Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Carmichael Healthcare Center during CMS and state inspections, most recent first.
A resident with fractures had orthopedic follow-up appointments cancelled and delayed, with staff documenting conflicting reasons for the cancellations and no documented evidence supporting the changes. Another resident with quadriplegia and high skin-breakdown risk was observed wearing offloading boots, but there was no physician order, TAR, monitoring documentation, or care plan intervention for the boots until staff later entered them after recalling the resident used them.
Two residents with suprapubic catheters did not have timely physician orders or documented urine output monitoring. One resident had quadriplegia and neurogenic bladder with a suprapubic catheter draining clear yellow urine, while the other had retention of urine and severe cognitive impairment with catheter tubing connected to a bag. The DON confirmed both residents had catheters on admission and that output monitoring was not documented as required by the care plans.
Unexplained weight loss was identified for three residents with significant medical histories, including malnutrition, dysphagia, dementia, diabetes, and dependence for feeding. IDT notes repeatedly addressed the weight loss and included interventions such as more frequent weights, fortified diets, snacks, supplements, and a swallow eval, but the RD acknowledged that no root cause had been identified in the residents’ notes. The ADON later stated that breathing difficulty, a healed wound, and feeding dependence may have contributed, but those factors were not documented as the cause or used to determine the interventions.
Failure to Offer Meal Substitutions When Meals Were Refused: A resident stated he sometimes passed on meals because he did not like them and was told no substitute would be offered, while two other residents also refused or left meals without receiving alternatives. One resident had most of the meal uneaten and reported weight loss during the stay. The RD stated nursing should offer a substitute when a meal is refused, and the DS stated nursing should notify the kitchen so the meal could be replaced.
Meals and snacks were not served in accordance with resident needs and preferences because the facility’s posted schedule left 14 1/2 hours between dinner and breakfast for a census of 129. Surveyors reviewed the meal schedule with the DS and found breakfast at 7:00 a.m., lunch at 11:30 a.m., and dinner at 4:30 p.m.; the DS denied that all residents were provided a substantial nighttime snack.
Food service safety standards were not met when the ice machine had calcium buildup, the floor in front of it had large breaks, dry storage labels did not match storage guidelines, an opened bag of beef patties was left exposed in the freezer, and the middle dining room was used for haircuts while residents were being prepared for lunch. The RD and ADON stated that haircutting in the dining room before the meal was a cross-contamination or infection control issue.
Staff failed to follow infection control practices for several residents during care and equipment handling. A resident on EBP was provided brief care without the expected gown, a nurse performing wound care did not clean hands between glove changes, and multiple residents had oxygen tubing, a nebulizer, or a glucometer handled or stored outside facility expectations. Residents involved had conditions including G-tube dependence, pressure injury, COPD, diabetes, and respiratory failure.
A resident with COPD and asthma received a prescribed inhaler, but an LPN did not instruct the resident to rinse his mouth after use as ordered. Another resident with Type 2 DM was eating breakfast when an LPN prepared to check blood glucose for sliding-scale insulin, rather than completing the check before the meal as expected. The DON confirmed both orders were not followed as directed.
Failure to provide proper foot care for two residents was identified. One resident with CVA-related deficits and dependence for personal hygiene had thick, long toenails that were not trimmed, and staff reported no podiatry care had been provided. Another resident with moderate cognitive impairment, a left femur fracture, COPD, CKD, and chronic pain had long, thickened toenails with the left first toenail curving into the second toe; the resident said the nail was starting to cut into the toe and had not been cut since admission. Records showed podiatry orders and care plan directions, but the resident had not been seen by podiatry and nursing had not referred the resident for the service.
Oxygen signage and BiPAP use were not managed according to orders and facility policy. A resident receiving continuous O2 by NC was observed without oxygen-in-use signage posted, and staff confirmed the sign should have been in place. Another resident with COPD, HF, respiratory failure, OSA, morbid obesity, and asthma was prescribed BiPAP with a large nasal mask, but the resident said the mask was too small and had not been wearing it; staff later acknowledged the mask did not fit and would not work.
A resident with ESRD and dependence on dialysis had a physician-ordered 1000 mL/24-hour fluid restriction that was exceeded on multiple days. The DON confirmed the resident was non-compliant, became angry when reminded, and that staff did not document the refusals or include the non-compliance in the care plan, despite the facility policy requiring fluid restrictions to be followed and refusal documentation to support the resident’s continued refusal.
