Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 East Bay Post-acute during CMS and state inspections, most recent first.
A resident with depression and anxiety but intact cognition was seated in a wheelchair in the smoking area when another cognitively impaired resident with dementia became upset after repeated objections to placing his drink next to the first resident’s drink. The impaired resident pushed the wheelchair-bound resident backwards to the ground and, according to the victim, then got on top of him and kneeled on his chest, leading the victim to shout that he could not breathe. Staff, alerted by another cognitively intact resident, found the victim on his back on the ground, assisted him back to his wheelchair, and noted a skin tear on his hand before transferring him to an acute care hospital, where records described an assault altercation with another SNF patient. These events occurred despite a written abuse-prevention policy stating residents’ right to be free from physical abuse, including abuse by other residents.
Two residents were involved in a physical altercation in a smoking area, during which one cognitively intact resident reported being pushed from a wheelchair by another resident with dementia, resulting in a fall, a skin tear, and hospitalization. A LVN found the injured resident on the floor and was told about the push and the resident’s request to call the police. Despite facility policy requiring immediate reporting of abuse allegations and timely submission of investigation results, the Ombudsman did not receive notice until weeks later, and the facility could not provide documentation that the State Survey Agency or Ombudsman were notified within required timeframes or that the investigation report was submitted with documented dates and times.
Facility staff failed to ensure that entrance and exit doors were locked and supervised outside of visiting hours, with both the main entrance and rear exit doors found to have malfunctioning locks. The rear exit door was repeatedly propped open, and staff were observed leaving it unsupervised, allowing unrestricted access to resident areas. Interviews confirmed that staff were not consistently aware of the broken locks, and maintenance records did not reflect timely reporting or repair.
Failure to make survey results readily accessible: the facility did not post the most recent CMS-2567 in a location residents, visitors, or others could easily view without asking staff. Resident council members said they did not know where the survey binder was or whether it was available for review, while the AD, Admin, and Maint. D gave conflicting information about its location and accessibility. The facility’s Resident Rights policy stated residents have the right to examine survey results.
The facility failed to ensure qualified oversight of Dietary Services when the RD did not work full time and the DM was not qualified to supervise the kitchen. The DM stated they only held a Safe-serv Food Manager certificate and were not a CDM, while the RD stated the DM handled day-to-day kitchen supervision. Record review showed the DM job description required approved dietary manager education, and the competency checklist noted the DM did not maintain CDM/CFPP credential and CEU requirements.
Advance directive information was not documented in the records for six sampled residents. Baseline care plans and related records did not show whether an advance directive was offered, accepted, declined, executed, or what the resident or RR wished. Some residents had intact decision-making capacity, while others had moderate to severe cognitive impairment. Interviews with the AC, DON, SSA, and residents showed the discussion was not consistently documented, and several residents stated they were not asked about an advance directive or given the option to create one.
A facility failed to ensure accurate MDS coding for two residents. One resident’s MDS incorrectly showed antianxiety medication use based on Hydroxyzine, even though the drug handbook did not identify it as an antianxiety classification, and another resident’s discharge MDS incorrectly stated discharge to an acute care hospital when the resident actually left with a friend and went home.
Physician orders were not followed promptly for three residents. One resident with intact cognition reported painful bilateral leg edema that had not been treated, and the MDSC found pitting edema in both lower legs while the chart showed orders for edema monitoring and daytime compression stockings. Two other residents had ordered weekly weights and one also had an order to monitor Nepro intake, but weights were missed for extended periods and supplement intake was not documented as ordered.
Unsanitary food handling and equipment were observed during meal service. A staff member picked up a resident’s meal ticket after it fell on the floor, placed it back on the tray, and continued food assembly without removing gloves or performing hand hygiene. Two black oven mitts used in food preparation were also observed dirty, with dry brownish matter and torn areas.
The facility did not have a qualified social worker supervising the social services department, and the SSA stated they were the only social services staff member and were not a qualified social worker. The AD and ADM also stated there was no social worker overseeing the department, despite records showing social services roles and a facility assessment that included a full-time SW. The facility also failed to post the CMS star rating in required public and communal areas, and the ADM stated the posting was not done and was unaware it was required.
Incomplete and inaccurate resident records were identified for multiple residents. One resident’s diet order incorrectly listed a milk allergy despite dairy items being served and the RD stating the allergy notation was not accurate. Another resident’s intake documentation conflicted, with weekly summaries showing 100% meal intake while amount-eaten worksheets showed meal refusals and less than full intake. A resident with ESRD had an incorrect weight entered compared with dialysis records, and another resident’s B&B care plan used the wrong resident identifiers. The DON and MRD acknowledged the discrepancies in the charting and record review process.
Failure to Provide Prescribed Reading Glasses: A resident with altered visual ability was not provided reading glasses prescribed by the doctor. She stated she could not read the wall clock, needed eyeglasses to see better, and felt frustrated because her eyes burned and the issue had been ongoing. Staff reported her vision was blurry, she often needed help with activities like bingo, and the SSA was unaware whether the facility followed up on the eyeglasses prescription or arranged another eye exam.
The facility failed to maintain adequate nutrition status for two residents. One resident with malnutrition and weight loss reported disliking the Nepro supplement she was receiving, requested Glucerna and chocolate pudding instead of yogurt, and the RD later documented an 8.4-pound loss over 7 weeks with a recommendation to change the supplement. Weekly weights were not consistently obtained as ordered. Another resident with malnutrition and MS was observed receiving yogurt and a Magic Cup despite a diet order slip stating a milk allergy and to avoid dairy; the DM said the items were given because of resident preference, and the RD stated the order was inaccurate and confusing.
A resident with severe cognitive impairment, limited ROM, and dependence for ADLs was found with bilateral padded bedrails raised and kept upright at all times. Staff said the rails were used as a safety precaution to prevent falls, while others stated the resident did not use them for support or could only use them with staff assistance. Record review showed alternative interventions were listed, but there was no documentation of when or how long they were tried, whether they worked, or that the rails were removed for re-evaluation.
Emergency IV Kit Missing Medication and Documentation Failure: The facility failed to maintain accurate accountability and replacement of drugs in an emergency IV kit. An LPN could not determine when the kit was last opened because the expected form was missing, and a usage slip showed 0.9% normal saline had been removed for a resident, yet the kit remained incomplete and undocumented beyond the required exchange timeframe.
Medication administration errors were observed during med passes when an LVN gave a resident an expired Breo Ellipta inhaler without instructing the resident to fully exhale before inhalation, and an RN placed an uncapped Lispro syringe on a resident’s overbed table before giving the injection. The RN acknowledged the syringe should not have been left on the table because of potential contamination.
Medication carts contained unidentifiable loose pills, an expired inhaler, and several opened meds without required open dates. An LVN and RN confirmed the items were present as observed and stated they did not know what the loose pills were or when the opened meds had been started; the facility policy required meds to remain in their original packaging and not be transferred between containers.
An RN prepared Lispro insulin for a resident and placed the uncapped syringe on the resident’s overbed table before administering it. The table was observed to hold personal food items and beverages, and the syringe remained there for about 20 seconds before the injection was given. The RN acknowledged the action was inappropriate because of the potential contamination of the syringe.
A facility failed to follow a physician's order for supervised feeding for a resident with dysphagia, who required one-on-one assistance due to a flaccid left upper arm from a stroke. The resident was observed eating alone, contrary to the care plan. Staff interviews confirmed the need for one-on-one feeding, indicating a lapse in care.
A resident with multiple health conditions developed a non-pressure ulcer that worsened due to inconsistent wound care. The facility's records showed missing documentation for several treatment dates, indicating that ordered care was not consistently provided. The resident's condition deteriorated, resulting in wound dehiscence and infection, and was eventually diagnosed with cellulitis and sent to the hospital.
A facility failed to maintain proper infection control during a wound dressing change for a resident. Treatment Nurse 2 and a CNA did not wear required disposable gowns, despite Enhanced Barrier Precautions being in place. Additionally, the nurse did not perform hand hygiene between glove changes, moving from a dirty to a clean procedure. The Infection Preventionist confirmed the necessity of these precautions to prevent infection.
The facility failed to properly store and dispose of garbage, with cracked and leaking bins, open lids, and waste spilling onto the ground. This unclean state was confirmed by both the housekeeping supervisor and the dietary services manager, highlighting a breach in the facility's waste disposal policy and FDA guidelines.
The facility failed to follow medication administration policies, provide adequate pharmacy services, and ensure controlled medications were fully accounted for. This led to a resident's hospitalization due to a medication error, delayed medication administration for another resident, and missing scheduled medications for a third resident. Additionally, there were significant documentation lapses for controlled medications, posing risks for misuse or diversion.
