Below 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 Double Tree Post Acute Care Center during CMS and state inspections, most recent first.
Kitchen sanitation and food storage practices were deficient when surveyors observed damaged walls, rusted shelving and vents, chipped flooring, and discolored linoleum in food areas. Spices were inconsistently labeled, including one expired curry spice, and clean items were stored wet in the ready-to-use area. Surveyors also found food residue on a colander and scoop, dust and crumbs in a knife holder, and 6 of 8 fry pans with chipped, greasy cooking surfaces.
Improper Use of Recipes During Meal Preparation: A cook prepared the alternate chicken entree and pureed pot roast and peas without following facility recipes or using measured ingredient amounts. Unmeasured seasonings, liquids, and large amounts of thickener were added during blending, while the facility recipes called for specific measured ingredients and gradual thickener use. The DM stated that using excessive fluid and thickener reduces nutrition and flavor.
Failure to Monitor Lithium Levels: A resident with MDD and schizophrenia was receiving Lithium, but the last documented serum level was old and there were no current lab orders in place. The care plan called for regular monitoring, the psych note referenced the outdated level and a plan for a new one, and the DON, LPN, PC, and FMD all confirmed the gap in monitoring and the absence of current orders.
Failure to report an alleged theft of resident funds within 24 hours. A resident with intellectual disabilities, substance abuse, and cognitive communication deficit reported that $2,300 from the sale of his truck was missing after he placed it in his fanny pack and went to sleep. The SSD and ADM confirmed the allegation needed investigation and expected it to be reported to CDPH, but no evidence of the required report was provided.
Improper Administration of Nasal Spray Medication: An LPN prepared fluticasone propionate nasal spray for a resident with allergy symptoms, then handed it to the resident to self-administer without giving the required instructions. The MAR and order directed the spray to be given as 1 spray in both nostrils daily, and the LPN confirmed she did not follow the medication instructions; the DON stated staff were expected to administer medications according to the specifications.
A resident with DM and malnutrition did not receive an ordered HbA1c test, had a low BS reading that was not documented on the MAR as required, and had no documented diabetic education or care plan focus for malnutrition. The DON confirmed the HbA1c was charted in error and that licensed staff did not follow the MD order, while the RD confirmed the resident’s bedside sugary foods, lack of diabetic teaching, and absence of diabetes-related staff in-services.
A resident with gait and mobility problems and a history of falls was identified as high risk for falls, with the care plan directing that the call light remain within reach. During repeated observations, the call light was found above the resident's head, on the floor, and behind a pillow, and the resident stated he could not reach it. CNAs, an LN, and the DON confirmed the call light was not within reach and stated it was expected to be placed near the resident.
Failure to address significant weight loss: A resident with DM2, MDD, dysphagia, and schizophrenia lost 22 pounds over 6 months. Staff observed the resident feeding slowly with a tremor and later noted he was bored with the food and felt he had no choice in what was served. The weight variance note did not identify a cause or add care plan interventions, the RD had not assessed the resident since 8/21/25, and the RD and DON could not identify a root cause for the weight loss.
A resident with dysphagia, esophagitis with bleeding, and NPO status was receiving enteral tube feeding while a swallow screen for diet update was started but ended early because of pain. The resident repeatedly asked to eat by mouth, yet the swallow evaluation was not rescheduled or completed, and the ST, LPN, and DON all confirmed the incomplete evaluation remained unresolved.
Metformin Given Without Meals as Ordered: A resident with DM was ordered metformin 1000 mg twice daily with meals, but an LPN administered the dose without food during a med pass. The LPN confirmed the order said to give with meals, and the resident stated he had not had snacks before the dose and dinner was not served until later. The DON and facility policy both indicated meds ordered with meals should be given at meal times.
A discharged resident's lidocaine patches were found in a med cart drawer mixed with active residents' oral, liquid, and topical medications. An LPN confirmed the box belonged to a resident who had already been discharged and stated discharged residents' medications should not remain in the cart. The DON stated all meds should be removed after discharge, and the facility policy required discontinued medications and medications left after discharge to be identified and removed from current medication supply in a timely manner.
RD did not use interpreter services to assess a non-English speaking resident who had significant weight loss and limited documented food preferences. The resident was awake and alert, reported preferred foods of chicken, rice, and vegetables, and said she avoided several foods served by the facility; however, the dietary system listed only rice as a preference, and the RD said she communicated by pointing and body movement instead of using an interpreter.
