Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmwood Care Center during CMS and state inspections, most recent first.
A resident with Type 1 DM had a physician order for daily NPH insulin 8 units SQ to be given before a meal, but the scheduled dose was held due to the insulin being pending delivery, with no documentation that the dose was administered later or that the physician was notified. Review of the MAR, progress notes, and facility P&P showed that required actions—administering medications as ordered, notifying the physician when a medication is held or omitted, and assessing/observing the resident—were not documented as completed, as confirmed by the DON during interview.
A resident with schizophrenia, moderate cognitive impairment, and a high fall risk score used a wheelchair and required supervision for ambulation but was allowed to walk independently in a hallway. Despite multiple prior falls and an interdisciplinary recommendation to transfer the resident to a high‑risk unit with 15‑minute rounding, the resident was not moved because a previous fall had not caused injury. While returning from the patio after smoking, the resident sustained an unwitnessed fall in the hallway, was found on the floor near a wheelchair with right hip pain, and was later diagnosed by X‑ray with an acute comminuted intertrochanteric femur fracture requiring hospital surgery. The facility’s own fall prevention policy required adequate supervision and assistive devices to prevent accidents, and leadership acknowledged the fall could have been prevented with closer monitoring and constant supervision during ambulation.
The facility failed to maintain a functional, locking front entry door, resulting in the door being found ajar and unlocked, with no audible alarm and no staff present at reception when surveyors entered unnoticed. The Administrator and Maintenance Supervisor reported they were unaware the door did not lock, and observation confirmed the locking mechanism did not engage and no alarm sounded when the door was opened. A prior quote for commercial door repair existed, but the Maintenance Supervisor did not know if or when the repair project started or was completed, and the maintenance logbook contained no entry or follow-up request for the broken lock.
During a COVID-19 outbreak, the facility failed to ensure consistent staff masking and active visitor screening. A maintenance worker and a laundry aide were observed moving through the building without face masks, and the maintenance supervisor and infection preventionist confirmed gaps in documented COVID in-service training for laundry and housekeeping staff. At the same time, the entrance reception area was left unmanned, with visitors expected to self-sign in and self-screen despite posted signs and available N95 masks; a visitor was seen entering without masking or completing the log. The DON acknowledged that no staff were actively monitoring visitor screening, contrary to CDC and CDPH guidance for outbreak conditions.
The facility did not report suspected abuse within the required timeframe for two residents—one with a bruise of unknown origin and another who alleged verbal abuse by a CNA. Required notifications to the State Survey Agency and the LTCO were not made as per facility policy, and staff interviews confirmed the omissions.
A resident with cellulitis and an ileostomy reported verbal abuse by a CNA, but the facility did not complete or document a thorough investigation within the required timeframe. Leadership confirmed the absence of an investigation summary, and there was no record of findings or actions taken in response to the allegation.
During a COVID-19 outbreak, multiple rooms with COVID-19 positive residents were left with doors open, and two residents were observed outside their isolation rooms. A CNA assisted a COVID-19 positive resident without full PPE, and the trash receptacle for soiled PPE was not properly placed. These actions were not in accordance with the facility's infection control policy, which required isolation, proper PPE use, and closed doors.
The facility did not create or implement individualized care plans for several residents when the call light system was down, instead providing handheld bells without assessing each resident's ability to use them. Some residents had cognitive or physical impairments that made using the bells difficult or impossible, and staff confirmed that no person-centered planning was done to address these needs.
Nursing staff at the facility failed to follow proper infection control protocols, as observed with two residents. A nurse was seen with a trash bag of waste tied to a treatment cart, and blood pressure machines had trash bags with used gloves. A CNA mishandled dirty gloves, using them to open doors and assist a resident without proper disposal. The facility's policy requires used gloves to be discarded in designated receptacles.
The facility failed to maintain a clean and safe environment for food storage and preparation, with issues such as unclean floor drains, poor kitchen tile conditions, improper cooling and thawing of meats, and unclean food storage equipment. Additionally, expired tube feeding formulas were available for use for residents with serious medical conditions, posing a risk to their safety.