Missing Annual CNA Performance Evaluations: The facility failed to ensure annual performance reviews were completed for three CNAs. The DSD stated he was responsible for CNA evaluations but had not completed any since starting, and he could not locate the annual evaluations for the three CNAs. The DON stated CNA reviews were to be done annually to assess knowledge, skills, resident care, safety, and documentation, and the facility policy required a formal written evaluation each year.
A resident with full dentures and a BIMS of 15 was found without a lower denture, and only one denture was seen in a cup. The resident stated the lower denture was broken or missing and reported trouble chewing at times, while a CNA said the missing denture had been noticed and reported to the charge nurse about two weeks earlier. A nurse later stated no report of the missing denture had been received, and the resident ate lunch without dentures.
Call Light Not Within Reach of a Resident A resident with COPD, DM, vascular dementia, and protein-calorie malnutrition was found unable to reach his call light, which was hanging low from the bed rail. The resident had moderate cognitive impairment and needed substantial assistance with multiple ADLs, while staff acknowledged the call light was not positioned within reach and should have been placed on the resident’s stronger side per facility policy.
Two residents who required assistance with eating, including one with severe cognitive impairment and GERD and another with dysphagia, were observed being fed while not properly positioned upright as required by their care plans and facility policy. Staff fed these residents while they were lying down or with the head of bed below 30 degrees, contrary to established protocols for safe feeding.
Discontinued non-controlled prescription medications and those left after a patient's discharge were not consistently destroyed in the presence of two licensed nurses, as required. Logbook reviews showed missing or incomplete signatures, and interviews with the IP, PC, and DON confirmed that the process was not being followed, increasing the risk for diversion or misuse.
Two residents experienced medication administration errors when a nurse gave insulin before a meal was available and another nurse administered pantoprazole outside the prescribed time window, resulting in a facility-wide medication error rate of 6.67%, which is above the acceptable 5% threshold.
Surveyors identified deficiencies in medication management, including an opened, unlabeled glucose gel tube left in a medication cart, a discharged resident's medications with an open pill bottle stored in a bag in the medication room, and a medication refrigerator operating above the recommended temperature range while containing insulin and other sensitive medications. Staff confirmed these practices did not follow facility policy or professional standards.
Surveyors found that food items in the kitchen, refrigerator, freezer, and dry storage were not properly labeled with open or use by dates, and some had lapsed use by dates. Several dented cans were stored with non-dented cans, and one was being prepared for use. Staff interviews confirmed knowledge of required food safety practices, but these were not followed, creating potential food safety risks.
Personal belongings were stored in medication carts with pharmaceuticals, two CNAs provided care to a resident on enhanced barrier precautions without required PPE gowns, and a nurse practitioner failed to wear a facemask during a respiratory infection outbreak, all contrary to facility policy and infection control standards.
Several residents with severe cognitive and physical impairments were found without accessible or working call light systems, including instances where call light buttons were on the floor, missing, or broken, and where bathroom call systems were not available. Staff and the DON confirmed that call lights should be within reach and functional, as required by facility policy.
A resident admitted with a PICC line for IV Vancomycin due to septic arthritis did not have a baseline care plan initiated within 48 hours of admission. The DON confirmed that no care plan addressing the PICC line was developed, despite facility policy requiring such plans for new admissions.
A resident with multiple medical conditions did not consistently receive wound care treatments as ordered by the physician. Review of treatment records and staff interviews confirmed that wound care was missed on several occasions, despite facility policies and care plans requiring licensed nurses to perform and document these treatments according to physician orders.
A resident with hand contractures did not have the ordered contracture device applied to the right hand on several observed occasions, despite care plan and OT orders requiring devices on both hands at all times. Multiple staff confirmed the device was missing, and facility leadership acknowledged the expectation for compliance with such orders.
A resident with severe cognitive impairment and a history of UTIs experienced increased confusion and frequent urination. Although a STAT urinalysis was ordered to rule out infection, the urine sample was not collected and processed in a timely manner, resulting in delayed detection and care. The resident's condition worsened, leading to transfer to an acute hospital. Facility policy and laboratory agreements required prompt action for STAT orders, but this was not followed.
A resident with respiratory failure, CHF, and asthma was observed receiving oxygen at 5 LPM, despite a physician's order for 2-3 LPM. Multiple staff confirmed the higher setting, and the care plan and facility policy required adherence to prescribed oxygen levels. This failure resulted in improper delivery of respiratory care.