A resident with severe cognitive impairment was struck in the head by another resident with intact cognition, resulting in pain and dizziness that required hospital evaluation. The incident occurred without staff present, and both individuals confirmed their involvement. Facility policy affirms the right to be free from abuse, but this right was not upheld in this case.
A resident with a history of aggression and alcohol-induced psychotic disorder was pushed by a visitor during an altercation. Despite documented aggressive behavior, there was no person-centered care plan addressing the risk, and the incident was witnessed by an LPN. Facility policy requires protection from abuse by anyone, but the resident was not safeguarded from physical abuse.
A resident was involved in a physical altercation with a visitor, during which both parties pushed each other. Although staff intervened and documented the event, the allegation of abuse was not reported to the state department within the required 2-hour window. Interviews with staff and review of facility policy confirmed that the delay was due to a lack of recognition that the incident was reportable.
A facility failed to protect a resident from physical abuse when a staff member witnessed an altercation between two residents. One resident, diagnosed with anxiety disorder, hit another resident with hemiplegia during a dispute over cigarettes on the smoking patio. Both residents confirmed the altercation, and facility policies on abuse prevention and residents' rights were not upheld.
A resident with Type 2 Diabetes Mellitus experienced dangerously high glucose levels due to the failure of LNs to follow physician orders and administer insulin correctly. The resident's blood sugar levels were not documented accurately, and symptoms of hyperglycemia were reported. Interviews revealed a lack of adherence to facility policies and procedures.
The facility failed to manage an emergency kit (e-kit) properly, which was found unsealed and undocumented in the medication storage room. A nurse could not confirm when the e-kit was opened or replaced, and it lacked required pharmacist signatures. The Director of Nursing and a registered pharmacist acknowledged the e-kit should have been sealed, labeled, and documented according to the facility's policy.
A LTC facility failed to maintain a medication error rate below 5% for two residents. A nurse did not administer insulin and Glipizide as per physician orders for one resident, and administered lactobacillus without verifying the strength for another. The DON acknowledged these errors, which were contrary to the facility's medication administration policy.
A resident in an LTC facility experienced significant medication errors when an LPN failed to administer Humulin R insulin and glipizide according to physician orders. The insulin was not given despite a high blood sugar reading, and the glipizide was administered after breakfast instead of 30 minutes before. These actions led to the resident experiencing symptoms of high blood sugar.
The facility failed to properly store and label medications, including latanoprost, glucose test strips, and insulin lispro, leading to potential medication errors. Expired Tuberculin vials and an unlabeled polyethylene glycol bottle were found, and the medication refrigerator was out of the required temperature range.
The facility failed to maintain the walk-in freezer in a safe condition, affecting 115 residents. Ice buildup was observed on the walls, ceiling, and food boxes, attributed to temperature fluctuations and old equipment. The Dietary Manager, Maintenance Supervisor, Registered Dietician, and Director of Nursing were aware of the issue, which posed risks to food quality and safety. Despite facility policies emphasizing safe food storage, the problem persisted.
Two residents with malnutrition diagnoses did not receive their prescribed supplement drinks as indicated on their meal tray tickets. The Dietary Supervisor and CNA acknowledged the omissions, and the RD and DON confirmed the importance of accurate meal trays to meet nutritional needs.
The facility failed to protect four residents from abuse, resulting in two separate altercations where two residents sustained skin tears. Despite the facility's abuse prevention policy, the incidents were confirmed as abuse by the Social Services Director and a Licensed Nurse.