The facility failed to comply with Federal regulations by not employing a full-time dietitian or a qualified full-time dietetic services supervisor. The Dietary Supervisor was not yet certified, and the Registered Dietitian worked part-time, focusing mainly on clinical duties. This lack of qualified supervision led to multiple issues in food service operations, including staff competency, menu adherence, and food safety.
The facility failed to follow the planned menu and provide diet-specific items, resulting in the substitution of maple chicken with teriyaki chicken due to missing ingredients and the absence of diet salad dressing for residents on a Heart Healthy diet. The Dietary Supervisor did not order or purchase the necessary items, and the Registered Dietitian was unaware of the issue.
The facility failed to ensure food was palatable by not following standardized recipes, resulting in bland and over-seasoned meals. Multiple residents expressed dissatisfaction, and observations confirmed the issues with food preparation. The Dietary Supervisor admitted to not adding salt during preparation, and the Registered Dietitian was unaware of deviations from recipes.
The facility failed to ensure food safety and sanitation, including unmonitored personal refrigerators, serving unpasteurized undercooked eggs, unclean ice machines, improper cooldown monitoring of TCS food, unlabeled refrigerated food, uncovered frozen raw fish, poor hand hygiene, incorrect sanitizer temperature, and unclean kitchen areas.
The facility failed to provide a refrigerator to store perishable food brought in by family members and visitors for residents. Staff encouraged residents to eat the food immediately, and any uneaten food was discarded due to the lack of refrigeration. Additionally, there was no microwave available to heat resident food. The DSD confirmed that the facility's policy allowed for the storage of perishable food for up to 72 hours, but admitted that there was no refrigerator available for this purpose.
The facility failed to complete the Annual Minimum Data Sets (MDS) for four residents within the required 14-day timeframe from the Assessment Reference Date (ARD). This deficiency was confirmed through interviews and record reviews, revealing that the comprehensive MDS assessments were submitted late, potentially impacting the care and services provided to residents with conditions such as quadriplegia, Diabetes Mellitus, metabolic encephalopathy, and hemiplegia.
The facility failed to complete quarterly MDS assessments within the required timeframes for four residents, potentially impacting their care. The MDS assessments for residents with significant medical conditions were overdue by 32 to 46 days, as confirmed by the MDS Coordinator.
The facility failed to ensure that the Minimum Data Sets (MDS) for eight residents were completed and submitted to CMS within the required time frames. The Annual MDS for four residents and the Quarterly MDS for another four residents were significantly overdue, ranging from 32 to 46 days past the required submission dates. The affected residents had various medical conditions, and the delays potentially impacted the quality of care they received.
The facility failed to ensure its nursing staff was competent in disinfecting shared glucometers, with two nurses using ineffective alcohol prep pads instead of the recommended germicidal wipes. Additionally, the facility lacked evidence of training or competency for two registry nurses on glucometer disinfection, potentially leading to the transmission of bloodborne diseases among residents.
The facility failed to ensure proper medication storage and labeling, allowing a non-licensed staff member access to the medication room and finding multiple expired, unlabeled, and undated medications in the medication room and on medication carts. The DON and LVNs acknowledged these deficiencies, which were against the facility's policies.
The facility failed to ensure kitchen staff were competent in using the three-compartment sink for cleaning equipment and utensils. Cook 1 was unaware of the correct water temperature and duration for submerging items in the sanitizer. The Dietary Supervisor confirmed the correct procedures, which were not being followed, posing a risk of contamination and illness for 69 residents.
The facility failed to provide milk to 43 out of 69 residents as indicated on the lunch menu and did not offer a nutritionally equivalent substitute. Additionally, cheese tortellini served as an alternate to chicken did not provide the same protein content, leading to potential nutritional deficiencies.
The facility failed to implement proper infection control practices, including not disinfecting blood pressure cuffs and glucometers between uses and allowing a resident's foley catheter equipment to lie on the ground, increasing the risk of infections.
The facility failed to maintain essential kitchen equipment, with a double oven unit and a plate warmer being non-operational. The Dietary Supervisor was aware but did not document the issues, and the Maintenance Supervisor was unaware until the survey. The lack of proper communication and documentation led to prolonged equipment downtime.
A resident with multiple sclerosis and morbid obesity was made to wear a tight, uncomfortable gown due to the unavailability of her preferred larger-sized gown. The facility failed to adhere to its policy on dignity and respect for resident preferences.
The facility failed to provide adequate fingernail care to a resident, resulting in long and bothersome nails despite multiple records indicating nail care was provided. The resident's grooming preferences were not met, leading to discomfort and potential risk of self-injury.
A non-nursing staff member assisted a resident by helping her sit up in bed and serving her lunch tray, despite not being certified or licensed to perform such tasks. The resident had specific dietary needs and allergies, and the action was outside the staff member's scope of duties. The Administrator confirmed that the staff member should have handed the tray to a Certified Nursing Assistant instead.
A resident experienced significant weight loss over a period of time, and the facility failed to ensure a timely evaluation. The RD did not perform assessments or progress notes between the initial and re-admission assessments and did not ensure reweighs were done. The RD only performed one-month weight comparisons, missing the significant weight loss.
A resident diagnosed with Schizoaffective disorder and Depression was prescribed aripiprazole and sertraline without proper side effect and behavior monitoring. The facility's E-MAR did not document the required monitoring, and the care plan did not match the physician's order for side effects. This lack of documentation and discrepancy in the care plan were confirmed by facility staff.
The facility had a 7.41% medication error rate when two medication errors were observed. A resident did not receive carvedilol as ordered, and another resident received the wrong calcium product. The errors were acknowledged by the LVNs involved, who stated they would notify the doctor and clarify the orders.
The facility failed to document oxygen and nebulizer use for a resident with chronic respiratory failure and hypoxia. Despite the resident receiving these treatments, the active orders did not reflect them, leading to incomplete and inaccurate medical records and potential risks for the resident.
A resident with hemiplegia and other conditions was without a call device for three days, preventing them from getting staff assistance. The absence was confirmed by both an LVN and a housekeeper, who noted the device might have been unplugged during cleaning. The facility's policy requiring call lights to be within reach was not followed.
The facility failed to post nurse staffing information for four consecutive days and did not maintain the required 18-month records. The Staffing Coordinator was working from home and did not ensure the information was posted, and the facility lacked records from August 2023 to January 2024.
Failure to Protect Resident From Physical Abuse in Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the designated smoking area. One resident (Resident 1), who had diagnoses of major depression and anxiety disorder but no cognitive impairment (BIMS 15/15), was seated in a wheelchair in the smoking area when another resident (Resident 2) pushed him to the ground. Resident 2 had diagnoses of dementia and a cognitive communication deficit, with a severely impaired cognition (BIMS 6/15). The incident occurred after Resident 1 repeatedly told Resident 2 not to place his drink next to Resident 1’s drink on the table, which led to Resident 2 becoming upset. According to Resident 1’s account, after he objected several times to Resident 2 placing his drink next to his, Resident 2 pushed him backwards, causing him to fall on his back and hit his head on the ground. Resident 1 further reported that Resident 2 then jumped on top of him, kneeled on his chest, and that he had to shout because he could not breathe and had to grab Resident 2 to get him off. Resident 1 stated that this incident made him feel scared of Resident 2 and that he was hospitalized for a few days afterward. Resident 2, when interviewed later, stated he did not recall any altercations with other residents. Staff accounts and documentation corroborated that a physical altercation occurred and that Resident 2 was the aggressor. An LVN reported being alerted by another resident (Resident 3, who had an unimpaired BIMS score of 15/15) that a fight had occurred in the smoking area. The LVN then observed Resident 2 entering the hallway from the smoking area and found Resident 1 lying on his back on the ground, yelling for assistance. Two LVNs assisted Resident 1 back to his wheelchair and noted a laceration/open area on his right hand, after which he was transferred to an acute care hospital. Progress notes documented that Resident 2 admitted to kicking Resident 1, causing his chair to fall, and hospital records described the event as an assault altercation with another SNF patient, with Resident 1 being struck in the chest, wrestling on the floor, and sustaining an abrasion to the right hand. This sequence of events occurred despite the facility’s written abuse prevention policy stating that residents have the right to be free from abuse, including physical abuse, and that the program is intended to protect residents from abuse by other residents.