The facility failed to provide a designated location for safely storing perishable food brought in by family members or visitors. Observations showed inconsistent practices, with some food stored in a staff refrigerator lacking a thermometer and temperature log. The facility's policy did not specify safe storage durations, potentially leading to foodborne illness. The DON was unaware of proper storage times, and no specific storage area was designated for residents' personal perishable food.
The facility did not follow prescribed Renal and Renal CCHO diets for six residents, serving cappuccino chocolate mousse instead of the specified cookies. This error was observed during a tray line inspection, and interviews revealed a lack of communication and clarity among dietary staff regarding the correct dietary requirements.
The facility failed to provide the correct food texture for residents on a Mechanical Soft diet, serving dry roast beef and coleslaw without necessary moistening. This oversight, confirmed by the CDM and SLP, contradicted the facility's Diet Manual, which requires moistening of meats and coleslaw for residents with chewing or swallowing limitations.
The facility failed to fortify food according to physician orders for two residents, potentially decreasing their calorie intake. During trayline service, staff did not call out the fortified component, leading to the omission of margarine on sweet potato fries. The Certified Diet Manager confirmed the oversight, which contradicted the facility's Diet Manual guidelines for fortified diets.
The facility failed to maintain a functioning call light system for 13 residents, leading to potential delays in care. Residents with various medical conditions, including Parkinson's Disease and cognitive impairments, reported broken or ineffective call lights. Staff confirmed the ongoing issues, and maintenance efforts to repair the system were unsuccessful, impacting the quality of care.
A facility failed to provide a comfortable, temperature-controlled environment for a resident due to a non-functional window missing a crank handle. The resident, who could communicate needs despite moderately impaired mental status, reported feeling cold at night due to a draft. Maintenance staff was unaware of the issue and did not use a maintenance log to track repairs.
A facility failed to maintain a medication error rate below five percent, resulting in a 15.38% error rate. An LVN administered expired insulin to a diabetic resident, and another LVN gave medications to a resident with Cerebral Infarction outside the prescribed timeframe. These actions deviated from the facility's policies, which require adherence to expiration dates and scheduled times to ensure medication effectiveness.
A facility failed to follow infection control practices during blood sugar testing for two residents. An LVN did not clean the glucose monitor between tests, disposed of contaminated lancets in residents' trash cans, and neglected hand hygiene. These actions violated facility policies and risked cross-contamination and infection.
A facility was found to have 34 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. Despite this, observations indicated sufficient space for care, no interference from equipment, and no resident complaints or safety concerns.
Failure to Administer Ordered Insulin and Notify Physician
Penalty
Summary
Surveyors identified a deficiency involving failure to administer insulin as ordered for one of three sampled residents with Type 1 Diabetes Mellitus. The resident was admitted in February 2026 with a physician’s order dated 2/1/26 for NPH insulin 8 units subcutaneously once daily, to be given 30 minutes before a meal starting on 2/2/26 at 6:30 a.m. Review of the Medication Administration Record (MAR) for February 2026 and the progress notes dated 2/2/26 showed that the 6:30 a.m. dose of NPH insulin was marked as held, with a progress note stating “Insulin NPH pending delivery.” There was no documentation that the ordered insulin dose was administered at that time. During interviews and concurrent record review on 4/16/26, the DON confirmed that there was no documentation on the MAR or in the progress notes that the resident received the NPH insulin at the ordered time or that the physician was notified after the dose was held. The DON stated that when insulin is not given as ordered, staff should assess the resident, obtain a blood sugar, and notify the physician for possible new orders, such as to hold the medication or provide an alternative. Review of the facility’s medication administration policy dated 1/1/24 showed that medications are to be administered as ordered, that the physician must be notified as soon as possible when medications are held and the reasons for holding, and that in the case of an omitted dose, the physician must be notified and the resident observed for status changes. These required actions were not documented as having occurred for this resident when the insulin dose was omitted.