Kitchen sanitation, storage, and equipment cleaning deficiencies
Penalty
Summary
The facility failed to ensure food safety standards were met in the kitchen and food storage areas for a resident population of 102. During an initial kitchen tour with the Dietary Manager, surveyors observed chipped paint and damaged drywall near the floorboards in the dry storage area and kitchen, worn and chipped floor tiles by the dish machine, and linoleum in the dry storage area and utility closet with dark discoloration, rust stains, and gouges. The bread shelf and food storage shelves were rusted, and later observation showed two air vents over food production areas with multiple layers of paint and rust. The Maintenance Director agreed the wall openings could allow bugs to live and multiply and that the rust and dirt could cause cross contamination of food. Surveyors also observed inconsistent labeling of spices in the kitchen. Twenty spices had varying use-by dating practices, including some labeled for 3 months, some for 20 days, some with only received dates, and some with no use-by date at all. One curry spice was found expired with an expiration date of 8/12/25. The Dietary Manager agreed the labeling was inconsistent and stated the expired curry should have been discarded. Facility policies reviewed by surveyors required dry foods to be labeled and dated with a use-by date, and the posted dry goods storage guideline indicated dried spices and herbs should have a use-by date of 6 to 12 months. Additional observations in the clean ready-to-use area showed five large plastic containers and 20 lids stacked with visible moisture between each piece, a metal colander with brown food residue in the openings and around the base, a plastic scoop with brown food residue inside its bowl, and a knife holder covered with dust and crumbs near the insertion sites. Six of eight fry pans were also observed with chipped cooking surfaces and greasy residue. The Dietary Manager stated the wet stacked items did not meet expectations and could cause bacterial growth, and that the dirty utensils and chipped pans were unsanitary and should have been discarded because chipped particles could leach into food.
Improper Use of Recipes During Meal Preparation
Penalty
Summary
Food and drink were not prepared in a manner that conserved nutritive value, flavor, and appearance when recipes were not used for the lunch meal on 1/21/26. During a return visit to the kitchen, a cook was preparing the meal and the alternative entree of Lemon Almond Chicken without any recipes visible on the counter. The cook opened thawed chicken breasts, counted out 6 pieces, placed them in a high-sided pan, and sprinkled them with unmeasured amounts of dry mustard, lemon/pepper seasoning, salt, chicken bouillon, and garlic powder before moving the chicken to a flat pan and placing it in the oven. The facility-provided Lemon Almond Chicken recipe called for a measured marinade made with specific ingredients, including lemon juice, canola oil, Dijon mustard, garlic, and rosemary, to be poured over the chicken and refrigerated for an hour before cooking, along with additional measured ingredients used during preparation. The cook also prepared pureed pot roast and pureed peas without following the facility recipes or using measured amounts. For the pot roast, the cook blended unmeasured beef juices and about one-third of the cooked meat, added about 2 ounces of thickener, then later added the remaining pot roast, more thickener, two more slices of pot roast, water, and chicken broth base before mixing everything into the same steam table pan. The facility recipe for pureed meat directed staff to use specific amounts of liquid and to start with 1 1/2 teaspoon of thickener, adding more gradually as needed. For the peas, the cook blended the vegetables with unmeasured butter and chicken broth, then added approximately 3.5 ounces of thickener when the mixture was too thin. The facility recipe for pureed vegetables directed staff to use reserved cooking liquid if needed and to start with 1 1/2 teaspoon of thickener, adding more gradually. The dietary manager stated that cooks should use the minimal amount of fluid so less thickener is needed, and that excessive fluid and thickener lead to food having less nutrition and flavor.
Failure to Monitor Lithium Levels
Penalty
Summary
The facility failed to ensure that one sampled resident with diagnoses including Major Depressive Disorder and Schizophrenia received safe and adequate monitoring of Lithium, a psychotropic medication. The resident’s care plan included monitoring Lithium levels every 3 months, but the last documented Lithium level was drawn on 12/26/24. During observation on 1/20/26, the resident was eating lunch and had visibly shaking arms and hands. The resident stated, “This place is like a warehouse where they keep us, I am kept here because I get very depressed.” Record review showed the most recent psychiatric provider note, dated 11/12/25, referenced the last Lithium level of 0.5 from 12/26/24 and stated Lithium levels should be monitored regularly, with a plan to order a new level. However, the order summary report showed no current orders for Lithium lab draws. The resident’s Lithium was last refilled by the FMD on 11/17/25. LN 2 and the DON both confirmed there was no current order and that the resident’s Lithium level had not been checked since 12/26/24. The DON stated the resident should have been monitored every 6 months, and the PC stated that if the care plan called for every 3 months, that schedule should have been followed.