Failure to Timely Report Resident-on-Resident Abuse Allegation to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged abuse incident between two residents and to submit the investigation results to the State Survey Agency and the Long Term Care Ombudsman within required timeframes. One resident, with diagnoses including major depressive disorder and anxiety disorder and a BIMS score of 15/15 indicating no cognitive impairment, reported that around Christmas 2025 another resident pushed him from his wheelchair in the smoking area following a verbal argument. He stated he fell backwards, hit his head, and that the other resident jumped on top of him and kneed him in the chest, resulting in a skin tear on his right hand and hospitalization at an acute care hospital. A LVN confirmed finding the resident lying on his back on the floor in the smoking area on 12/27/25 and was told by the resident that the other resident had physically pushed him down; the resident requested that the LVN call the police so the incident would be documented. The other resident involved had diagnoses of dementia and cognitive communication deficit and a BIMS score of 6/15, indicating severely impaired cognition. The Ombudsman reported not receiving notice of the physical altercation until 1/12/26, although the incident occurred on 12/27/25, and the facility was unable to provide documentation that the State Survey Agency or Ombudsman were notified of the allegation or the investigation within the required timelines. The Administrator and DON acknowledged that the Administrator was responsible for these notifications and that no records of timely notification could be located, including in prior emails. Review of the facility’s abuse, neglect, exploitation, and misappropriation prevention policy dated April 2021 showed that all allegations were to be reported immediately within two hours and investigation results within five working days, with documentation of times, notifications, and investigation steps, but the internal investigation summary lacked documented date and time of submission to the state agency or Ombudsman, demonstrating noncompliance with the policy and federal reporting requirements.
Failure to Secure Facility Entrances and Exits Due to Broken Locks and Lack of Supervision
Penalty
Summary
The facility failed to ensure that entrance and exit doors were properly secured and supervised, resulting in unlocked and unsupervised access points outside of designated visiting hours. Observations revealed that both the main entrance and rear exit doors had malfunctioning locks, with the rear exit door repeatedly found propped open by objects such as a wet floor sign and an orange traffic pylon. Staff were observed exiting and reentering the building without closing the rear exit door, and the main entrance door was found unlocked and accessible from the outside. During these times, surveyors were able to enter resident hallways and common areas without encountering staff or any security measures in place. Interviews with facility staff, including a registered nurse, licensed vocational nurse, maintenance director, and operations assistant, confirmed that the expectation was for all doors to be closed and locked from the outside outside of visiting hours. However, staff were not consistently aware of the broken locks, and maintenance records did not reflect timely reporting or repair of the issues. The maintenance director acknowledged being informed of the broken rear exit lock a week prior and had only recently placed an order for a replacement. The front entrance door was also found to have a misaligned locking mechanism, preventing it from being secured. Facility policy required doors to be locked from the outside after visiting hours, but this was not being followed due to the inoperable locks and lack of supervision.
Failure to Make Survey Results Readily Accessible
Penalty
Summary
The facility failed to post the most recent Statement of Deficiencies (CMS-2567) in a location that residents, visitors, or other individuals could readily access without asking staff. During interview, resident council members stated they did not know where the survey binder was located or whether the results were available for their review without request. They also stated that not being able to access the survey results independently fostered dependence on staff and decreased their ability to act according to their own wishes. During observation and interview, the Activities Director stated the survey binder was located at the receptionist desk, but was unable to locate it there. The Administrator later stated the binder was in his office and not accessible to residents. In a subsequent observation and interview, the Administrator stated there was a holder on the wall outside the copy room that housed the survey binder, while the Maintenance Director stated that holder had been removed during facility renovations and painting. The Maintenance Director also stated the renovations started in 2022 and finished in 2024. The facility policy on Resident Rights stated residents have the right to examine survey results.
Unqualified Dietary Oversight
Penalty
Summary
The facility failed to ensure qualified, full-time oversight of Dietary Services when the Registered Dietitian did not work full time and the Dietary Manager was not qualified to supervise the kitchen for 19 weeks. During interview and record review, the Dietary Manager stated they only held a Safe-serv Food Manager certificate, were not a Certified Dietary Manager, and had not completed the education requirements to qualify as a qualified dietetic service manager. The Dietary Manager also stated they were hired in April 2025. The Registered Dietitian stated they were contracted to work 24-32 hours per week based on facility needs and that the Dietary Manager had oversight of day-to-day kitchen supervision. The Administrator stated the facility had not hired a qualified Certified Dietary Manager to replace the previous one, and that the Dietary Manager was responsible for kitchen supervision while the Registered Dietitian was responsible for clinical management of residents. Record review showed the Dietary Manager job description required graduation from an approved dietary manager's course meeting state and federal care regulations, and the competency checklist noted the Dietary Manager did not maintain CDM/CFPP credential and continuing education unit requirements. The Registered Dietitian contract listed contracted hours of .16-24 hours a week, while invoices showed varying weekly hours from May through August 2025.
Advance Directive Information Not Documented in Resident Records
Penalty
Summary
The facility failed to ensure residents’ medical records were updated to show whether advance directives were offered, whether the resident or responsible representative accepted or declined to create one, whether an advance directive had been executed, or the resident’s wishes for six of six sampled residents. The deficiency involved Residents 1, 2, 4, 7, 8, and 10, and the report stated this had the potential for the facility to provide treatment and services against the residents’ wishes. Resident 1 was admitted with acute respiratory failure with hypoxia and had a BIMS score of 15/15, indicating intact short- and long-term memory and decision-making capacity. Resident 4 was admitted with end stage renal disease and also had a BIMS score of 15/15. For both residents, the baseline care plans stated that advance directives were discussed, but the records did not detail the discussion or indicate whether an advance directive was offered, accepted, declined, executed, or what the resident wished. Resident 2 was admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage and had a BIMS score of 8/15, indicating moderate cognitive impairment. Resident 7 was admitted with hemiplegia and hemiparesis following cerebrovascular disease and had a BIMS score of 7/15, indicating severe cognitive impairment. Resident 8 was admitted with cerebral infarction due to embolism of the left middle cerebral artery and had a BIMS score of 6/15, also indicating severe cognitive impairment. Resident 10 was admitted with type 2 diabetes mellitus and had a BIMS score of 10/15, indicating moderate cognitive impairment. For Residents 7 and 8, the baseline care plans stated that advance directives were discussed, but did not detail the discussion or document whether an advance directive was offered, accepted, declined, executed, or what the resident or responsible representative wished. For Resident 2, the baseline care plan was not available due to the resident’s length of time in the facility, and for Resident 10, the advance directive documents from 2022 were not available. During interviews, the AC stated the admission packet included resident rights, consent to treat, and related documents, and that these items were discussed and reviewed at admission, but there was no documentation in the records for Residents 1, 2, 4, 7, 8, and 10 showing the advance directive discussion details, whether an option to create an advance directive was offered, whether one had been executed, or the resident wishes. The DON stated the admitting nurse asks the resident or RR about an advance directive and social services documents the discussion in the medical record, while the SSA stated the resident or RR is verbally informed about advance directives, DNR, and POLST, but she does not always document the discussion and needs to improve her documentation. Residents 1, 4, and 10 stated they were not asked about an advance directive, not informed what one was, and not given the option to create one.
Inaccurate MDS Assessments for Medication Use and Discharge Disposition
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. For Resident 29, the MDS dated [DATE] indicated use of antianxiety medications during the 7-day look-back period, but record review and interview showed she received Hydroxyzine 25 mg by mouth as needed for anxiety, restlessness, and sleep for five days from 7/23/25 through 7/27/25. The MDS Coordinator stated the assessment was marked that way because Hydroxyzine was classified in the order entry system as an antianxiety agent, although the facility’s drug handbook identified Hydroxyzine as being used to relieve symptoms of anxiety, pruritis, and urticaria and did not identify it as an antianxiety classification. For Resident 87, the discharge MDS dated [DATE] inaccurately indicated discharge to an acute care hospital. Nursing progress notes showed the resident left the facility with a friend on 7/30/25 and stated they wanted to go home but never returned. During interview, the MDS Coordinator acknowledged the discharge assessment incorrectly reflected a hospital discharge when the resident actually went home and did not come back to the facility.