A resident with multiple diagnoses did not have pharmacist-recommended changes implemented for their anti-acid, breathing, and PRN pain medications. The consultant pharmacist's recommendations, including specific administration instructions and the addition of non-pharmacological interventions, were not documented or applied in the resident's orders, as confirmed by the ADON. This was not in accordance with facility policy requiring staff to act on medication regimen review recommendations.
Staff failed to follow facility policy requiring all food brought in by families or visitors to be labeled with the resident's name, date received, and use-by date. Unlabeled food items, including cooked noodles, jam, and juice, were found in a resident refrigerator, and staff confirmed that these procedures were not followed for multiple residents.
A resident with polyosteoarthritis and other conditions did not receive the prescribed frequency of physical therapy sessions, as several sessions were missed. The facility's policy required adherence to the therapy plan, but the frequency was not followed, risking the resident's mobility improvement.
A resident's medications were left unattended at the bedside, posing a safety concern. The resident, with anxiety and chronic pain syndrome, had no documented assessment or care plan for self-administration of medications. Facility policies require medications to be administered within one hour and self-administration to be approved by a physician and interdisciplinary team, but these were not followed.
A resident with paraplegia and moderate cognitive impairment was physically abused by another resident who was cognitively intact, resulting in injury and pain. The incident occurred when the second resident, upset by a racial slur, hit the first resident with a cane. The facility's policy on abuse was not effectively implemented to prevent this incident.
A resident with parkinsonism and depression alleged that a female staff member grabbed his arm, resulting in a wrist fracture. Despite the resident's daughter reporting the incident to nursing staff, the facility failed to report the abuse allegation to the state agency within the required timeframe, delaying the investigation.
The facility failed to hire a qualified Director of Food and Nutrition Services. The Dietary Manager had not completed the necessary certification or training, and the Consultant Registered Dietitian's role did not include supervisory duties. This deficiency had the potential to lead to foodborne illness for the 124 residents eating facility-prepared meals.
The facility failed to store, prepare, and distribute food in accordance with professional standards, leading to potential foodborne illnesses. Issues included improper labeling, expired foods, unsafe storage temperatures, uncovered food items, ice buildup in the freezer, dirty cutting boards, and a rusted can opener.
The facility failed to assist three residents with nail care, resulting in long, dirty, and jagged fingernails. One resident had severe cognitive impairment and required substantial assistance, another had intact cognition but needed moderate assistance, and the third was dependent on assistance for personal hygiene. Staff confirmed the poor condition of the residents' nails, and clinical records showed no documented refusals of care.
The facility failed to maintain pharmacy services when controlled drug record forms were inaccurately signed for five discharged residents, suggesting that controlled drugs were given to residents at discharge instead of being destroyed by the nurse. The DON verified this discrepancy, acknowledging the potential for drug diversion.
The facility failed to ensure proper medication storage and labeling, leading to deficiencies such as loose pills, undated and expired medications, and improper storage. These issues were verified by LNs and acknowledged by the DON, posing risks to resident safety and care quality.
The facility failed to prepare and serve food that conserved nutritive value, flavor, and appearance, and served food at unappetizing temperatures. Vegetables were heated for over two hours, pureed meals were prepared without measuring ingredients, and pureed food was prepared in a dirty food processor bowl. These actions led to potential poor intake, malnutrition, and weight loss among the 124 residents eating facility-prepared meals.
The facility failed to accommodate food allergies and preferences for six residents, leading to potential health risks. Issues included serving incorrect food items, not adhering to dietary restrictions, and serving cold or lukewarm food. The facility's policy required documentation and review of resident preferences, but this was not consistently followed.
The facility failed to maintain an effective infection prevention and control program, including dusty linen carts and shelves, unlabeled nasal cannulas and IV tubing, and a urinary catheter bag touching the floor. These lapses could lead to infection and cross-contamination among residents.
The facility failed to ensure essential kitchen equipment, including the ice machine and oven, were in safe operating conditions. The ice machine had issues with randomly shutting off, and the right side of the oven was non-functional, affecting meal preparation and thermometer calibration.
The facility failed to ensure the privacy and dignity of a resident with severe memory impairment and total dependence on staff for ADLs. During care, the door was open, and privacy curtains were not pulled, exposing the resident's lower body to the hallway. This was confirmed by the Medical Record Assistant and the Director of Nursing, and acknowledged as an oversight by the involved Licensed Nurse.