Failure to Report Alleged Theft of Resident Funds
Penalty
Summary
The facility failed to report an allegation of theft within 24 hours to CDPH for one of 28 sampled residents, Resident 102. Resident 102’s admission record showed he was readmitted in July 2024 with diagnoses including intellectual disabilities, substance abuse, and cognitive communication deficit. A nursing note dated 4/23/25 documented that at 7:05 p.m. the resident came to the nursing station reporting that $2,300 was missing from his fanny pack after he had taken a nap and later found the money gone. The note stated the incident was reported and referred to Social Services. During interview, Resident 102 stated he had sold his truck for $2,300 and later placed the money in his fanny pack in his room before going to sleep, after which the money was missing. The Social Services Director confirmed the resident reported the missing money and stated it was a large amount that had to be investigated, and that she expected the incident to be reported to the department. The Administrator also confirmed the resident reported that money from the sale of his truck was missing and expected the incident to be reported, but he was unable to provide evidence that the report was sent. The facility policy stated that alleged or suspected staff misappropriation of resident property must be reported to the State Licensing and Certification Agency within 24 hours.
Improper Administration of Nasal Spray Medication
Penalty
Summary
The facility failed to ensure that Resident 74 received fluticasone propionate nasal spray in accordance with the medication administration instructions. Resident 74 was admitted with diagnoses that included nasal allergy symptoms, and the order summary directed that Flonase Allergy Relief Nasal Suspension 50 mcg/act be given as 1 spray in both nostrils once daily for allergy symptoms. The medication administration record also reflected this order for administration at 1700. During a medication pass observation, LN 4 prepared the nasal spray, entered Resident 74's room, and handed the medication to the resident, who sprayed it into each nostril himself. LN 4 did not provide instructions on how to administer the medication. When the fluticasone propionate nasal spray quick start guide was reviewed with LN 4, she confirmed that she allowed the resident to use the spray on his own and did not follow the medication instructions. The DON stated that nurses were expected to follow the medication specifications during administration.
Missed HbA1c Testing and Lack of Diabetic Education
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for one sampled resident with diabetes mellitus and malnutrition. Resident 113’s physician ordered hemoglobin A1c testing every 3 months, with the first test to be obtained on 1/13/26, but the laboratory record did not show a result for HbA1c. During review of the MAR, the column for diabetic HbA1c testing showed a check mark indicating the test was done, but the DON confirmed this was documented in error by licensed staff. Resident 113’s care plan included a focus for diabetes with an intervention for lab work as ordered and reporting to the MD, but it did not identify a focus for malnutrition or for diabetic education. The resident had a blood sugar reading of 49 mg/dl on 1/17/26, and during observation and interview the resident stated he was diabetic, had been on insulin for 11 years, and had not received diabetic teaching from facility staff. The resident also stated that blood sugar had been checked the prior night, was high, and had not been checked or treated that morning. The DON acknowledged the facility missed obtaining the ordered HbA1c lab, that licensed staff did not follow the physician’s order, and that the resident had not received admission or periodic diabetic teaching. The DON also confirmed the MAR did not document the low blood sugar reading on the diabetic section for responsive patients with BS less than 70 mg/dl. The RD confirmed the resident had diabetes and malnutrition, saw sugary food items at bedside, had not discussed or reviewed the resident’s blood sugar summary, had not documented the bedside foods in progress notes, and had not provided diabetic education or staff in-services related to diabetes, diabetic medication, or documentation.
Call Light Not Kept Within Reach for High Fall-Risk Resident
Penalty
Summary
The facility failed to maintain a safe environment for one of 28 sampled residents when Resident 83's call light was not kept within reach. Resident 83 was admitted in fall 2021 with diagnoses including abnormalities of gait and mobility and a history of falls. The care plan dated 12/25 identified a fall assessment score of 12, indicating a high risk for falls, and directed that the resident's call light remain within reach. During multiple observations and interviews, Resident 83's call light was found tucked above his head, on the floor, and behind his pillow, and the resident stated he could not reach it. CNA 1, CNA 3, CNA 2, and LN 5 each confirmed at different times that the call light was not within reach and stated it was expected to be placed near the resident or clipped to the bed. The DON stated it was the expectation that call lights be within reach for assistance and needs. The facility policy titled Safety and Supervision of Residents stated that interventions to reduce accident risks and hazards include ensuring that interventions are implemented.