Physician Orders Not Followed for Edema, Weights, and Nutritional Intake
Penalty
Summary
The facility failed to ensure physician orders were followed promptly for three residents. Resident 77, who had a BIMS score of 15 out of 15 and was able to communicate clearly, reported swelling in both legs that had not been treated, and stated it was painful and made him feel frustrated and uncomfortable. During observation, he was found sitting on the edge of his bed and later in a wheelchair wearing nonskid socks. When the MDS Coordinator removed the socks, Resident 77 had 3+ pitting edema in the right lower leg and 2+ pitting edema in the left lower leg. The record review showed physician orders to monitor edema in both lower extremities and to apply compression stockings during the day and remove them at bedtime. Resident 76 was admitted with diagnoses including unspecified protein calorie malnutrition and chronic kidney disease stage 5. Review of physician orders and the facility’s Weights and Vitals Summary showed that MD ordered weekly weights and later ordered a re-weigh to confirm weight gain, but the resident was weighed on 6/3/25 and not again until 6/17/25. The DON stated the order to reweigh the resident on 6/5/25 was not followed until 6/17/25 and that this was not a reasonable time frame for the order to be followed. The record also showed an order for Nepro 8 oz once daily with monitoring of percentage intake, but the MAR did not reflect intake monitoring between 1/23/25 and 3/6/25. Resident 75 was admitted with diagnoses including acute respiratory failure, unspecified protein calorie malnutrition, and muscle weakness. Review of physician orders showed that the resident was to be weighed weekly, but the Weights and Vitals Summary showed weights on 9/9/25, 9/3/25, and 8/18/25, with a 16-day gap between the 9/3/25 and 8/18/25 weights. The DON stated that not checking the resident’s weight weekly meant the facility did not have information needed to monitor the resident and could not monitor for weight loss and status.
Unsanitary Food Handling and Dirty Oven Mitts
Penalty
Summary
Food was not prepared, distributed, and served in a sanitary manner when a staff member handling meal tray assembly picked up Resident 11’s meal ticket after it fell on the floor and placed it back on the resident’s tray. The staff member then continued food service activities with the same gloved hand without removing the gloves or performing hand hygiene. During interview, the staff member acknowledged the meal ticket was contaminated and stated a new ticket should have been printed, and the Dietary Director stated the ticket should have been discarded and replaced. Food service sanitation was also compromised when two black oven mitts used to remove pureed creamy polenta from the oven were observed to be dirty, with dry brownish matter and two torn areas. During interview, staff stated the mitts were dirty, and the Dietary Director stated the mitts should either be thrown away or washed. The facility policy stated meals will be delivered free from the risk of cross contamination and that employees must wash their hands after activities that contaminate the hands.
Lack of Qualified Social Work Supervision and Missing CMS Star Rating Posting
Penalty
Summary
The facility failed to have a qualified social worker supervise, train, and ensure the provision of medically-related social services for nine months. During interview, the social services assistant stated they were the only staff member in the social services department and were not a qualified social worker. The assistant also stated they had only received some training for a few months while assisting a former social services director in 2024. The Director of Staff Development stated there was no training record for the assistant’s position. Facility records showed the assistant had been promoted to Social Services Assistant, and the job description stated the assistant reports to the Social Service Director and assists in planning, developing, organizing, and implementing the facility’s social service programs. The Activities Director stated they had served as social services director despite not being a social worker and having only three days of prior social services training, and the Administrator stated there was no plan to have a social worker in the department and that the assistant was the only staff member working in social services. The facility also failed to post the CMS star rating in required public areas. Observation of the main posting board, two dining areas, the facility entrance, the reception desk area, and the main posting board near the entrance showed no posting of the facility star rating. During interview, the Administrator stated the CMS star rating was not posted and did not know that posting was required. The facility assessment listed a staffing plan that included a full-time Social Worker on AM and PM shifts, and the facility policy stated it provided medically-related social services. California regulation cited in the report required the social work service unit to be organized, directed, and supervised by a social worker, and state law required the overall facility rating information to be posted in areas accessible and visible to the public and in communal resident areas.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four sampled residents. For one resident with diagnoses including protein-calorie malnutrition, hypertension, and multiple sclerosis, the diet order slip on the tray stated the resident was allergic to milk and noted not to give milk or dairy products, yet the tray contained dairy items including Greek yogurt and a sugar-free vanilla magic cup. During interview, the DM stated the yogurt and ice cream were being given because of resident preference, and the RD stated the milk allergy notation was not accurate and could create confusion. For another resident with acute respiratory failure, protein-calorie malnutrition, and muscle weakness, the nursing weekly summaries documented that the resident ate 100% of meals, but the facility’s amount eaten worksheets showed the resident refused 10 meals in the prior two weeks and did not eat 100% of meals in August 2025. The DON acknowledged the discrepancy between the weekly summaries and the intake worksheets. For a third resident with unspecified protein-calorie malnutrition and chronic kidney disease stage 5, the weights and vitals summary listed a weight of 149 pounds on 6/3/25 and 139 pounds on 6/17/25, but the dialysis center communication documented the 6/3/25 weight as 57.5 kg, or 126.7 pounds. The DON stated the 149-pound entry was incorrect and should have been rechecked and struck out. For a fourth resident with hemiplegia and hemiparesis following cerebrovascular disease and a BIMS score of 7/15, the bowel and bladder care plan identified the resident as “Resident 82 or Resident 83” and referred to the wrong resident identifiers. The MRD stated record reviews were done in PCC and that nursing documentation accuracy was not reviewed by medical records. The facility policy on charting errors stated that errors should be lined through or struck out with the reason documented, but the MRD stated the Medical Records Administrative Services Manual did not require records for each resident to be complete and accurate.
Failure to Provide Prescribed Reading Glasses
Penalty
Summary
The facility failed to ensure that one of two sampled residents, Resident 35, was provided reading glasses as prescribed by the doctor. Resident 35’s admission record showed she was admitted to the facility on [DATE], and her MDS assessment dated [DATE] indicated she did not wear glasses at the time of assessment and was able to understand others and make herself understood. Her care plan for vision, dated 6/20/25, identified altered visual ability related to visual loss that may impact her ability to participate in ADLs and directed staff to perform an eye exam as ordered or if indicated. During observation on 09/08/25, Resident 35 stated she was not able to read the wall clock in her room, needed eyeglasses to see better, did not have any, and reported that her eyes usually burned and that she felt frustrated because this had been an ongoing issue. During later interviews, she stated she could not play bingo very well because she could not see well. An AA stated bingo was her favorite activity and that she often had to assist Resident 35 because her vision was blurry and she could not see very well, and that she had informed direct care nurses about the issue in the past. A CNA stated he had not seen Resident 35 wearing eyeglasses or having eyeglasses in her possession, an LVN stated she was not aware of any vision issues, and SSA reviewed a vision examination report dated 7/22/24 showing a prescription for reading glasses while stating she was unaware whether the facility had followed up on the prescription and that the resident had not been seen by an eye doctor since then.
Failure to Honor Nutrition Preferences and Maintain Accurate Dietary Orders
Penalty
Summary
The facility failed to ensure adequate nutrition status for Resident 75 and Resident 6. Resident 75 was admitted with diagnoses including acute respiratory failure, unspecified protein-calorie malnutrition, and muscle weakness, and had an MDS BIMS score of 15/15, indicating intact memory and decision-making capacity. During interview, Resident 75 stated she did not like the Nepro supplement she was receiving, requested Glucerna instead, and asked for chocolate pudding instead of yogurt. The Dietary Manager confirmed that the request for chocolate pudding was documented on progress notes but was not received by the kitchen until several days later. The Registered Dietician stated dietary preferences should be honored and later documented that Resident 75 had lost 8.4 pounds in 7 weeks due to not eating and drinking enough, and recommended changing the supplement to Glucerna. Record review for Resident 75 also showed a physician order for weekly weights, but the DON acknowledged there was a 16-day gap between weights on 8/18/25 and 9/3/25. The weights summary also showed a 26-day gap between weights on 3/6/25 and 4/1/25. The DON stated that not checking weights weekly means there is no information to monitor the resident for weight loss and health status. For Resident 6, the admission record showed diagnoses including unspecified protein-calorie malnutrition, hypertension, and multiple sclerosis. During observation of the lunch tray, the Dietary Manager saw two Chobani Greek yogurts with peaches and a vanilla Magic Cup on the tray, even though the diet order slip stated the resident was allergic to milk and to not give milk or dairy products. The Dietary Manager stated the yogurt and ice cream were given because of resident preference. The RD reviewed the diet order and stated the resident was not allergic to milk and that the order should be corrected because it could create confusion.
Failure to Attempt Least Restrictive Alternatives Before Using Bedrails
Penalty
Summary
The facility failed to ensure least restrictive alternatives were attempted for a reasonable amount of time before installing bedrails for one resident on admission. The resident had severe cognitive impairment with a BIMS score of 6 out of 15, impairment in range of motion on both sides of her extremities, and dependence on staff for activities of daily living, indicating minimal strength to use her arms. She was observed in bed with bilateral bedrails raised and padded, including while lying in bed and while sitting up eating lunch. Staff interviews showed the bedrails were being kept up as a safety precaution and to prevent the resident from falling out of bed. CNA staff stated the resident did not use the rails to prop herself up, and one CNA said the resident could pull on the rail for positioning during incontinence care only with staff assistance placing her hands on the rail. RN staff stated the rails were always kept upright and that the resident was often restless and leaning on them, while another RN stated she had not seen the resident use the rails for support. The ADON reviewed physician orders showing the resident may have bilateral 1/4 side rails as an enabler for bed mobility and position, with side rail pads to prevent injury. The DON stated the rails were needed for mobility purposes, but also stated that with padding the resident was no longer able to hold onto the rails. Record review showed bed rail and entrapment risk assessments identified alternatives such as an adjustable bed, anticipation of needs, a bedside floor mat, and items within reach, but the DON could not find documentation showing when or for how long those alternatives were used or whether they were successful. The record also did not show that the bedrails were removed for re-evaluation.