Failure to Adequately Supervise High‑Risk Resident Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident with a known high risk for falls. The resident was admitted in early April and had a Minimum Data Set dated in October showing a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, and a diagnosis of schizophrenia. The MDS documented that the resident used a manual wheelchair, could wheel at least 50 feet, and could walk at least 50 feet with supervision or touching assistance, but was not assessed to walk 150 feet due to medical or safety concerns. A Fall Risk Assessment dated in October showed a fall score of 50 related to a history of falls, unsteady and weak gait, and wheelchair use, and the fall care plan identified the resident as at risk for falls. The care plan included an intervention dated in September to admit the resident to a high-risk unit, anticipate and meet needs, and follow the facility’s fall protocol. Staff interviews confirmed that the facility had a designated high fall risk unit where staff conducted 15‑minute rounds on high fall risk residents. However, the resident was not moved to this high‑risk unit after a fall on September 10, which had occurred due to loss of balance while ambulating, despite the interdisciplinary team’s recommendation to do so. The administrator later stated the facility decided not to move the resident because there were no injuries from that September fall. As a result, the resident remained outside the high‑risk unit at the time of the subsequent fall. On the night of the incident in November, the resident ambulated independently in the hallway while returning from the patio after smoking and experienced an unwitnessed fall. Nursing documentation and interviews indicated the resident was found sitting on the ground in the hallway near his room, next to his wheelchair, awake and alert, and complaining of right hip and leg pain. An RN assessed the resident, noted pain in the right hip and groin area, and obtained a STAT X‑ray, which showed an acute comminuted fracture of the right intertrochanteric femur. The resident was transferred to an acute care hospital and underwent right hip surgery. The acting DON later stated that the fall could have been prevented if staff had monitored the resident closely and provided constant supervision while he was walking alone, and the facility’s fall prevention policy required that all residents receive adequate supervision and assistive devices to prevent accidents.
Failure to Maintain Functional, Secure Front Entry Door Lock
Penalty
Summary
The facility failed to ensure the front entry door locked, compromising the resident's right to a safe, clean, comfortable, and homelike environment, including safe supports for daily living. During an observation, the survey team found the front door ajar and unlocked, and they were able to enter the building without staff awareness. There was no audible alarm to indicate that someone had entered, and the reception area was unattended. The report states this failure had the potential to result in a significant security and safety issue potentially endangering residents, staff, and visitors. In a subsequent phone interview, the Administrator and Maintenance Supervisor both stated they did not know the entry door did not lock. During a concurrent observation and interview, the Maintenance Supervisor demonstrated that when the front entry door was pushed closed from the outside, the locking mechanism did not activate, and confirmed there was no alarm to notify staff when the door was opened. The Maintenance Supervisor stated he did not know how long the door lock had been malfunctioning. He presented a quote dated several months earlier for commercial door repair but had no knowledge of the project start or completion date. Review of the maintenance logbook for the current year showed no entry or request for follow-up on the broken entry door lock, and the Maintenance Supervisor stated he did not have access to prior logbooks.
Failure to Enforce Staff Masking and Active Visitor Screening During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its infection prevention and control program during a COVID-19 outbreak, specifically related to staff masking and visitor screening. On one observation date, a maintenance worker was seen walking through the facility without a face mask and acknowledged he was aware of the COVID outbreak and did not have a mask. Around the same time, a laundry aide was observed exiting a stairwell and walking to the time clock without a face mask or name badge; she stated she was not wearing a mask and had received the facility’s COVID education training. The maintenance supervisor stated staff should always wear a mask upon entry and exit during a COVID outbreak, but reported that the maintenance worker and laundry aide were not listed on the general in-service record, and he did not keep minutes of his staff meetings. The infection preventionist’s review of COVID isolation and PPE in-service training sheets showed that CDC and California Department of Public Health (CDPH) COVID-19 guidance had been reviewed with CNAs, RNs, and all departments, but the in-service report did not include names or signatures for laundry and housekeeping staff. The infection preventionist stated that staff not receiving in-service training and not wearing a face mask could cause transmission of the COVID outbreak to residents, staff, and visitors. A second deficiency was identified regarding visitor screening and source control during the same COVID outbreak. On two separate observations, the receptionist area at the entrance was unmanned, with boxes of N95 masks and signs instructing visitors to wear a mask due to the outbreak, but no staff were present to perform visitor screening or temperature monitoring. A visitor was observed entering the facility without putting on a mask or signing the visitor logbook, which contained symptom-related questions. The DON stated that the receptionist and several other staff were out due to COVID, that the receptionist area was unmanned, and that visitors were expected to self-sign in, with no one monitoring the self-sign-in process. Review of CDPH Healthcare-Associated Infections Program guidance for 2024–2025 indicated that during periods of increased community transmission of respiratory viruses and in the event of an outbreak, facilities should implement active screening of visitors for signs and symptoms of respiratory virus infections.
