Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartwood Avenue Healthcare during CMS and state inspections, most recent first.
Blood pressure, medication administration, and oxygen care were not provided as ordered for multiple residents. An LPN took a resident’s BP over a jacket on the forearm instead of on bare upper-arm skin, another resident received amLODIPine despite SBP being below the hold parameter, and a resident ordered Mounjaro 15 mg received a 2.5 mg dose because the ordered dose was not available. The same resident was also observed on nasal cannula oxygen despite an order for PRN oxygen only.
Incomplete documentation of controlled medication administration was identified for three residents receiving PRN narcotics for pain. The MARs did not match the CDRs for Morphine Sulfate, Percocet, and Hydrocodone-Acetaminophen, with doses removed from controlled drug records but not signed as given on the MAR. An LN stated narcotics must be signed in both the MAR and CDR, and the DON confirmed the missed MAR entries.
PRN antihypertensive medication was not administered for two residents during repeated episodes of elevated BP. One resident with a hx of stroke, irregular heartbeat, and heart disease had multiple SBP readings above the ordered threshold, but clonidine was never given despite the order. Another resident with CHF, HTN, and hypertensive urgency had very high BP readings, including 240/112, and the DON confirmed no PRN clonidine was administered as ordered.
Unlabeled and expired medications were found in storage, including an open tuberculin vial without an opened date, unlabeled mirtazapine and ondansetron tablets in a med cart, and expired olanzapine, fluticasone/salmeterol, and degludec insulin. An emergency kit also contained IV meds with an expired date. The DON and LN confirmed the findings, and the facility policy required proper labeling and removal of outdated drugs.
Unsanitary food storage, handling, and transport practices were observed when clean utensils, pans, trays, stock pots, and a plate were found wet or contaminated with food debris, a coffee carafe had residue inside, a food service staff member handled a wiping cloth and continued food prep without washing hands, and the food transport van and warmers were dirty with food debris and dried liquid marks. The RD stated items must be fully clean and dry before storage, and facility policy required clean food contact surfaces, air-drying, and proper hand hygiene.
Medication error rate exceeded 5% when an LPN failed to administer ordered diclofenac gel to a resident’s left leg because it was not available in the cart and also missed PRN clonidine despite the resident’s SBP being 189 and the order calling for the medication when SBP was over 150. The MAR did not document the clonidine as given, and the nurse stated she forgot to check PRN medications.
A resident with significant cardiopulmonary and renal comorbidities had a standing order for BiPAP at bedtime, but MARs over multiple months showed it was consistently not performed, and the acting DON confirmed there was no documentation of BiPAP use and that the order lacked specific timing. The same resident had a PRN order for Morphine 15 mg PO q6h for severe pain (7–10/10), yet an LN administered Morphine twice for documented moderate pain levels of 5 and 6, contrary to the order and facility expectations to follow the pain scale and use the least potent effective analgesic. Later that evening, the resident developed severe SOB and hypoxemia, EMS found critically low O2 saturation, administered Narcan, and the hospital ED documented opiate overdose, acute respiratory failure with hypoxia, and acute encephalopathy that improved with Narcan boluses and a drip. Review of orders showed Narcan was not ordered until many days after the opioid was started, despite the DON, another nurse, and the MD all stating Narcan should be ordered automatically with an opioid, and the facility policy required medications to be administered per prescriber orders.
A resident with Alzheimer’s disease and a moderate elopement risk score had a care plan that only directed staff to check the resident’s whereabouts without specifying frequency or timing, despite facility policy requiring measurable, person-centered interventions. A cognitively intact resident and a CNA reported seeing this resident open a conference room door and walk outside, but staff documented zero exit-seeking attempts on the MAR, contrary to a physician order to monitor and record the number of exit-seeking behaviors each day shift, and the DON later acknowledged the documentation should have reflected the elopement attempt.
A resident with impaired cognition was physically assaulted by another resident, resulting in a minor lip injury. The incident was witnessed by a CNA, and the aggressor admitted to being provoked. Despite facility policies prohibiting abuse, the event occurred and was confirmed by staff interviews and medical assessment.