Emergency IV Kit Missing Medication and Incomplete Documentation
Penalty
Summary
The facility failed to maintain procedures to ensure accurate accountability and replacement of drugs in the emergency IV kit for 1 of 1 kits reviewed. During observation on 09/08/2025 at 11:15 AM, the emergency IV kit was found missing normal saline. When asked when the kit was last opened, LVN 4 stated that a form is typically left inside the kit and faxed to the pharmacy, but no such documentation was present, and she could not determine when the kit had last been opened. During an interview on 09/08/2025 at 12:00 PM, the Minimum Data Set Coordinator stated she found the Emergency Drug Kit usage slip and acknowledged that the policy was to change the kits within 72 hours once they are opened. The usage slip dated 08/27/25 at 10:00 AM showed that 0.9% normal saline was removed for a resident. As of the survey observation on 09/08/25, the kit had been opened 12 days earlier, yet the facility had not replaced or properly documented the emergency kit contents in accordance with policy. The facility policy required emergency pharmaceutical services to be available 24 hours a day, medications to be secured and checked regularly, and staff to document removals, notify the pharmacy immediately, and reseal the kit until exchange.
Medication Administration Errors During Inhaler and Insulin Passes
Penalty
Summary
Medication administration errors occurred during observation of medication passes when staff did not follow manufacturer instructions and accepted standards of clinical practice. During administration of Breo Ellipta inhaler to Resident 79, an LVN did not instruct the resident to fully exhale before inhaling the dose. In interview, the LVN acknowledged she had not given that instruction and stated she was unaware the inhaler expired six weeks after opening; she also admitted she administered the inhaler after its expiration date. The inhaler label showed it had been opened on 07/26/2025 and expired on 09/06/2025, but it was administered on 09/08/2025. A separate medication pass observation involved RN 2 preparing Lispro insulin for Resident 93. After drawing up the insulin, the RN placed the uncapped syringe directly onto the resident’s overbed table, which was observed to contain personal food items and beverages, and left it there for about 20 seconds before administering the injection. In interview, the RN stated she had left the syringe on the table and acknowledged that it was inappropriate because of the potential for contamination.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled and stored according to accepted professional principles and manufacturer instructions for 3 of 4 medication carts observed. During a medication storage observation, cart 4 contained multiple unidentifiable loose pills, and LVN 4 stated she did not know what the pills were and confirmed they should not have been present in the cart. The same cart also contained a Breo Ellipta inhaler that had expired two days before the observation, and LVN 4 stated she did not know it was expired and did not know to check the open date or calculate the expiration date. During another medication storage observation, multiple opened medications in medication carts 1 and 2 were found without dates opened, including Advair HFA inhaler, Advair Diskus inhalation powder, and Azelastine HCl 0.1% nasal spray. RN 2 and LVN 3 confirmed the medications had been opened but were not dated and stated they did not know when the medications had been opened. Review of the facility’s Medication Labeling and Storage Policy showed medications were to be stored in the packaging or containers in which they were received and not transferred between containers, but this standard was not maintained.
Unclean Surface Used During Insulin Injection Preparation
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration for Resident 93 when RN 2 prepared Lispro insulin for subcutaneous injection and placed the uncapped syringe directly onto the resident’s overbed table before giving the dose. During observation on 09/09/25 at 8:15 AM, RN 2 drew up the insulin at the medication cart and then set the syringe on the overbed table, which was observed at other times during the survey to hold personal food items and beverages. The syringe remained on the table for approximately 20 seconds before RN 2 picked it up and administered the injection. When interviewed shortly afterward, RN 2 stated that leaving the syringe on the table was a mistake and acknowledged it was inappropriate because of the potential contamination of the syringe.
Failure to Provide Supervised Feeding for Resident with Dysphagia
Penalty
Summary
The facility failed to adhere to a physician's order for supervised feeding for a resident with dysphagia, a condition characterized by difficulty swallowing. The resident, admitted in July 2023, required one-on-one feeding assistance with aspiration precautions due to a flaccid left upper arm resulting from a stroke. However, during an observation on September 6, 2024, the resident was seen eating breakfast alone without staff assistance, contrary to the care plan and physician's order. Interviews with the Dietary Manager, Registered Dietician, and Director of Nursing confirmed the resident's need for one-on-one feeding assistance, highlighting the facility's failure to provide the necessary care as prescribed.
Failure to Provide Consistent Wound Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a non-pressure ulcer, leading to the worsening of the condition. The resident, who was admitted with multiple diagnoses including diabetes mellitus, morbid obesity, and heart disease, developed redness in the abdominal folds that progressed to open areas. Despite the initiation of treatment with Nystatin powder and other wound care measures, the Treatment Administration Record (TAR) showed multiple dates without documentation that the treatments were performed as ordered. The resident's condition deteriorated, resulting in wound dehiscence and infection. The facility's records indicated that the resident did not have any skin issues upon admission, but over time, the redness and skin tears worsened, leading to open areas in the abdominal folds. The resident was eventually referred to a wound doctor, but the lack of consistent treatment documentation suggests that the ordered care was not consistently provided. The resident was later diagnosed with cellulitis and was sent to the hospital, where further tests revealed bacterial infections. The facility's policy on wound care required documentation of the care provided, including the date, time, and name of the individual performing the care, which was not adhered to in this case. This lack of adherence to the facility's wound care policy contributed to the resident's avoidable wound complications.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) during a wound dressing change for Resident 2. Both TN 2 and CNA 1 did not wear disposable gowns, which were required as part of Enhanced Barrier Precautions (EBP) for high-contact activities such as wound care. This oversight occurred despite the presence of a posted sign outside Resident 2's room indicating the need for gowns and gloves during such procedures, and the availability of PPE supplies at the room entrance. Additionally, TN 2 failed to perform hand hygiene between glove changes during the wound dressing change, moving from a dirty procedure to a clean one without washing hands or using an alcohol-based hand rub. This lapse in protocol was acknowledged by TN 2, who admitted that hand hygiene should have been performed to prevent infection. The Infection Preventionist confirmed that EBP should be observed during care involving wounds and that staff are required to change gloves and perform hand hygiene between clean and dirty procedures.
Improper Garbage Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage of garbage and refuse, as observed during an inspection of the outside trash cans and dumpsters. Two of the four large green plastic bins designated for organic food waste were cracked and leaking dark brown liquid, with lids left open. Waste was piled over the tops of the bins, and food waste and trash were spilling onto the ground. The housekeeping supervisor confirmed the area was unclean and could result in infection due to insects, vermin, and pests. The dietary services manager also confirmed the unclean state of the outside trash area and noted that kitchen staff were responsible for maintaining cleanliness. The facility's policy on waste disposal, revised in January 2012, indicated that all infectious and regulated waste should be handled and disposed of in a safe and appropriate manner, with containers replaced routinely and not allowed to overfill. The United States Food and Drug Administration's 2022 Food Code requires that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The facility's failure to adhere to these guidelines resulted in the observed deficiencies.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to follow its medication administration policy, provide adequate pharmacy services, and ensure controlled medications were fully accounted for several residents. Licensed Vocational Nurse 8 (LVN 8) administered medications to two residents without verifying their identities and did not name the medications given. This resulted in Resident 400 receiving the wrong medications, leading to excessive sedation, respiratory failure, and hospitalization. Additionally, Resident 69 did not take her medications for one hour after LVN 3 left them on her overbed table without observing the administration. Resident 329 did not receive scheduled medication for 44 hours because the medications had not been delivered, potentially putting her at risk for high blood pressure complications. The facility also failed to document the administration of controlled medications properly. An as-needed controlled medication for Resident 42 was administered but not documented in the Electronic Medication Administration Record (E-MAR). Three controlled medications were administered but not documented in the Controlled Substance Accountability Sheet for Residents 20 and 70. Thirteen vials of lorazepam for Resident 30 were not counted during shift changes and were not removed from active stock for over a year. The Controlled Drugs-Count Record was incomplete for two medication carts, and controlled medication use audits for Residents 41, 57, and 330 did not reconcile, indicating discrepancies between the Count Sheet and the E-MAR. These failures resulted in significant adverse outcomes for the residents involved. Resident 400's hospitalization was due to an opioid overdose caused by the medication error. Resident 69's medications were delayed, and Resident 329's essential medication was not available for an extended period. The lack of proper documentation and accountability for controlled medications posed a risk for misuse or diversion, further compromising resident safety.