Failure to Timely Report Suspected Abuse and Notify Ombudsman
Penalty
Summary
The facility failed to report suspected allegations of abuse within the required 24-hour time frame for two residents. One resident, who had diagnoses including dementia, cognitive decline, and major depressive disorder, was observed with a bruise of unknown origin on her right upper arm. The bruise was first noted in the morning, but the investigation and required notifications to the State Survey Agency were not initiated until two days later. Additionally, the facility did not notify the Long-Term Care Ombudsman (LTCO) about this incident as required by policy. Another resident, admitted with cellulitis and an ileostomy, reported that a CNA was verbally inappropriate, making a statement that was considered verbally abusive. The facility did not provide evidence that this allegation was reported to the LTCO. Interviews with facility staff, including the Infection Preventionist and the Administrator, confirmed that notifications to the LTCO were not made for either incident. The facility's policy requires prompt reporting of all abuse allegations, including injuries of unknown source, to both the State Survey Agency and the LTCO, but this was not followed in these cases.
Failure to Complete Timely Abuse Investigation and Documentation
Penalty
Summary
The facility failed to conduct and complete a thorough investigation within five working days following an allegation of abuse involving a resident who was admitted with cellulitis of the abdominal wall and an ileostomy. The resident reported that a CNA was verbally inappropriate and rude, specifically stating, "You're here because God doesn't like you." Documentation review revealed that there was no investigation summary available for this allegation, and the Infection Preventionist, who also served as the DON designee, confirmed the absence of documentation regarding the findings or results of the investigation. Interviews with facility leadership, including the Administrator, confirmed that the required investigation summary was not completed as per facility policy, which mandates that all abuse allegations be thoroughly investigated and findings reported within five working days. The lack of documentation meant that it could not be determined what actions, if any, were taken during the investigation, nor whether protective interventions or corrective actions were implemented to address the allegation.
Failure to Maintain Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during a COVID-19 outbreak. Multiple resident rooms housing COVID-19 positive individuals were observed with doors left open, despite posted contact precaution signs indicating the need for closed doors. COVID-19 positive residents were seen outside of their isolation rooms, including one resident walking unassisted in the hallway and another seated in a wheelchair outside their room with their mask lowered below the nose and mouth. Staff interviews confirmed that these residents should have remained in their rooms under isolation, and that doors to COVID-19 rooms should have been kept closed to prevent the spread of infection. Additionally, a certified nurse assistant was observed inside an isolation room assisting a COVID-19 positive resident without wearing complete personal protective equipment (PPE). The trash receptacle for soiled PPE was not positioned near the exit door, requiring staff to cross the room to dispose of PPE, increasing the risk of contamination. After providing care, the CNA exited the isolation room without closing the door. The facility's own policy required exposed or symptomatic residents to remain in their rooms, staff to adhere to hand hygiene and PPE protocols, and isolation room doors to remain closed except when entering or exiting.