An incident involving two residents with cognitive impairments resulted in one resident making physical contact with another's arm during a dispute over a glove box. Although the event was witnessed and reported to the ombudsman and police, facility staff did not report the allegation of abuse to the State Agency as required, due to a misunderstanding of reporting obligations. This failure delayed the abuse investigation process.
The facility failed to protect resident privacy and dignity, as privacy curtains did not fully enclose personal spaces and vertical blinds were broken or missing for several residents. A resident with muscle weakness and impaired memory expressed concerns about privacy due to missing blinds. Two residents shared a room where curtains did not provide adequate privacy, confirmed by a CNA. Another resident with severe memory impairment also lacked sufficient privacy curtains. Staff interviews confirmed these deficiencies, indicating non-compliance with the facility's dignity and privacy policy.
The facility failed to follow its medication storage policy, resulting in unlabeled and expired medications in the medication carts. Observations revealed unlabeled inhalers and insulin, as well as expired eye drops. Nurses confirmed the labeling issues, and the DON emphasized the importance of proper labeling and disposal of expired medications.
A long-term care facility failed to adhere to infection prevention protocols, including a CNA not wearing a gown for a resident on Enhanced Barrier Precautions, another CNA not washing hands after caring for a resident with C Diff, and an unlabeled gastrotomy tube feeding bottle. These actions could contribute to the spread of infections among residents.
A resident with multiple health issues, including a high risk for falls, was found to have their call light placed out of reach, contrary to their care plan and facility policy. A CNA confirmed the oversight, and the DON stated that call lights should always be accessible.
The facility failed to follow physician orders for two residents. A resident's PICC dressing was not changed as required, increasing infection risk, while another resident received metformin without food, contrary to orders. The DON confirmed the importance of adhering to these orders to prevent health risks.
A dietary staff member in an LTC facility was observed touching a fork with bare hands and putting on gloves without hand hygiene, violating infection control protocols. The Dietary Manager and DON confirmed these actions were unacceptable, especially given the vulnerability of immunocompromised residents.
The facility failed to maintain a clean and safe environment, with observations of sticky floors, feces on bathroom surfaces, and improperly stored items posing infection control issues. Staff confirmed these conditions were unacceptable and violated residents' rights. Additionally, a hole in a bathroom door was identified as a safety risk, with a lack of communication leading to delayed repairs.
The facility failed to provide the required two-person assistance to a resident during care, resulting in a fall and a left tibia fracture. Additionally, the facility did not respond promptly to another resident's call light, leading to a fall and subsequent hospital visit for neck pain and dizziness.
Blood pressure, medication, and oxygen care were not provided as ordered
Penalty
Summary
Resident 7’s blood pressure was not accurately assessed. During observation, a Licensed Nurse took Resident 7’s blood pressure while the resident was wearing a long sleeve down jacket, placing the cuff on the forearm over the jacket instead of on the bare upper arm. The nurse confirmed this was not an accurate way to monitor blood pressure. The DSD and DON both stated blood pressure should be taken on the upper arm on bare skin, and the facility policy directed staff to expose the arm and wrap the cuff around the upper arm. Resident 22 was administered amLODIPine outside of the ordered parameters. The physician order directed amLODIPine 10 mg daily for hypertension and to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 65. The MAR showed the medication was given when the resident’s systolic blood pressure was 98 and again when it was 107. The administering nurse confirmed she gave the medication despite the hold parameters, and the DON confirmed the medication was given outside the physician-ordered limits. Resident 60 received a lower dose of Mounjaro than prescribed and also had oxygen documentation and monitoring concerns. The order was for Mounjaro 15 mg/0.5 mL weekly, but the resident stated staff had been giving 2.5 mg doses, and the medication available in the medication refrigerator was a 2.5 mg/0.5 mL prefilled pen. The pharmacy technician stated the 15 mg dose was not delivered, and the DON confirmed the ordered dose was not available and that a lower dose had been administered. Resident 60 also had an order for oxygen at 2 L/min via nasal cannula PRN for oxygen saturation less than 92%, yet during observation the resident was lying upright in bed on oxygen via nasal cannula and stated he needed continuous oxygen to prevent hallucinations, shortness of breath, and chest pain.