Non-Compliance with Food Service Management Standards
Penalty
Summary
The facility failed to comply with Federal regulations related to the oversight of food service operations by not employing a full-time dietitian or a qualified full-time dietetic services supervisor. According to the California Code, Health, and Safety Code - HSC S 1265.4, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor who meets specific educational and certification requirements. The Dietary Supervisor (DS) at the facility was not qualified for the position and was still working towards becoming a Certified Dietary Manager (CDM). The Registered Dietitian (RD) worked part-time at the facility, splitting her time between two facilities, and her primary responsibilities were clinical rather than kitchen-related. This lack of qualified supervision had the potential to result in unsafe food practices and foodborne illness for the 69 residents eating facility-prepared foods. During the Re-certification Survey, multiple issues were identified regarding Food and Nutrition staff competency, following the planned menu, providing palatable food, serving substitution food and drink of equal nutritive value, and ensuring food was stored, prepared, and served in a safe and sanitary manner. Interviews with the DS and RD revealed that the DS was not yet certified and the RD's time was primarily focused on clinical duties rather than overseeing kitchen operations. The Administrator confirmed that the DS did not have documentation of coursework toward CDM certification, further highlighting the facility's non-compliance with the required standards for food service management.
Failure to Follow Menu and Provide Diet-Specific Items
Penalty
Summary
The facility failed to ensure the menu was followed, resulting in the substitution of planned meals and the absence of diet-specific items. On 1/9/24, the lunch menu indicated maple chicken was to be served, but teriyaki chicken was prepared instead due to the unavailability of chicken thighs and maple syrup. The Dietary Supervisor (DS) confirmed that the substitution was made because the necessary ingredients were not ordered or purchased in time. The DS admitted that she could have purchased the needed items from a local grocery store but did not do so despite the Administrator being on-site and available to provide a credit card for the purchase. Additionally, the Registered Dietitian (RD) confirmed that the menu change was unnecessary if the ingredients had been available, indicating a lapse in proper menu planning and execution by the dietary staff. Furthermore, the facility failed to provide diet salad dressing for residents on a Heart Healthy diet as indicated on the lunch menu for 1/9/24. During the preparation of lunch trays, it was observed that all residents received the same Caesar dressing, regardless of their dietary restrictions. The Dietary Aide confirmed that diet dressing was not available, and the RD was unaware that residents were not receiving the appropriate diet dressing. The DS admitted to not ordering the diet dressings, further highlighting the failure to adhere to the planned menu and meet the nutritional needs of the residents.
Failure to Ensure Palatable and Properly Seasoned Food
Penalty
Summary
The facility failed to ensure food was palatable when recipes were not followed, resulting in bland and over-seasoned meals. During interviews, multiple residents expressed dissatisfaction with the food quality, describing it as bad or not good. Observations revealed that Cook 1 did not follow the standardized recipe for chicken teriyaki, instead using a ready-made teriyaki glaze. Additionally, the carrots and rice prepared were found to be bland, and the chicken teriyaki was very salty. The Dietary Supervisor (DS) admitted that salt was not added during food preparation, even if the recipe called for it, to cater to all residents, including those on no added salt diets. The Registered Dietitian (RD) confirmed that recipes should be followed and was unaware of the use of ready-made teriyaki sauce, which could alter the nutrient content of the meal. The facility's standardized recipes document indicated that only tested, standardized recipes should be used to prepare foods. Job descriptions for the cook, DS, and RD emphasized the importance of following recipes and preparing nutritionally adequate meals. Despite these guidelines, the facility's failure to adhere to standardized recipes and proper seasoning practices led to the preparation of unpalatable meals, placing 69 residents at risk for decreased nutrient intake and potential nutrition-related medical complications.
Facility Fails to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner. A resident's personal refrigerator was not monitored for temperature, food expiration dates, and cleanliness. The refrigerator contained various unlabeled and undated food items, including raw fish and cheese, and had significant residue buildup. The Director of Staff Development was unaware of who was responsible for monitoring and cleaning the refrigerator, and the administrator confirmed that all food in the refrigerator was discarded due to lack of labeling and dating. Unpasteurized, undercooked eggs were served to a resident upon request. The eggs were stored in a reach-in refrigerator and were confirmed to be unpasteurized by the cook and dietary supervisor. The registered dietitian stated that unpasteurized, undercooked eggs should not be served to residents as they are immunocompromised and could get very sick. The facility's policy indicated that only pasteurized eggs should be used for undercooked preparations. Two ice machines in the facility were found to be unclean, with pink, black, and brown residue on various surfaces. The maintenance staff confirmed that the ice machines had not been cleaned recently and were unaware of the cleaning schedule. Additionally, the facility failed to monitor the cooldown of prepared, leftover Time/Temperature Control for Safety (TCS) food, and refrigerated TCS food was not labeled with use-by or discard dates. Other issues included uncovered frozen raw fish, improper hand hygiene practices by kitchen staff, and surface sanitizer solution not being at the appropriate temperature for testing. The kitchen and food storage areas were also found to be unclean and in disrepair, with various equipment and surfaces having significant residue buildup and peeling paint.
Failure to Provide Refrigeration for Resident Food Brought by Family
Penalty
Summary
The facility failed to provide a refrigerator to store perishable food brought in by family members and visitors for residents. During an interview, an LVN stated that staff encouraged residents to eat the food immediately, and any uneaten food was discarded due to the lack of refrigeration. Additionally, there was no microwave available to heat resident food. The Director of Staff Development confirmed that the facility's policy allowed for the storage of perishable food for up to 72 hours, but admitted that there was no refrigerator available for this purpose. The policy also lacked guidance on time frames for use-by dates.
Failure to Complete Annual MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that the Annual Minimum Data Sets (MDS) for four residents were completed within the required time frames. Specifically, the MDS for Residents 31, 50, 47, and 53 were not completed within 14 days of the Assessment Reference Date (ARD). This deficiency was identified through interviews and record reviews, which revealed that the comprehensive MDS assessments for these residents were submitted late, potentially impacting the appropriateness of care and services provided based on their current health status. Resident 31 had a diagnosis of quadriplegia, Resident 50 had Diabetes Mellitus, Resident 47 had metabolic encephalopathy, and Resident 53 had hemiplegia and hemiparesis. During a concurrent interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed that the MDS assessments for these residents should have been completed and submitted within the 14-day timeframe. The facility's Final Validation Report indicated that the care plans for these residents were completed late, exceeding the 14-day requirement. The MDS Manual from the Centers for Medicare and Medicaid Services (CMS) specifies that the MDS Completion Date for Annual Assessments should be no later than 14 days from the ARD, which the facility failed to adhere to in these cases.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure the quarterly Minimum Data Sets (MDS) were completed within the required timeframes for four residents. Resident 67, Resident 51, Resident 13, and Resident 30 had their quarterly MDS assessments delayed beyond the 14-day requirement from the Assessment Reference Date (ARD). Specifically, Resident 67's MDS was 34 days overdue, Resident 51's was 46 days overdue, Resident 13's was 32 days overdue, and Resident 30's was 40 days overdue. These delays were confirmed during an interview and record review with the MDS Coordinator, who acknowledged the overdue assessments and stated that they should have been completed and submitted in a timely manner to provide appropriate resident care. The residents involved had significant medical conditions, including diabetes mellitus, cerebral infarction, end-stage renal disease, and Alzheimer's disease. The failure to complete the MDS assessments on time had the potential to impact the care and services provided to these residents based on their current health status. The MDS Coordinator confirmed that the assessments were not completed within the required timeframes, which is essential for guiding resident care effectively.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) for eight residents were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames. Specifically, the Annual MDS for four residents and the Quarterly MDS for another four residents were not completed and transmitted within 14 days of the Assessment Reference Date (ARD). This deficiency was identified through interviews and record reviews, which revealed that the MDS assessments for these residents were significantly overdue, ranging from 32 to 46 days past the required submission dates. The Minimum Data Set Coordinator (MDSC) confirmed the delays and acknowledged that the assessments should have been completed and submitted in a timely manner to ensure appropriate resident care. The residents affected by this deficiency had various medical conditions, including quadriplegia, diabetes mellitus, metabolic encephalopathy, hemiplegia, cerebral infarction, end-stage renal disease, and Alzheimer's disease. The delayed MDS assessments for these residents meant that their care plans were not updated in a timely manner, potentially impacting the quality of care they received. The facility's Final Validation Report further confirmed that the care plans and assessments for these residents were completed late, exceeding the 14-day requirement from the ARD. The MDS Manual from CMS specifies that both comprehensive and non-comprehensive assessments must be completed and transmitted within 14 days of the ARD to ensure effective resident care, a standard that the facility failed to meet in these cases.