Failure to Develop and Implement Person-Centered Care Plans During Call Light System Outage
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for five residents when the call light system was not operational. Instead of a functioning call light system, residents were provided with handheld bells, but there was no individualized care planning to address each resident's ability to use these devices or their specific needs. The Director of Nursing confirmed that no such care plans were created for residents using handheld bells during the period when the call light system was inoperative. Observations and interviews revealed that residents had varying degrees of cognitive and physical abilities, which affected their capacity to use the handheld bells. For example, one resident with a history of falls and intact cognition refused to use the bell, preferring to call out for help. Another resident with moderate cognitive impairment and a recent fall reported delays in staff response when using the bell. Residents with significant cognitive or physical limitations, such as those with advanced dementia or who were rarely understood, often had the bell placed out of reach or were unable to use it effectively. Staff interviews corroborated that the call light system had been nonfunctional for an extended period, and that the use of handheld bells posed risks, especially for residents unable or unwilling to use them. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for residents affected by the call light system failure.
Infection Control Breach Due to Improper Glove Disposal
Penalty
Summary
The facility's nursing staff failed to adhere to proper hand hygiene and infection control protocols, as observed during interactions with two residents. One resident was admitted with malignant neoplasm of the prostate and mild intermittent asthma, while the other had heart failure, bacteremia, sepsis, and COPD. During an observation, a Licensed Vocational Nurse was seen pushing a treatment cart with a trash bag filled with waste and used gloves tied to it, which is against infection control standards. Additionally, blood pressure machines in the hallway had trash bags tied to them, containing used gloves and dirty paper towels. A Certified Nurse Assistant was observed mishandling dirty gloves after cleaning a standing scale. Instead of disposing of the gloves, the CNA held them in her hand, used hand sanitizer, and then entered a resident's room, using the gloves to open a bathroom door and assist a resident. The CNA acknowledged the mistake during an interview, admitting that the gloves should have been discarded before entering the room. The facility's Infection Preventionist confirmed that tying trash bags to equipment used for resident care is not allowed, as it poses a risk of spreading infection. The facility's policy on glove use, revised in 2010, mandates that used gloves be discarded in designated waste receptacles inside the room.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to maintain a clean and safe environment for food storage and preparation, as evidenced by several observations and interviews. Floor drains in the kitchen were not properly maintained, with thick sludge build-up and standing water, which attracted small flies and emitted a bad odor. The kitchen tile floors were also in poor condition, with loose and broken tiles, missing grout, and pooling water, all of which could harbor bacteria. Additionally, the facility did not ensure proper cooling of Time/Temperature Control for Safety Food (TCS), as there was no documentation of cooldown temperatures for cooked meats, and meat was not thawed appropriately, leading to potential cross-contamination. The facility's food storage practices were also deficient. The inside of a food storage refrigerator was found to be unclean, with sticky residue on the wire shelving. An industrial can opener was not properly maintained, with dark matter and sticky residue on its surfaces, posing a risk of foodborne illness or metal contamination. Clean plates were handled with dirty oven mitts, and a food service equipment drawer contained food crumbs and sticky substances, increasing the risk of cross-contamination. Furthermore, the ceiling above a food preparation area was not clean, with visible gray, fuzzy matter on the tiles. The facility also failed to ensure the safety of tube feeding formulas, as expired formulas were stored and available for use for three residents with serious medical conditions, including Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Nontraumatic Intracerebral Hemorrhage. The Director of Nursing acknowledged the expired formulas and stated they would not be given to residents. The facility's policy required maintaining inventory controls and discarding expired formulas, which was not adhered to, potentially compromising resident safety.