Incomplete Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate reconciliation and accountability of controlled medications for three sampled residents when discrepancies were found during random controlled medication audits. For Resident 22, the MAR showed orders for Morphine Sulfate solution for pain, but doses documented as removed on the CDR on 4/22/26, 4/23/26, 4/25/26, 4/27/26, 4/28/26, and 5/3/26 were not documented on the MAR as administered. For Resident 56, the MAR showed an order for Percocet 10-325 mg as needed for pain, but doses removed from the narcotic medication card on 4/28/26 and 5/2/26 were not documented on the MAR as given. For Resident 57, the MAR showed an order for Hydrocodone-Acetaminophen 10-325 mg as needed for pain, but a dose removed from the narcotic medication card on 4/23/26 was not documented on the MAR as given. During interview, LN 1 stated that when narcotics were administered, the nurse was required to sign both the CDR and the MAR, and that this was important for accurate counts and to show when the last dose was given. The DON reviewed the records for Residents 22, 56, and 57 and confirmed the MAR had missed entries for narcotic administration. The facility policy titled Administering Medications stated that the person administering the medication records the date and time the medication was administered, the results achieved and when observed, and the signature and title of the person administering the drug.
PRN Antihypertensive Medication Not Given for Elevated Blood Pressure
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when prescribed PRN clonidine for elevated systolic blood pressure was not administered during repeated episodes of high blood pressure. One resident had diagnoses including stroke, irregular heartbeat, and heart disease, and the order dated 4/2/26 directed clonidine 0.1 mg by mouth every 12 hours as needed for SBP greater than 150. From 4/2/26 through 5/6/26, the resident had multiple documented SBP readings above 150, including readings as high as 189, but the MAR showed clonidine was not administered for any of those elevated readings. During interview and record review, the LN, DON, and MD all confirmed that the medication should have been given as ordered. The second resident was admitted with diagnoses including CHF, HTN, and hypertensive urgency. The OSR dated 4/4/26 ordered clonidine hydrochloride 0.1 mg every 8 hours as needed for systolic BP above 160 or diastolic BP above 90. The resident had documented blood pressure readings of 240/112 and 175/87, yet the DON confirmed that no PRN clonidine had been administered for either episode. The DON stated the expectation was for the nurse to administer the PRN blood pressure medication as ordered and notify the physician. The facility policy stated medications are to be administered in a safe and timely manner and as prescribed, with documentation of administration details in the medical record.
Unlabeled and Expired Medications Found in Storage
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted professional principles. During observation and interview, a vial of tuberculin in the medication storage refrigerator was found open without an opened date, and the DON confirmed it was not labeled. In medication cart 2, two 15 mg mirtazapine tablets, one 8 mg ondansetron tablet, and three 4 mg ondansetron tablets were found unlabeled, without a resident name, and available for use; LN 1 confirmed the medications were not labeled. Expired medications were also found stored and available for use. An emergency kit contained intravenous medications with an expiration date of April 2026, which the DON verbally confirmed. In medication cart 2, staff found one packet of 30 olanzapine 10 mg tablets with an expiration date of 12/2/25, one fluticasone propionate/salmeterol 500 mcg/50 mcg inhaler with an open date of 3/10/26, and one degludec insulin pen with an open date of 2/11/26; LN 1 confirmed these items were expired. The DON stated that expired medications should not have been available for use and that medications needed to be labeled with an opened date if required. The facility policy stated that drug containers with missing, incomplete, improper, or incorrect labels are to be returned to the pharmacy for proper labeling before storing, and discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.