Failure to Ensure Proper Disinfection of Shared Glucometers
Penalty
Summary
The facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers according to the manufacturer's instructions and accepted professional standards of practice. Two out of three nurses observed during medication administration did not use the appropriate disinfectant to clean and disinfect shared glucometers for two sampled residents. Instead of using the recommended Micro-kill Germicidal wipes, the nurses used alcohol prep pads, which are not effective against all bacteria or viruses. The nurses admitted they had not received proper orientation or training from the facility regarding the correct disinfecting wipes to use and were relying on their own experience. Additionally, the facility did not have evidence of training or competency related to blood glucometer cleaning and disinfection for two registry nurses. The Director of Nursing and the Director of Staff Development/Infection Preventionist acknowledged that the orientation provided to registry nurses did not include training on glucometer disinfection. The facility's checklist for registry orientation/training also did not include this training. The registry nurses' training records from the agency did not show documented training or competency on disinfecting glucometers or clinical training on infection control practices. The facility's policies and procedures, as well as the glucometer manufacturer's guidelines, were not followed. The facility's policy on cleaning and disinfection of resident-care items and equipment indicated that reusable items should be cleaned and decontaminated or sterilized between residents according to CDC recommendations and OSHA standards. However, the observed practices and lack of training documentation indicated non-compliance with these guidelines, potentially leading to the widespread transmission of bloodborne diseases among residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as observed in the medication room and on medication carts. A non-licensed staff member had access to the main medication room, which is against the facility's policy that only licensed nurses, pharmacy personnel, and those authorized to administer medications should have access. This was acknowledged by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) during the inspection. Multiple expired, unlabeled, and undated medications were found in the medication room and on medication carts. These included lorazepam, latanoprost eye drops, Victoza injectable pens, Trulicity injectable pens, lidocaine multi-dose vials, sterile water vials, Alphagan P eye drops, and Breo Ellipta inhalers. Some medications were also found to be stored improperly, such as ear drops stored with eye drops and a Covid-19 reagent stored with other medications. The DON and LVNs acknowledged these findings and confirmed that the medications were expired or improperly labeled. The facility's policies and procedures were reviewed and indicated that medications should be properly labeled with open dates and discarded within specified time frames to ensure medication purity and potency. The policies also stated that drug containers with missing, incomplete, or incorrect labels should be returned to the pharmacy for proper labeling. The facility failed to adhere to these policies, leading to the potential for medication errors and reduced potency of medications administered to residents.
Incompetence in Kitchen Staff Regarding Three-Compartment Sink Procedures
Penalty
Summary
The facility failed to ensure kitchen staff were competent regarding job duties, specifically in the use of the three-compartment sink for cleaning equipment and utensils. During an observation and interview, Cook 1 demonstrated the manual dishwashing process but was unaware of the correct water temperature for washing dishes and the appropriate duration for submerging items in the sanitizer. Cook 1 stated that the wash water should be warm but did not know the exact temperature, and she believed items should be submerged in the sanitizer for about three to four minutes. Further observation and interview with the Dietary Supervisor (DS) revealed that the correct temperature for wash water, rinse water, and sanitizer should be over 110 degrees Fahrenheit, and items should be submerged in the sanitizer for 30 seconds. A review of the facility's policy and procedure, as well as the manufacturer's instructions for the sanitizer, indicated that the wash water should be at least 171 degrees Fahrenheit for 30 seconds or follow the chemical sanitizing solution instructions, which required immersion for no less than one minute. This lack of knowledge and adherence to proper procedures had the potential to result in contamination of kitchen equipment and utensils, posing a risk of illness for the 69 residents receiving food from the kitchen.
Failure to Provide Nutritional Substitutes
Penalty
Summary
The facility failed to provide food and drink substitutes of similar nutritive value to residents, leading to potential nutritional deficiencies. Specifically, milk was indicated on the planned lunch menu but was not provided to 43 out of 69 residents who received food from the kitchen. The Dietary Supervisor stated that milk was only provided if indicated on the tray ticket, and the Registered Dietitian confirmed that milk was part of the approved menu and nutrient analysis. However, no consistent substitute for milk was provided to ensure residents received the necessary nutrients such as calories, protein, calcium, and vitamin D. The RD did not recommend supplements unless lab results showed deficiencies, and the tray tickets did not indicate milk for the majority of residents on diets that allowed milk, excluding those on renal diets or with lactose intolerance/allergies. Additionally, the facility did not provide an alternate of equal nutritional value for residents who did not like chicken during a lunch meal. The main entree was chicken, and cheese tortellini was served as an alternate. The RD approved the tortellini as an alternate but later acknowledged that it did not provide the same amount of protein as the chicken. The nutrition facts showed that the tortellini provided significantly less protein compared to the chicken, with 6 grams of protein per half-cup serving of tortellini versus 18.2 grams of protein for a two-ounce portion of chicken. This discrepancy in protein content meant that residents who chose the tortellini did not receive an equivalent nutritional substitute for the chicken entree.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented in several instances. Two out of three nurses did not disinfect the blood pressure cuff before and/or after use for two residents. One nurse acknowledged the oversight, while another stated she was not informed about the need to disinfect the cuff. The Director of Staff Development/Infection Preventionist confirmed that the blood pressure cuff should be disinfected between resident use, as per the facility's policy and procedure on cleaning and disinfection of resident-care items and equipment. Additionally, two out of three nurses were observed using alcohol prep pads instead of the appropriate disinfectant to clean shared glucometers for two residents. Both nurses admitted they were not oriented on the correct disinfectant to use, and one nurse mentioned that there were no germicidal wipes available in the medication cart. The Director of Nursing and the Infection Preventionist confirmed that alcohol prep pads were not acceptable for disinfecting shared glucometers, and the facility's policy required the use of disinfecting wipes based on the manufacturer's guidelines. Furthermore, a resident's foley catheter equipment was found lying on the ground, which could increase the risk of urinary tract infections. The resident's care plan indicated that the foley bag should have a privacy cover and the tubing should be kept off the ground. During an observation, a nurse corrected the placement of the foley bag and tubing but admitted not knowing how it ended up on the floor. The Infection Preventionist stated that staff were expected to check the proper placement of foley catheter equipment at least every shift and during incontinence care, as per the facility's policy on the care of catheters.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment was in operational working condition. The right-hand side of a double oven unit was not operational for about three months, and a plate warmer was broken for two days. Cook 1 reported the oven issue to the Dietary Supervisor (DS), who was aware of the problem but did not document it in the maintenance log. The Maintenance Supervisor (MS) was unaware of the broken equipment until the survey and confirmed the oven's pilot was not on. The Administrator (ADM) and Registered Dietician (RD) were also unaware of the ongoing issues with the kitchen equipment. The facility's policy and procedure documents indicated that maintenance issues should be documented and communicated to the Maintenance Director through work orders. However, the DS admitted to not following this procedure and did not provide documentation to show that the oven had been repaired. The lack of proper communication and documentation led to the prolonged non-operational status of essential kitchen equipment, impacting the facility's ability to prepare food efficiently.
Failure to Provide Appropriate Gown for Resident
Penalty
Summary
The facility failed to provide Resident 32 with an appropriate facility gown according to her size and preference. Resident 32, who has multiple sclerosis and morbid obesity, was observed wearing a green-colored facility gown that was tight on her upper arms and chest, making her feel restricted and uncomfortable. The resident expressed that it was important for her to choose her clothing, and she preferred the larger yellow-colored gowns, which had not been available for a week. Certified Nursing Assistants (CNAs) confirmed that the resident preferred the yellow gowns but had to wear the green gown due to the unavailability of the larger size. Housekeeping/Central Supply staff confirmed that the clean linen storages were replenished regularly, and the facility used outside laundry services for washing and providing clean linen supplies. However, the last order of yellow gowns was received on 12/19/23, and no replacements were ordered until 1/9/24. The facility's policy on dignity emphasized that residents should be cared for in a manner that promotes their well-being and respects their preferences, which was not adhered to in this case.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care to one of the sampled residents, Resident 13. Despite being admitted to the facility and requiring limited assistance with personal hygiene, Resident 13's fingernails were observed to be long and bothersome to him. The Minimum Data Set (MDS) assessment indicated that Resident 13 was able to understand others and make himself understood. During multiple observations and interviews, it was noted that Resident 13's fingernails remained long, even though records indicated that nail care was provided on several occasions. The Director of Staff Development (DSD) and the assigned Certified Nursing Assistant (CNA) both confirmed that nail care was supposed to include trimming and cleaning, but Resident 13's nails were still long and not trimmed to his preference. The facility's policy and procedure for fingernail care, dated February 2018, emphasized the importance of trimmed and smooth nails to prevent accidental scratching and injury. Additionally, the facility's policy on dignity, dated February 2021, stated that residents should be groomed as they wish to be groomed. Despite these policies, the facility did not meet the grooming preferences of Resident 13, as his nails were not trimmed to his satisfaction, leading to discomfort and potential risk of self-injury.