The facility failed to ensure call light accessibility for two residents, resulting in their inability to call for help when needed. One resident's call light was repeatedly found on the floor, while another resident with hand contractures was not provided with an appropriate call light type.
The facility failed to complete a comprehensive assessment for a resident within the regulatory time frame. The resident, admitted with multiple diagnoses, had an overdue MDS, confirmed by staff. Observations showed the resident was alert but minimally responsive. The delay was due to pending input from social services, as confirmed by the MDS Director.
The facility failed to complete baseline care plans (BCPs) within 48 hours for two residents, leading to incomplete assessments and potential unmet care needs. One resident had missing assessments in the Dietary/Nutritional Status and Social Services sections, while another had an incomplete Social Services section and unaddressed limb prosthesis. Staff confirmed the deficiencies and acknowledged the failure to meet the required timeframe.
The facility failed to provide appropriate treatment and services to maintain or improve mobility for two residents. Both residents did not receive the prescribed restorative nursing program (RNA) exercises three times a week as required, potentially leading to a decline in their range of motion and mobility.
The facility failed to ensure a safe environment for a resident with mobility issues due to an uneven pathway in the designated smoking area. Despite the resident's concerns and the facility's policies emphasizing safety, the cracks in the sidewalks were not addressed, posing a risk of accidents and injuries.
The facility failed to ensure proper delivery of respiratory care for a resident with COPD, respiratory failure, and dementia. The resident was observed using an oxygen concentrator set at 5 LPM instead of the prescribed 2 LPM, with no documentation of titration to maintain oxygen saturation. The DON confirmed that physician's orders should always be followed, and the facility's policy emphasized the importance of adhering to these orders.
Delayed orthopedic follow-up and missing offloading boot monitoring
Penalty
Summary
The facility failed to ensure that Resident 51 received follow-up orthopedic care in accordance with the physician’s orders and the resident’s documented needs. Resident 51 was admitted with diagnoses including displaced comminuted fracture of the left tibia and fibula, fracture of the left femur neck, and major depressive disorder, and the MDS dated 5/8/26 indicated moderate cognitive impairment. The hospital record dated 2/3/26 included an orthopedic follow-up appointment for 3/17/26 with instructions to arrive one hour early for x-ray. The record showed that the orthopedic appointment was first rescheduled from 3/17/26 to 3/24/26, with a nursing note stating the appointment was rescheduled and that Resident 51 did not have capacity to make health care decisions and needed family or staff to accompany her. This conflicted with the physician order dated 2/3/26, which stated that Resident 51 had capacity to make health care decisions. The social services director and DON both confirmed there was no documented reason for the original cancellation and no documented evidence supporting the stated reason that the resident lacked capacity or required accompaniment. The record further showed that the follow-up process continued to be delayed. On 4/7/26, the physician ordered x-rays to be done in the facility and forwarded to the clinic for review. On 4/9/26, social services documented that the physician’s office was still waiting for the x-rays before scheduling the appointment. On 4/10/26, the x-ray was reviewed and an appointment was scheduled for 5/19/26. On that date, Resident 51 stated the appointment for x-ray and left leg brace had been cancelled and she did not know why. The DON confirmed the facility had not documented why the appointment was cancelled or rescheduled and stated staff probably forgot to document. The facility also failed to monitor and care plan Resident 126’s use of offloading boots. Resident 126 was admitted with diagnoses including quadriplegia, necrotizing fasciitis, polyneuropathy, and major depressive disorder, and the MDS indicated intact cognition. The care plan identified impaired skin integrity and continued risk for skin breakdown related to fragile skin, and the resident was observed in bed wearing offloading boots on both feet while stating he wore them most of the time. Interviews with nursing staff confirmed that offloading boots should have a physician order, should be checked and assessed every shift, and should be included in the care plan. Treatment Nurse 2 confirmed that Resident 126 had been using offloading boots since admission, but there was no physician order, no TAR, and no care plan intervention for the boots until 5/21/26, when the nurse entered them because she remembered the resident used them. The DON confirmed Resident 126 was bedbound, had a history of an open wound, and was at high risk for skin breakdown, and also confirmed there was no documented evidence that the boots were being monitored.