Failure to Address Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for Resident 46, who had a documented 22-pound weight loss over 6 months. During lunch observation, Resident 46 was slowly feeding himself and had a tremor that increased the time needed for self-feeding. In a later interview, Resident 46 stated he did not pay attention to his weight, had a history of depression, felt he was being warehoused at the facility, and was bored with the facility food and felt he had no choice in what he was served. During a breakfast observation the next day, Resident 46 was the only resident in the dining room and had finished 90% of the meal while still eating. Record review showed Resident 46 was admitted in 2/2017 with diagnoses including type 2 diabetes, major depressive disorder, dysphagia, and schizophrenia. A weight variance note documented weights decreasing from 210 pounds on 5/3/25 to 189 pounds on 11/1/25, with a 7-pound loss over 1 month, 17-pound loss over 3 months, and 22-pound loss over 6 months. The note did not discuss a potential cause for the weight loss or add interventions to the care plan. RD notes showed Resident 46 had not been assessed since 08/21/25. The RD stated significant weight losses were discussed with the IDT to determine root cause and make recommendations, but for Resident 46 the RD did not have a cause and stated depression had not been considered, and no interventions had been initiated. The DON stated the IDT would normally identify potential causes such as diuretic use, poor intake, or dislike of the facility and work with the physician to develop a plan, but no root cause was given for Resident 46's weight loss.
Incomplete swallow evaluation for a resident receiving tube feeding
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for one resident with dysphagia and esophagitis with bleeding who was receiving enteral tube feeding and was ordered NPO. The resident’s MDS showed that more than 51% of nutrition was provided by tube feeding, and the care plan identified the resident as at risk for aspiration. A progress note dated 10/30/25 documented a new order for a swallow screen for diet update, but the swallow screen ended early because the resident reported pain, and the note stated that a further swallow evaluation was needed when the resident was feeling her best and able to participate. Subsequent documentation showed the resident repeatedly requested to eat by mouth, including in nursing notes and progress notes, but the swallow evaluation was not rescheduled or completed. During observation, the resident was receiving tube feeding by pump and stated that the swallow evaluation had not been completed and that she had only received nutrition through tube feeding since admission. The speech therapist and an LPN both confirmed that the swallow screen had not been completed and that the resident should have been re-evaluated by that time. The DON stated that staff were expected to address resident needs and that an incomplete swallow evaluation should have been followed up and completed.
Metformin Given Without Meals as Ordered
Penalty
Summary
The facility failed to ensure that Resident 119 received metformin with meals as ordered. Resident 119’s admission record showed diagnoses including diabetes mellitus, and the order summary and MAR both directed that Metformin HCl 1000 mg be given by mouth twice a day with meals. During a medication pass observation, Licensed Nurse 5 administered the metformin to Resident 119 at 5:05 p.m. without meals or food. During the observation and interview, LN 5 reviewed the medication bubble pack and confirmed the instruction to give with meals, and stated she administered the medication without meals or food. Resident 119 stated he had not taken any snacks before the medication and that dinner was served around or after 6 p.m. The DON later reviewed the record and stated she expected staff to follow medication instructions for anti-diabetic medications and to administer medications ordered with food at the resident’s meal times. The facility policy also stated that medications to be given with meals are to be scheduled for administration at the resident’s meal times.
Discharged Resident Medication Left in Active Med Cart
Penalty
Summary
The facility failed to ensure medications of a discharged resident were removed from the nurse's medication cart and were instead mixed with the active medication supplies of other residents. During a task observation, two medication carts were inspected, and in the lower drawer of medication cart #3, oral, liquid, and topical medications for active residents were stored together with one full box of lidocaine patches that belonged to a resident who had already been discharged. During the concurrent observation and interview, the LPN confirmed the name on the lidocaine patch box belonged to a resident discharged the prior month and stated discharged residents' medications should have been removed from the cart and not mixed with medications for active residents. The LPN also stated nurses were not supposed to keep medications for residents no longer in the facility because they might be administered in error. The DON stated the expectation was for nurses to remove all medications once residents were discharged, and that medications left in the cart could be expired and could be administered in error. The facility policy on disposal of medications stated discontinued medications and medications left after discharge are to be identified and removed from current medication supply in a timely manner for disposition.