Deficiency in Safe Storage of Perishable Food Brought by Family
Penalty
Summary
The facility failed to ensure that residents had a designated location to safely store perishable food brought in by family members or visitors. Observations and interviews revealed that perishable food items were sometimes stored in the staff refrigerator, which lacked an internal thermometer and a temperature log. Certified Nursing Assistants (CNAs) reported inconsistent practices regarding the storage and disposal of perishable food, with some food items being left at residents' bedsides for extended periods. The Director of Nursing (DON) was unaware of the proper duration for which perishable food could be stored without refrigeration, and there was no specific place designated for storing residents' personal perishable food. The facility's policy on food brought by family or visitors, last revised in 2014, required perishable foods to be stored in re-sealable containers with tightly fitting lids in the refrigerator, labeled with a use-by date. However, the policy did not specify the duration for which perishable food could be safely stored. According to the 2022 Federal Food Code, Time/Temperature Control for Safety (TCS) food must be maintained at specific temperatures to prevent foodborne illness. The lack of a clear policy and proper storage facilities had the potential to result in foodborne illness and did not create a homelike environment for the residents who consumed food brought in by family members.
Failure to Follow Prescribed Renal Diets
Penalty
Summary
The facility failed to adhere to the prescribed dietary requirements for six residents on Renal diets and Renal Consistent Carbohydrate (CCHO) diets. During a lunch service, these residents were served cappuccino chocolate mousse instead of the specified desserts for their diets, which were two small sugar cookies for Renal diets and two small diet sugar cookies for Renal CCHO diets. This discrepancy was observed during a tray line inspection, where it was noted that the dietary aide placed the incorrect dessert on the trays and did not replace them with the appropriate cookies. Interviews with the dietary staff revealed a lack of clarity and communication regarding the correct dietary requirements. The dietary aide confirmed the error but did not rectify it, and another staff member claimed no responsibility for the desserts. The Certified Dietary Manager (CDM) admitted to not consulting with the Registered Dietitian (RD) about the correct number and type of cookies for the Renal diets. The RD later confirmed that the menu should have been followed and expressed uncertainty about the availability of appropriate diet cookies in the kitchen.
Failure to Provide Appropriate Food Texture for Mechanical Soft Diets
Penalty
Summary
The facility failed to provide the appropriate food texture for residents prescribed a Mechanical Soft diet, which is designed for individuals with chewing or swallowing limitations. During an observation of the trayline food service, it was noted that residents were served dry, shredded roast beef on a bun without the necessary au jus, and dry coleslaw without dressing or moistener. The Certified Dietary Manager (CDM) confirmed that the mechanical beef was dry and should have been moistened with au jus, and the coleslaw should have been mixed with dressing as per the recipe. The Speech Language Pathologist (SLP) indicated that moist food is generally safer for residents on a Mechanical Soft diet. The facility's Diet Manual specifies that meats should be ground with meat juices, gravy, or sauce, and dry meat is not allowed. This deficiency had the potential to cause difficulty with eating, chewing, and/or swallowing, leading to an increased risk of choking for all 10 residents who received the prescribed Mechanical Soft diets.
Failure to Fortify Diets as Prescribed
Penalty
Summary
The facility failed to fortify resident food according to physician orders, which had the potential to result in decreased calorie intake for two residents out of seven who had physician-prescribed fortified diets. During an observation of the trayline food service, it was noted that the tray tickets included fortified diets for seven residents. However, the staff member responsible for calling out the diets did not mention the fortified component, leading to the omission of margarine on the sweet potato fries for the first food cart delivered, which included the trays for the two affected residents. The Certified Diet Manager confirmed that fortified diets were physician-prescribed, and the facility's Diet Manual outlined that the Fortified Diet is intended for residents who cannot consume adequate calories or protein to maintain their weight or nutritional status. The manual specifies that the goal is to increase calorie density by approximately 300-400 calories per day, with examples such as adding extra margarine or butter to food items. The failure to follow these orders was confirmed during an interview with the Certified Diet Manager.
Call Light System Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was functioning for 13 of 68 sampled residents, leading to potential delays in care and services. Residents reported that their call lights were either broken or ineffective, with some residents waiting extended periods for assistance. Observations confirmed that call lights were not working in several rooms, and staff interviews corroborated the ongoing issues with the call light system. Residents affected by the malfunctioning call lights had various medical conditions, including Parkinson's Disease, urinary tract infections, and cognitive impairments. Many of these residents required assistance with toileting and transfers, making the call light system crucial for their care. Despite being aware of the problem, the facility's attempts to fix the call lights were unsuccessful, leaving residents without a reliable means to request help. Staff interviews revealed that the call light issues had persisted for weeks, with some staff members noting that the problem existed since they began their employment. Maintenance staff confirmed the broken call lights and reported unsuccessful repair attempts to the Operations Manager. The facility's failure to address the call light deficiencies impacted the quality of care provided to residents, as they were unable to effectively communicate their needs to staff.