Non-Nursing Staff Provided Resident Care
Penalty
Summary
The facility failed to ensure care provided to a resident was in accordance with professional standards of practice when a non-nursing staff member provided resident care. Specifically, Maintenance Staff 1 (MS1) assisted Resident 27 by helping her sit up in bed and serving her lunch tray, despite not being a certified nursing assistant or licensed to perform such tasks. This action was observed on 1/9/24, when MS1 delivered a lunch tray to Resident 27, who was on a Consistent Carbohydrate, No Added Salt therapeutic diet and had allergies to gluten and iodine. The tray card indicated specific dietary needs and preferences, including small portions of starch foods and a dislike for wheat bread. In an interview, MS1 confirmed that he served food trays to residents as a way to get to know them, unaware that this was outside his scope of duties. The Administrator later stated that MS1 should not have entered the resident's room to pass the food tray directly to the resident and should have handed it to a Certified Nursing Assistant instead. According to the Board of Registered Nursing, unlicensed assistive personnel, such as MS1, are not permitted to perform nursing tasks or reassign tasks. Health and Safety Code Section 1338.5(a)(2)(A) also requires that any individual with direct resident care duties must be enrolled in a nurse aide training program and complete the training and competency testing within four months of employment.
Failure to Timely Evaluate Resident's Severe Weight Loss
Penalty
Summary
The facility failed to ensure a timely evaluation of a resident's severe weight loss. Resident 72, who was initially admitted on [DATE], experienced significant weight loss over a period of time. The resident's weight history showed a decrease from 207.8 pounds on 11/2/23 to 178.8 pounds on 12/27/23, which constitutes an 8.4% weight loss in 48 days. The Registered Dietitian (RD) did not perform any assessments or progress notes for Resident 72 between the initial assessment on 11/2/23 and a re-admission assessment on 12/26/23. The RD only reviewed residents' documented weights monthly and weekly if time permitted, and it was not until the resident was readmitted from the hospital on 12/26/23 that the RD noticed the weight loss. The RD suspected the initial weight of 207.8 pounds was inaccurate but did not have documentation to show a request for a reweigh was made, nor was a reweigh performed to verify the accuracy of the initial weight. The RD confirmed that Resident 72 had a significant weight loss of 8.5% when comparing the weight of 178.8 pounds on 12/27/23 to the weight of 195.3 pounds on 11/10/23. However, the RD did not catch this significant weight loss because she only performed one-month weight comparisons. The RD admitted that she did not ensure reweighs were done after requesting them and did not have documentation to support that a reweigh was requested. This failure to timely evaluate and address the resident's weight loss had the potential to result in further unintentional and undesirable weight loss for the resident.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was diagnosed with Schizoaffective disorder and Depression, was prescribed aripiprazole and sertraline. However, there was no documentation of side effects and behavior monitoring for these medications. The Medical Record/Operations Manager acknowledged that the monitoring orders did not link with the Electronic Medication Administration Record (E-MAR), resulting in a lack of documentation. The Registered Nurse Supervisor confirmed that there was no evidence of staff monitoring for side effects and behaviors related to the use of these medications from August 2022 to January 2024. Additionally, the resident's care plan for antipsychotic medication did not match the side effect profile written on the physician's order. The care plan listed different side effects than those specified in the physician's order for aripiprazole. This discrepancy was confirmed by the Registered Nurse Supervisor. The facility's policy and procedure on psychotropic medication use emphasized the importance of adequate monitoring for efficacy and adverse consequences, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 7.41% medication error rate when two medication errors out of 27 opportunities were observed during the medication pass for two of six sampled residents. Resident 28 did not receive carvedilol, a medication used to treat high blood pressure, as ordered. During a medication administration observation, the LVN preparing and administering medications to Resident 28 missed giving the carvedilol dose scheduled for 9:00 a.m. The LVN later found the missed dose in the medication cart drawer and acknowledged the error, stating she would notify the doctor about the missed dose. Resident 52 received the wrong calcium product during a medication administration observation. The LVN administered calcium 600 mg plus vitamin D 400 IU instead of the ordered calcium 600 mg plus vitamin D 800 IU. Upon checking the medication cart, the LVN found that the correct medication was not available and confirmed that the administered medication did not match the doctor's order. The LVN stated she would clarify the order with the doctor. The facility's policy and procedure for administering medications indicated that medications should be administered in accordance with prescriber orders, including any required time frame.
Failure to Document Oxygen and Nebulizer Use
Penalty
Summary
The facility failed to accurately document entries for one resident, resulting in incomplete and inaccurate medical records. Specifically, the current physician orders for a resident with chronic respiratory failure and hypoxia did not reflect the use of oxygen and a nebulizer, despite these treatments being observed in use. The resident's care plan indicated the need for oxygen and nebulizer treatments, but these were not included in the active orders, leading to a risk of the resident not receiving necessary care and treatments as needed. During an observation, the resident was noted receiving oxygen from a portable concentrator and had a nebulizer machine in the room. However, the resident's Order Summary Report did not include orders for these treatments. The Registered Nurse Supervisor confirmed the absence of these orders and acknowledged the risk of the resident not receiving appropriate oxygen treatment or experiencing medication errors. The facility's policies and procedures require physician orders for oxygen administration and nebulizer use, which were not followed in this case.
Failure to Provide Resident with Call Device
Penalty
Summary
The facility failed to ensure that Resident 34 had access to a call device, which resulted in the resident being unable to get staff assistance when needed. Resident 34, who was admitted in February 2019 with diagnoses including hemiplegia, hemiparesis, arthritis, and muscle wasting, reported not having a call light for three days. During an observation and interview, it was confirmed that there was no call device in Resident 34's room. The Licensed Vocational Nurse (LVN) and Housekeeper (HSKG) both confirmed the absence of the call device, with the HSKG noting that the cable might have been accidentally unplugged during cleaning. The LVN acknowledged that an unplugged call device would not alert staff via the panel at the nursing station, potentially compromising patient care. Further interviews revealed that Resident 34 had been moved to another bed three days prior and did not receive a call device afterward. The facility's policy and procedure on call lights, dated January 2024, indicated that staff should ensure call lights are within reach of residents. However, this policy was not followed, leading to Resident 34's inability to call for assistance, especially at night or when needing help with dropped items. The failure to provide a working call device directly impacted Resident 34's ability to receive timely care and assistance.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted and readily available for four consecutive days from January 8, 2024, through January 11, 2024. This deficiency was identified through observation, interview, and record review. The Director of Staff Development/Infection Preventionist (DSD/IP) stated that the Staffing Coordinator (SC) was working from home and unable to post the daily nurse staffing information in the designated location within the facility. The Operations Manager (OM) confirmed that the nurse staffing information had not been posted daily since January 8, 2024, due to the SC's unavailability to work in person. Additionally, the facility was unable to maintain the required 18-month records of nurse staffing information, with records missing from August 2023 through January 2024. During a telephone interview, the SC confirmed her responsibility for staffing and posting daily nurse staffing information but admitted to failing to ask the OM to post the information in her absence. The Director of Nursing 2 (DON 2) acknowledged that the facility was required to keep a minimum of 18-month records of nurse staffing information available upon request. A review of the facility's document titled 'Posting Direct Care Daily Staffing Numbers' indicated that the facility was supposed to post nurse staffing data daily and maintain records for at least 18 months. However, this protocol was not followed, resulting in the deficiency.
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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 Castro Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Pointe Nursing & Rehabilitation Center | 0 mi | ★★★★★ | 20 | 0 |
| Baywood Court Health Center | 1 mi | ★★★★★ | 0 | 0 |
| Kaiser Permanente Post-acute Care Center | 1.1 mi | — | 0 | 0 |
| St John Kronstadt Convalescent Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Canyon Creek Post-acute | 1.3 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.