Unsanitary food storage, handling, and transport practices
Penalty
Summary
Food was not prepared and stored in a safe and sanitary manner in the kitchen and food transport areas for a census of 54 residents. During an initial kitchen tour, several kitchen utensils stored inside a plastic container had visible food debris and dried watermarks, and the bottom of the container designated for clean utensils contained dirt and food debris. The Dietary Manager confirmed the findings, and the Registered Dietitian stated that clean utensils must be fully clean, completely dry, and stored in sanitized containers. During the same tour, 35 metal pans and several plastic trays and stock pots were observed stacked wet on the clean rack. The Dietary Manager confirmed the items were not dry, and the Registered Dietitian stated dishes must be fully clean and completely dry before storage because wet storage creates an environment for bacterial growth. A plastic coffee carafe on the countertop also contained a white substance on the interior walls and debris at the bottom; staff confirmed it came from the other facility, and the Registered Dietitian stated coffee carafes should be cleaned after every meal. A food service staff member used a wet wiping cloth from a red bucket to wipe a food preparation countertop while cooking, returned the cloth to the bucket, and continued food preparation without washing hands, repeating the action again. The facility’s food transport van, used to bring meals from an off-site kitchen, contained food debris and new and dried liquid stains, and three plastic food warmers inside the van had food debris, dried liquid marks, and dried food drippings on their interior surfaces with dirty exterior surfaces. A plate stored in the clean tray area was also found with dried food debris. Facility policies reviewed stated that food service areas, utensils, and equipment must be kept clean, food contact surfaces must be washed to remove soils, manually washed items must air dry, and staff must use proper handwashing and glove practices.
Medication Error Rate Exceeded 5% Due to Missed Ordered Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% for one of three sampled residents, resulting in 2 medication errors out of 35 opportunities and a 5.71% error rate. Resident 9 had an order for diclofenac sodium external gel 1% to be applied to the left leg four times daily for pain, but during a medication pass observation, the Licensed Nurse did not apply the gel and stated it was not available in the medication cart. The nurse also checked the resident’s blood pressure and recorded a reading of 189/73. Resident 9 also had an order for clonidine HCl 0.1 mg every 12 hours as needed for systolic blood pressure greater than 150. During the same medication pass, the resident’s systolic blood pressure was 189, but clonidine was not administered and was not documented as given on the MAR. During interview, the nurse confirmed the blood pressure was greater than 150 and stated the clonidine should have been given, but she forgot to check the as-needed medications. The DON stated she expected medications to be administered correctly according to physician orders, and the facility policy stated medications are to be administered safely, timely, and in accordance with prescriber orders.
Failure to Follow BiPAP and Opioid Orders Resulting in Opioid Overdose and Hospital Transfer
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for a resident with multiple serious cardiopulmonary conditions. The resident’s diagnoses included acute respiratory failure, heart failure, chronic kidney disease stage 3, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation. The physician had ordered BiPAP to be applied at bedtime, but review of the Medication Administration Records (MARs) for January, February, and March 2026 showed the order was marked with an "X" for every day, indicating it was not performed. During interview, the acting DON confirmed there was no documentation that BiPAP was applied in March, stated that PM nurses were responsible for placing and documenting BiPAP use, and acknowledged the order lacked specific application and removal times despite the known importance of BiPAP in helping the resident breathe and correct CO2 problems. The facility also failed to administer an opioid medication in accordance with the physician’s pain management order. The resident had a physician order for Morphine Sulfate 15 mg by mouth every 6 hours as needed for severe pain rated 7–10/10. Review of the March 2026 MAR showed that Morphine 15 mg was administered on two occasions with documented pain scores of 5 and 6, which correspond to moderate pain, not severe pain as required by the order. The DON stated that these two administrations were not appropriate based on the documented pain levels and the physician’s order, and that nurses were expected to follow the pain scale and give the least powerful pain medication needed according to the resident’s reported pain level. The DON further acknowledged that giving a stronger pain medication than indicated by the resident’s stated pain level could result in adverse effects, including respiratory distress. Following the second Morphine administration, the resident experienced a significant change in condition. A change-in-condition note documented shortness of breath and an oxygen saturation of 46%, and the resident was sent to the emergency department. The nurse who administered the Morphine reported that later that evening the resident was found in her wheelchair complaining of shortness of breath, was desaturating despite supplemental oxygen, and required EMS activation. EMS reported the resident had received 15 mg of Morphine and found her oxygen saturation at 50% on room air; Narcan was administered and the resident became more responsive. Hospital records documented differential diagnoses including opiate overdose, acute respiratory failure with hypoxia, and acute encephalopathy, with improvement after Narcan boluses and a Narcan drip. The hospital discharge summary identified receipt of 15 mg Morphine at the facility as a precipitating factor for the resident’s respiratory distress and hypoxemia and directed that Morphine Sulfate be stopped. Additionally, the facility failed to ensure that Narcan was ordered concurrently with the opioid medication. The resident’s order summary showed that Morphine Sulfate was ordered on 3/13/26, while Naloxone (Narcan) was not ordered until 3/24/26, 11 days later. The DON stated that Narcan should be ordered once an opioid is ordered, and a second nurse confirmed that when a narcotic is ordered, Narcan also has to be ordered. The attending physician stated that Narcan should automatically be ordered when an opioid is ordered and that he could not find in the medical record the exact reason for ordering Morphine Sulfate for this resident. The facility’s medication administration policy required that medications be administered in accordance with prescriber orders, which did not occur in this case with respect to BiPAP use, opioid administration, and timely ordering of Narcan.