Failure to Maintain Temperature-Controlled Environment
Penalty
Summary
The facility failed to provide a comfortable, temperature-controlled environment for a resident due to a non-functional window. The window in the resident's room was missing a crank handle, preventing the resident from opening or closing it to control the room's temperature. This issue was observed during an interview with the resident, who reported feeling cold at night due to a draft from the open window. The resident, who had a moderately impaired mental status but could communicate needs, had reported the issue to staff the previous day. However, the maintenance staff was unaware of the broken crank and did not use a maintenance log to track or report broken items.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 15.38 percent due to four errors out of 26 opportunities. One significant error involved a Licensed Vocational Nurse (LVN) administering expired insulin to a resident with Type 2 Diabetes Mellitus and Diabetic Neuropathy. The insulin was expired for 13 days, which could potentially decrease its effectiveness. The facility's policy required documenting the open date on insulin vials and disposing of them according to the manufacturer's expiration guidelines, which was not followed in this instance. Another error involved a different LVN administering medications to a resident with Cerebral Infarction outside the prescribed timeframe. The medications, including Senna, Divalproex, and Levetiracetam, were given two to three hours past their scheduled times. The facility's policy allowed for a one-hour window before or after the scheduled time, which was not adhered to, potentially affecting the resident's medication schedule and effectiveness. Interviews with the LVNs and the Director of Nursing (DON) confirmed the deviations from the facility's medication administration policies. The DON emphasized the importance of adhering to scheduled times and expiration dates to ensure medication effectiveness. The facility's policies clearly outlined the procedures for safe medication administration, which were not followed, leading to the identified deficiencies.
Infection Control Lapses During Blood Sugar Testing
Penalty
Summary
The facility failed to adhere to proper infection control practices during fingerstick blood sugar tests for two residents. Licensed Vocational Nurse 3 (LVN 3) did not clean and sanitize the glucose monitor between tests for Residents 5 and 39. Additionally, LVN 3 disposed of the contaminated lancets in the residents' trash cans instead of the designated sharps container. Furthermore, LVN 3 did not perform hand hygiene between the tests for the two residents. These actions were observed during a specific incident and were confirmed through interviews and record reviews. Resident 5 was admitted to the facility in 2021 with multiple diagnoses, including unspecified sequelae of cerebrovascular disease. Resident 39 was admitted in 2024 with type 2 diabetes mellitus and diabetic neuropathy. The facility's policies require that reusable resident care equipment be decontaminated between uses, contaminated sharps be disposed of in designated containers, and appropriate hand hygiene be performed between resident interactions. The Director of Nursing confirmed that the failure to follow these policies placed residents at risk for injury, cross-contamination, and infection.
Deficiency in Resident Room Size
Penalty
Summary
The facility was found to have 34 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. The rooms in question included numbers 100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 116, 118, 200, 202, 204, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 225. The square footage per resident in these rooms ranged from 71.18 to 79.06 square feet, which is below the regulatory requirement. This deficiency was identified through observations conducted between July 15 and July 18, 2024. Despite the deficiency in room size, observations during the same period indicated that there was sufficient space for the provision of care, and no heavy equipment was present in the rooms that could interfere with resident care. Each resident had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in these rooms.
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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 Berkeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashby Care Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Kyakameena Care Center | 0.3 mi | ★★★★★ | 24 | 0 |
| Berkeley Pines Skilled Nursing Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Chaparral House | 1.3 mi | ★★★★★ | 2 | 0 |
| The Rehabilitation Center Of Oakland | 2.2 mi | ★★★★★ | 2 | 0 |
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