RD Did Not Use Interpreter Services to Assess Non-English Speaking Resident With Significant Weight Loss
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian, when the Registered Dietitian did not use interpreter services to assess a non-English speaking resident. During a lunch observation, Resident 11 was in bed, awake and alert, and stated she did not speak English and identified her preferred language. A review of the medical record showed a weight variance note documenting weights of 106 pounds on 10/11/25, 99.5 pounds on 11/1/25, 89 pounds on 12/1/25, 84 pounds on 1/3/26, and 88 pounds on 1/15/26. During a later observation, Resident 11 communicated through a CNA interpreter and stated she preferred chicken, rice, and vegetables, ate some beef but not often, and avoided pork, fish, and yogurt. She also reported a prior weight of 110 pounds and a current weight of 89 pounds. The RD stated she did not speak the resident’s language and had communicated by pointing and body movement. The DON stated interpreter services were expected to be used for communication and that without an interpreter residents could not be thoroughly assessed. The dietary computer system showed only rice as a preference, and the resident was served pot roast, peas, and roasted potatoes even though chicken, rice, zucchini, and carrots were available.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when one resident with severe cognitive impairment was struck in the head by another resident with intact cognition. The incident was confirmed through clinical record review, interviews, and documentation. The resident who was hit reported pain and dizziness following the altercation and was sent to the hospital for evaluation. The altercation took place in a room without staff present, and both residents acknowledged their involvement in the incident during interviews. The facility's policy states that residents have the right to be free from abuse, including physical abuse. Despite this, the facility failed to protect this right, resulting in one resident experiencing pain and ongoing discomfort after being hit. The event was documented in the residents' clinical records and confirmed by the DON, who acknowledged the residents' rights as outlined in facility policy.
Resident Not Protected from Physical Abuse by Visitor
Penalty
Summary
A resident with a diagnosis of alcohol-induced psychotic disorder and intact cognition was involved in an altercation with a visitor, during which the visitor pushed the resident. Prior to the incident, the resident had exhibited verbal and physical aggression toward both visitors and staff, as documented in the SBAR communication tool. Despite this history, there was no documented evidence of a person-centered care plan addressing the resident's potential risk of aggression. The incident was witnessed by a licensed nurse, and the facility's policy states that residents must be free from abuse by anyone, including visitors. The failure to implement appropriate care planning and protective measures resulted in the resident not being protected from physical abuse by a visitor.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident and a visitor was reported to the appropriate authorities within the required 2-hour timeframe. On the evening of 7/1/25, a resident became verbally aggressive and pushed a visitor, who then pushed the resident in response. Staff intervened and calmed the situation. The incident was documented in the facility's records, and the primary care clinician was notified the same evening. However, the initial report to the state department was not faxed until the following day, more than 2 hours after the incident occurred and was recognized as a potential abuse situation. Interviews with facility staff, including licensed nurses and the Director of Nursing (DON), confirmed awareness of the requirement to report abuse allegations within 2 hours. The DON stated that the delay in reporting was due to not recognizing the incident as a reportable event at the time. Review of facility policy and federal regulations further confirmed the obligation to immediately report all suspected abuse, neglect, or mistreatment. The failure to report the incident in a timely manner constituted noncompliance with both facility policy and federal requirements.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a staff member witnessed an altercation between two residents. Resident 1, who had intact cognition and was diagnosed with anxiety disorder and muscle weakness, was seen hitting Resident 2, who also had intact cognition and was diagnosed with hemiplegia and reduced mobility. The incident occurred on the smoking patio, where Resident 1 confronted Resident 2 over a dispute involving cigarettes. The Director of Nursing was informed of the incident by a janitor who witnessed the altercation, and the Social Services Director confirmed the event through video observation. Interviews with both residents confirmed the physical altercation, with Resident 1 admitting to hitting Resident 2 in the face, and Resident 2 attempting to retaliate. Progress notes and communication forms documented the incident, including Resident 1's admission of hitting Resident 2 and Resident 2's account of being struck in the head. The facility's policies on abuse prevention and residents' rights emphasize the commitment to protecting residents from abuse and ensuring they are treated with respect and dignity, which was not upheld in this instance.