Failure to Develop Specific Elopement Care Plan and Accurately Monitor Exit-Seeking Behavior
Penalty
Summary
The deficiency involves the facility’s failure to provide quality care to a resident at risk for elopement by not developing specific and measurable care plan interventions and not accurately following physician orders for monitoring elopement attempts. Resident 1, admitted 29 days prior and diagnosed with respiratory failure, falls, and Alzheimer’s disease, had an elopement risk assessment score of 7, indicating a moderate elopement risk. The resident’s care plan identified risk for elopement and wandering due to a history of elopement/wandering and impaired cognitive function and safety perception, with an intervention to “check resident’s whereabouts,” but it did not specify how often or when staff should check on the resident. During an interview and record review, the DON acknowledged that the care plan intervention was not specific. The facility’s care plan policy required comprehensive, person-centered care plans with measurable objectives and timetables. The facility also failed to follow a physician order related to monitoring elopement attempts. The order summary included an order to monitor the number of times per shift the resident attempted exit-seeking behavior on every day shift, starting on 1/30/26. On 2/19/26, a grievance documented that a family member was informed by another resident that Resident 1 had left the building. Resident 2, who was cognitively intact per a BIMS score of 15, and CNA 1 both stated they saw Resident 1 open the conference room door and walk outside. However, review of the MAR for February showed that staff documented “0” exit-seeking attempts for that date, and the DON stated staff should have charted a “1” for the elopement attempt. The facility’s wandering and elopement policy stated that residents identified as at risk for wandering or elopement would have care plans including strategies and interventions to maintain safety, which was not fully implemented for this resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition was physically abused by another resident with intact cognition. The incident took place in a shared room, where a certified nursing assistant (CNA) observed one resident standing beside the other, making closed fist contact with the resident's chest while the latter was lying in bed. The assaulted resident sustained a minor laceration to the upper lip, which was confirmed by a licensed nurse upon assessment. The resident who committed the act admitted to being provoked by something the other resident said. The facility's policy and procedures on abuse prevention state that residents have the right to be free from abuse, including physical abuse, and that the administration is responsible for protecting residents from abuse by anyone, including other residents. Despite these policies, the facility failed to prevent the physical abuse, resulting in injury to the resident. Interviews with staff and both residents confirmed the occurrence of the incident and the resulting injury.
