practices increased the risk of spreading infections within the facility.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which is a deficiency in accommodating the needs and preferences of each resident. Resident 6, who was admitted with multiple diagnoses including aftercare following joint replacement surgery and muscle weakness, was observed with her call light on the floor and out of reach. Despite being cognitively intact and requiring partial assistance for activities of daily living, Resident 6 expressed difficulty in calling for help when the call light was not accessible. The care plan for Resident 6, dated prior to the observation, indicated that the call light should be within reach to mitigate fall risks related to impaired mobility. Similarly, Resident 307, who had severely impaired cognition and required substantial assistance for activities of daily living, was found with the call light wrapped under the bedrail and out of reach. During an interview, Resident 307 expressed discomfort due to the inability to call for help when needed. The care plan for Resident 307, which included a bladder re-training program, also specified that the call light should be within reach and answered promptly. The Director of Nursing confirmed that the call light should be accessible to prevent resident distress. The facility's policy on the call light system mandates that each resident should have a means to call a staff member directly.
Failure to Timely Submit Discharge MDS
Penalty
Summary
The facility failed to submit a Minimum Data Set (MDS) for a resident in a timely manner, as required by federal regulations. Specifically, the discharge MDS for a resident who was admitted in September and discharged on an unspecified date was not submitted to the Centers for Medicare and Medicaid Services (CMS) within the mandated seven-day timeframe. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged the delay and the need to adhere to submission deadlines. The facility's policy, revised in July, mandates compliance with federal and state submission timeframes as outlined in the Resident Assessment Instrument (RAI) Manual. The RAI Manual, dated October, specifies that discharge MDS must be submitted within seven days of completion.
Failure to Implement Resident's Care Plan for Activities
Penalty
Summary
The facility failed to implement a comprehensive and person-centered care plan for a resident diagnosed with dementia, who was totally dependent on staff for all care needs, including bed mobility, dressing, hygiene, and activities. The resident's care plan indicated that they should be up in a chair daily and out of the room for activities. However, multiple observations over several days revealed that the resident remained in bed and did not participate in any activities as outlined in their care plan. Interviews with staff, including a CNA and the Activities Director, confirmed that the resident was not assisted to get out of bed and participate in activities. The Activities Director also confirmed the absence of documented evidence of activities offered to the resident or any refusal by the resident to participate. This lack of adherence to the care plan posed a risk to the resident's ability to attain their highest practicable physical, mental, and psychosocial well-being.
Lack of Physician's Order for Foley Catheter
Penalty
Summary
The facility failed to meet professional standards of nursing practice for a resident who had a Foley catheter without an active physician's order. The resident was admitted with diagnoses including obstructive and reflux uropathy and an infection due to an indwelling catheter. Despite the presence of a catheter, there was no active order documented in the resident's records, including the Order Summary Report and the Medication Administration Record (MAR). This oversight was confirmed during an observation and interview with a licensed nurse, who acknowledged the absence of an active order for the Foley catheter. The Director of Nursing stated that an order for a Foley catheter should include catheter care instructions, the need for changing the catheter, and a diagnosis justifying its use. The facility's policy also required verification of a physician's order for catheter insertion. However, the resident's care plan, which mentioned the indwelling catheter, did not have an accompanying active order. This lack of documentation and adherence to policy placed the resident at risk for not receiving proper nursing care related to the catheter.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in care. The resident, who was admitted in August 2024 with diagnoses including Type 2 Diabetes Mellitus, dysphagia, and long-term use of insulin, was served a food item they disliked. Specifically, during a meal observation, the resident was served a filet of breaded fish despite having a documented dislike for fish. This oversight was confirmed by both a Certified Nursing Assistant and the Dietary Supervisor, who acknowledged that the resident's food preferences were not respected. The Dietary Supervisor and the Director of Nursing both confirmed that not honoring food preferences could negatively impact the resident's nutritional status. The facility's policy on nutrition and unplanned weight loss emphasizes the importance of considering resident wishes and food intake in treatment decisions. However, in this instance, the facility did not adhere to its policy, resulting in the resident receiving a meal that did not align with their documented preferences.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to provide services according to professional standards of quality for a resident when the resident's pain medication was not administered per physician order. The resident, who was admitted for rehabilitation therapy after hip and knee surgery, reported severe pain rated at 8 out of 10. Despite the physician's order to administer two tablets of oxycodone 5 mg for severe pain, the Licensed Nurse (LN) on duty only provided one tablet. The Director of Nursing (DON) confirmed that the LN did not follow the physician's order, which was also corroborated by a review of the resident's Medication Administration Record (MAR) and care plan interventions. The facility's policy and procedure for administering medications, which requires medications to be administered as prescribed, was not adhered to in this instance.
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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 Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eskaton Village Care Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Sacramento Post-acute | 1.1 mi | ★★★★★ | 16 | 0 |
| American River Center | 1.1 mi | ★★★★★ | 12 | 0 |
| Mission Carmichael Healthcare Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Whitney Oaks Care Center | 1.4 mi | ★★★★★ | 6 | 0 |
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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 August 2026) and official state health department websites.