Failure to Manage Diabetes Leads to Hyperglycemia
Penalty
Summary
The facility failed to properly manage a resident's Type 2 Diabetes Mellitus, leading to dangerously high glucose levels and symptoms of hyperglycemia. The Licensed Nurses (LNs) did not follow physician orders, resulting in the resident not receiving the prescribed morning insulin. The resident's blood sugar level was recorded at 466 mg/dl, which was above the sliding scale order, yet the LN did not notify the physician or administer the necessary insulin. Throughout the day, the resident continued to experience high blood sugar levels, with readings reaching as high as 577 mg/dl. Despite these critical levels, the LNs failed to document the readings accurately and did not administer the correct insulin dosage as per the physician's orders. The resident complained of symptoms such as headache, dizziness, and thirst, indicating the severity of the hyperglycemia. Interviews with the LNs revealed a lack of understanding and adherence to the facility's policies and procedures regarding insulin administration and changes in a resident's condition. The Director of Nursing acknowledged the failure to follow physician orders and the potential harm caused by untreated hyperglycemia. The facility's documentation system also had limitations, as it could not record non-numerical values for blood sugar levels, further complicating the situation.
Failure to Manage Emergency Kit in Medication Storage
Penalty
Summary
The facility failed to properly manage an emergency kit (e-kit) containing medications, which was observed to be unsealed in the north station medication storage room. A Licensed Nurse (LN) was unable to provide information on when the e-kit was opened or when it should have been replaced. The use of the e-kit was not logged in the e-kit logbook, and the contracted facility pharmacy was not contacted for a replacement. Additionally, the e-kit lacked the required pharmacist signatures on the white labels, indicating a failure in the verification and documentation process. Interviews with the Director of Nursing (DON) and a registered pharmacist (RPh) revealed that the e-kit should have been sealed, properly labeled with pharmacist signatures, and documented for any use. The facility's policy and procedure for emergency pharmacy services, dated 2007, requires that any medication or supply item removed from the e-kit be documented and communicated to the pharmacy. The failure to adhere to these procedures could lead to expired pharmaceutical products, decreased availability of medications in an emergency, or increased risk of drug diversion.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5% for two residents, leading to potential adverse health outcomes. For Resident 31, a Licensed Nurse (LN) did not administer Humulin Insulin as per the physician's order. The resident's blood sugar level was recorded at 466 mg/dl, which required a specific insulin dosage and notification to the Medical Doctor (MD), neither of which were carried out. Additionally, the same resident was given Glipizide after breakfast, contrary to the physician's order to administer it 30 minutes before a meal. For Resident 103, the LN administered lactobacillus without verifying the strength of the medication as per the physician's order. The order lacked specific strength details, and the LN failed to consult the medication label or seek clarification from the MD or charge nurse. This oversight could have led to improper dosing, as the label indicated a different serving size than what was administered. The Director of Nurses (DON) acknowledged these errors, confirming that the medications were not administered according to the prescriber's orders. The facility's policy and procedure for administering medications, which emphasizes adherence to prescriber orders and timing, was not followed in these instances, exposing residents to potential health risks.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin and glipizide. Licensed Nurse (LN) 1 did not administer the resident's Humulin R insulin as per the physician's order. The resident's blood sugar level was recorded at 466 mg/dl at 6 a.m., but LN 1 did not administer the insulin dose required for such a high level, nor did they notify the physician. This oversight led to the resident experiencing symptoms of high blood sugar, including headache, dizziness, thirst, and general malaise. The facility's policy requires medications to be administered according to prescriber orders, which was not followed in this instance. Additionally, LN 1 administered the resident's glipizide 5 mg after breakfast, contrary to the physician's order to give it 30 minutes before a meal. LN 1 acknowledged the error, noting that the breakfast tray was delivered about thirty minutes before the medication was given. The Director of Nursing confirmed that LN 1 failed to administer the medication as ordered. The facility's policy emphasizes that medication administration times should be determined by resident need and benefit, not staff convenience, 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, leading to several deficiencies. Three unopened bottles of latanoprost ophthalmic solution were found in a medication cart instead of being refrigerated as per the manufacturer's instructions. Additionally, an opened glucose test strip bottle and an opened bottle of insulin lispro were found without open dates, making it impossible to determine their expiration dates. These oversights were acknowledged by the Licensed Nurse (LN) and the Director of Nursing (DON), who confirmed that staff were expected to follow the manufacturer's instructions and facility policies regarding medication storage and labeling. Further deficiencies were identified in the North Station Medication room, where two expired multidose vials of Tuberculin purified protein derivative were found. These vials had been opened beyond the 30-day usage period specified on the product label. Additionally, a prescription bottle of polyethylene glycol with electrolytes was found without a patient-specific prescription label, which could lead to medication errors. The DON acknowledged these issues and confirmed that medications should be properly labeled and expired medications removed. The temperature of the medication refrigerator in the North Station Medication room was also found to be out of range, recorded at 30 degrees Fahrenheit, which is below the required range of 36 to 46 degrees Fahrenheit. This issue persisted for 13 out of 30 days in September, as noted in the facility's temperature log. The DON acknowledged that the refrigerator's temperature was not within the required range, which is necessary for the safe storage of pharmaceutical products requiring refrigeration.