Failure to Timely Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for one of four sampled residents. Specifically, an incident occurred in which two residents, both with cognitive impairments including dementia, were involved in a physical interaction over a box of gloves. One resident made contact with another's arm, witnessed by staff, and both residents were assessed with no injuries noted. The incident was documented and reported to the ombudsman and police, but not to the State Agency as required by regulations and the facility's own policy. Interviews with the Administrator and Director of Nursing revealed a misunderstanding of reporting requirements, as both believed that incidents involving residents with dementia and no injuries only needed to be reported to the ombudsman and police, not to the State Agency. Review of facility policy indicated that all alleged violations involving abuse must be reported to the State licensing/certification agency. The failure to report the incident to the State Agency resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from harm.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and their privacy was protected, as evidenced by inadequate privacy curtains and broken or missing vertical blinds for five residents. Resident 19, who was admitted in the spring of 2023 with muscle weakness and a moderately impaired memory, expressed concerns about privacy due to missing vertical blind slats and inadequate privacy curtains. Similarly, Resident 7 and Resident 31 shared a room where the divider curtains did not provide sufficient privacy, verified by a CNA who acknowledged the lack of coverage. Resident 14, admitted in the winter of 2024 with severe memory impairment, also had inadequate privacy curtains. Resident 16, who was alert and oriented, had missing and broken vertical blind slats in their room. Interviews with staff, including a CNA, the Maintenance Supervisor, the Environmental Services Manager, and the Director of Nurses, confirmed the deficiencies in privacy measures. The facility's policy on dignity and privacy was not adhered to, as staff failed to ensure complete privacy for residents during personal care.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several medications being improperly labeled and stored. During an observation and interview, it was found that medication cart two contained unlabeled opened medications, including an inhaler of budesonide/formoterol, an inhaler of fluticasone furoate/vilanterol, and a vial of insulin lispro. Additionally, an expired bottle of cromolyn sodium eye drops was found in the same cart. The facility's document, Abridged List of Medications with Shortened Expiration Dates, indicated specific discard timelines for these medications, which were not followed. Licensed Nurse 5 confirmed the presence of the undated medications and the expired eye drops, acknowledging the importance of labeling medications with the opened date to prevent decreased effectiveness. Another observation with Licensed Nurse 6 revealed an unlabeled inhaler in medication cart one. The Director of Nursing expressed the expectation that staff should dispose of expired medications and label opened medications. The facility's policy on labeling medication containers, revised in April 2019, requires all medications to be properly labeled according to state and federal guidelines.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observed deficiencies. In one instance, a Certified Nursing Assistant (CNA) did not wear a gown while providing high-contact care to a resident who was on Enhanced Barrier Precautions (EBP) due to a peripherally inserted central catheter (PICC) and a methicillin-susceptible Staphylococcus aureus infection. Despite clear signage indicating the need for gown and glove use during specific care activities, the CNA admitted to not wearing the required protective equipment while changing the resident's clothes, briefs, and bed linens. Another deficiency was observed when a CNA failed to wash hands after providing care to a resident with a Clostridium Difficile (C Diff) infection, who was on contact precautions. The CNA was seen moving between rooms without performing hand hygiene, which is a critical step in preventing the spread of C Diff. The facility's Infection Preventionist confirmed the requirement for handwashing with soap and water after contact with residents on C Diff precautions, as outlined in the facility's policy. Additionally, a gastrotomy tube feeding bottle for a resident was found unlabeled, contrary to the facility's policy that requires labeling with the date, time, and rate of feed. The Licensed Nurse confirmed the oversight, acknowledging that the bottles are only viable for a certain period once opened. These lapses in infection control practices could potentially contribute to the spread of infections among the facility's residents.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 27, by not ensuring that the call light was within reach. Resident 27, who was admitted in the fall of 2017, had multiple diagnoses including lung disease, muscle weakness, and was at high risk for falls. The resident's care plan specifically indicated that the call light should be within reach and that the resident should be encouraged to use it for assistance. However, during an observation and interview, it was noted that the call light was placed on a chest of drawers behind the resident, making it inaccessible. A Certified Nurses Assistant (CNA) confirmed that the call light was not within reach and acknowledged that it should have been. The Director of Nurses (DON) also stated that call lights should be accessible at all times. The facility's policy and procedure on answering call lights, dated September 2024, also required that call lights be within easy reach when a resident is in bed. This oversight increased the risk that Resident 27's needs would go unmet, as the resident was unable to call for assistance when needed.
Failure to Follow Physician Orders for PICC Dressing and Medication Administration
Penalty
Summary
The facility failed to meet professional standards for two residents. For Resident 206, the facility did not change the peripherally inserted central catheter (PICC) dressing as per physician orders. The dressing was supposed to be changed every seven days, but it was observed that the dressing dated 2/17/25 was not changed by 2/24/25, as required. The Director of Nursing (DON) confirmed that the dressing change was overdue and emphasized the high risk of infection due to the central line's proximity to the heart. The facility's policy also indicated that midline catheter dressings should be changed every 5-7 days to prevent infections. For Resident 19, the facility administered metformin, a diabetes medication, without food, contrary to the physician's orders which specified that it should be given with breakfast and dinner. An observation confirmed that the medication was given without any food or snacks present. The DON acknowledged that diabetes medications should be given with food to prevent hypoglycemia, and the facility's policy stated that medications should be administered according to prescriber orders, considering the resident's needs rather than staff convenience.