Ice Buildup in Walk-In Freezer Compromises Food Safety
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, affecting 115 residents who received facility-prepared foods. During an observation and interview with the Dietary Manager (DM), ice buildup was noted on the walls, ceiling, and boxes of food within the freezer. The DM acknowledged the issue, attributing it to temperature fluctuations caused by the door opening and closing. The Maintenance Supervisor (MS) also confirmed awareness of the ice buildup, suggesting it was due to old equipment and insulation issues, but was unaware of the potential impact on food quality. The Registered Dietician (RD) and the Director of Nursing (DON) both confirmed awareness of the ice buildup, with the RD noting the potential for ice burn and compromised food quality, and the DON highlighting the risk of contamination and food safety concerns. The facility's policy on preventing foodborne illness emphasized the importance of storing food to minimize contamination risks, and the Maintenance Director's job description included ensuring equipment is maintained in a safe and efficient manner. Despite these guidelines, the ongoing issue with the freezer's ice buildup was not adequately addressed, posing a risk to food safety and quality.
Failure to Provide Accurate Meal Trays
Penalty
Summary
The facility failed to ensure that the meal tray tickets for two residents, who were part of a sample of 25, were accurate and followed. Resident 100, admitted in January 2024, had diagnoses including muscle wasting and protein-calorie malnutrition. Resident 72, admitted in February 2024, had diagnoses including muscle weakness and protein-calorie malnutrition. During observations on September 30, 2024, it was noted that both residents' meal trays were missing the prescribed house supplement drinks, which were indicated on their meal tray tickets. The Dietary Supervisor and a Certified Nursing Assistant acknowledged the omissions, attributing the responsibility to the kitchen staff. Interviews with the Registered Dietician and the Director of Nursing confirmed that the residents were supposed to receive house supplement drinks to prevent weight loss. The Registered Dietician emphasized that not receiving the correct meal trays could potentially result in unmet nutritional needs. The Director of Nursing reiterated the expectation that meal trays should match the meal tray tickets and acknowledged the potential for continued weight loss if the supplements were not provided. The facility's policy on Food and Nutrition Services, revised in October 2017, mandates that food trays be inspected to ensure the correct meals are provided to each resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that four residents were free from abuse, resulting in two separate altercations. Resident 1 and Resident 2 were involved in a physical altercation where Resident 2 sustained a skin tear on his right arm. Resident 1, who had no cognitive impairment, claimed that Resident 2 hit him first, and Resident 2, who also had no cognitive impairment, stated that Resident 1 hit him first. A witness, Resident 5, confirmed seeing Resident 2 hit Resident 1 with a cane. The Social Services Director and Licensed Nurse 1 confirmed the incident as a form of abuse for both residents involved. In another incident, Resident 3 and Resident 4 were involved in a physical altercation where Resident 3 sustained a skin tear on her right arm. Resident 3, who had no cognitive impairment, reported that Resident 4 spit at her, leading her to hit Resident 4, who then hit her back. Resident 4, who had severe cognitive impairment and advanced dementia, was unable to recall the incident. The Social Services Director and Licensed Nurse 1 confirmed the altercation and the resulting injuries. The facility's policy on abuse prevention, which stipulates that residents have the right to be free from abuse, was not adhered to in these cases. The Administrator acknowledged the difficulty in determining the aggressor in each altercation but agreed that all four residents were victims of physical abuse. The incidents highlight a failure in the facility's responsibility to protect residents from abuse by anyone, including other residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 667 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capital Post Acute | 1 mi | ★★★★★ | 28 | 0 |
| City Creek Post Acute | 2.7 mi | ★★★★★ | 0 | 0 |
| Acc Care Center | 2.7 mi | ★★★★★ | 23 | 0 |
| Bridgewood Post Acute | 2.9 mi | ★★★★★ | 2 | 0 |
| Greenhaven Healthcare Center | 3.5 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Double Tree Post Acute Care Center.
100% money-back within 48 hours.
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.