Infection Control Breach by Dietary Staff
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by the dietary staff. During an observation, a dietary staff member was seen touching the part of a fork that goes into a resident's mouth with bare hands. This action was acknowledged by the dietary staff and confirmed by the Dietary Manager, who stated that such practice was not acceptable for infection control purposes. Additionally, the dietary staff member was observed putting on a glove without performing hand hygiene beforehand. This was verified by both the dietary staff and the Dietary Manager, who emphasized the importance of hand hygiene, especially in a facility caring for immunocompromised residents. The Director of Nursing also confirmed that staff should not touch utensils with bare hands and should perform hand hygiene before putting on gloves, as failure to do so could transfer bacteria to residents or their food.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary conditions in several rooms. Sticky floors were noted in various rooms, and brownish stains, identified as feces, were found on bathroom floors and toilet seats. Additionally, clothes were improperly stored on towel racks and floors, and tissue paper was found touching the bathroom floor, all of which were confirmed by multiple staff members as significant infection control issues. Interviews with staff, including unlicensed staff, licensed staff, housekeeping, and the Director of Nursing (DON), consistently highlighted the unacceptable nature of these conditions. Staff members acknowledged that sticky floors indicated inadequate cleaning, and the presence of feces and improperly stored items posed a risk of cross-contamination. The DON and other staff members affirmed that these conditions violated residents' rights to a clean and safe environment. Furthermore, a hole in a bathroom door was observed, which had been present for some time without being reported to maintenance. This was identified as a safety risk, potentially causing cuts and splinters to residents. The Maintenance Director confirmed that the hole had not been reported, and staff interviews revealed a lack of communication regarding the need for repairs. The facility's policies on cleaning and maintenance were not adhered to, contributing to the deficiencies observed.
Failure to Provide Adequate Assistance and Supervision
Penalty
Summary
The facility failed to ensure that Resident 1 received the required two-person assistance during care, which resulted in the resident falling out of bed and sustaining a left tibia fracture. Resident 1 was admitted with diagnoses including cerebral infarction and muscle weakness and was totally dependent on staff for all activities of daily living (ADLs). Despite this, Unlicensed Staff C provided care without the assistance of another staff member, leading to the resident rolling over and falling off the bed during perineal care. This incident was corroborated by interviews with other staff members who confirmed that Resident 1 required two-person assistance for turning and repositioning in bed. The facility also failed to respond promptly to Resident 2's call light, which resulted in the resident attempting to get out of bed without assistance and subsequently falling. Resident 2, who had left-side hemiplegia and hypertension, required substantial assistance with toileting and transfers. On the day of the incident, Resident 2 turned on her call light for assistance to use the toilet but waited for over an hour without receiving help. This delay led Resident 2 to attempt to get out of bed on her own, resulting in a fall that caused neck pain, headache, and dizziness, necessitating a hospital visit. Interviews with staff and the Director of Nursing (DON) revealed that the facility's failure to provide timely assistance and adequate supervision contributed to the accidents involving both residents. The DON acknowledged that Resident 1 required two-person assistance for turning in bed and that Resident 2's call light was not answered promptly due to staff being occupied with other residents. These deficiencies highlight the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents.
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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 Vallejo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs Road Healthcare | 1.1 mi | ★★★★★ | 2 | 0 |
| Solano Post Acute | 2.4 mi | ★★★★★ | 24 | 0 |
| Alhambra Post Acute | 8 mi | ★★★★★ | 2 | 0 |
| Legacy Post Acute Care | 10.3 mi | ★★★★★ | 2 | 0 |
| Greenridge Post Acute | 11.1 mi | ★★★★★ | 0 | 0 |
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