Missing catheter orders and output monitoring for two residents
Penalty
Summary
Appropriate care for residents with indwelling catheters and for prevention of urinary tract infections was not provided for two residents. Resident 126 was admitted with diagnoses including quadriplegia and neurogenic bladder, and the MDS indicated intact cognition and an indwelling catheter. The care plan identified a suprapubic catheter and directed staff to monitor and document intake and output, but during observation the resident was seen with a suprapubic catheter draining clear yellow urine, and the record review showed no physician order for the catheter or for urine output monitoring until 5/19/26. The DON confirmed the resident had a suprapubic catheter upon admission and stated there should have been a physician order and output monitoring from admission. Resident 144 was admitted with retention of urine, and the MDS indicated severe cognitive impairment. The care plan identified an indwelling suprapubic catheter and directed staff to monitor and document intake and output, but during observation the resident was seen in bed with catheter tubing connected to a catheter bag, and the DON confirmed the resident had a catheter upon admission. The DON also confirmed there was no physician order to monitor output before 5/20/26 and no documented evidence that output had been monitored and recorded. The facility policy stated indwelling urinary catheters, including suprapubic catheters, are to be used in accordance with physician orders and with interventions to prevent complications.
Unexplained Weight Loss Without Root Cause Analysis
Penalty
Summary
Provide enough food and fluids to maintain residents’ health was not met for three residents who experienced ongoing weight loss without a documented root cause analysis. Resident 1 was admitted with pneumonitis, immunodeficiency, severe protein calorie malnutrition, and diabetes, and lost 20 lbs. from 155 lbs. to 135 lbs. over about one year. Interdisciplinary team notes repeatedly identified concern about the weight loss and suggested interventions such as more frequent weighing, fortifying the diet, adding snacks, and changing nutrition supplements, but no root cause was identified in the notes. The RD acknowledged that a root cause had not been identified, and the ADON stated that breathing difficulty may have contributed, but that information was not included in the resident’s notes used to determine interventions. Resident 3 was admitted with diabetes, depression, dysphagia, and protein calorie malnutrition, and lost 22 lbs. from 175 lbs. to 153 lbs. over about one year. The RD documented a 12-lb. loss in one month, which was identified as significant weight loss, and IDT notes showed concern on multiple occasions. Interventions included increasing weighing frequency, adding snacks, and arranging a swallow evaluation, but no root cause was documented. The ADON stated that a healed wound and dependence for feeding may have contributed, but that this information was not included in the resident’s notes or used to determine interventions. Resident 56 was admitted with diabetes, dementia, and cerebrovascular accident, and lost 23 lbs. from 132 lbs. to 109 lbs. over about 10 months. The RD documented significant weight loss over 2 weeks, 3 months, and 6 months, and IDT notes repeatedly addressed the weight loss. Interventions included more frequent weighing, fortifying the diet, adding snacks, and adding nutrition supplements, but no root cause was identified. The ADON stated that a wound and dependence for feeding may have contributed, but that this was not stated as the cause in the resident’s notes or used in determining interventions.
Failure to Offer Meal Substitutions When Meals Were Refused
Penalty
Summary
The facility failed to provide substitutions when meals were refused for three residents, including Resident 1, Resident 26, and Resident 82. During an initial interview, Resident 82 stated that he did not like the facility-provided meals at times and said he would pass, but no meal substitute would be offered, which led to hunger. During a lunch observation, Resident 26 looked at her meal and wheeled out of the lower dining room, stating that she did not like the look of the meal. Later observations showed Resident 26 asleep in bed with no meal tray on the bedside table, and she later stated that she did not receive a substitute meal for lunch the previous day. During a lunch observation, Resident 1 was in bed with his meal tray on his bedside table and most of the meal uneaten. No substitute was offered when the tray was removed. Resident 1 stated that he had lost weight during his stay at the facility. The RD stated that when a meal was refused, nursing should offer a meal substitute. The DS stated that nursing staff should notify the kitchen when a meal was refused so it could be replaced with something else. The facility's Food Preparation Guidelines stated that staff shall offer residents appropriate alternatives when they choose not to consume food or drink that is initially served.
Meal Schedule Exceeded Allowed Overnight Interval
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests because the facility did not keep the time between dinner and breakfast to 14 hours or less for a census of 129. During a concurrent interview and record review with the Dietary Supervisor, surveyors reviewed the meal schedule and found breakfast started at 7:00 a.m., lunch at 11:30 a.m., and dinner at 4:30 p.m., creating 14 1/2 hours between dinner and breakfast. The Dietary Supervisor denied that the facility provided all residents with a substantial nighttime snack.
Food Storage and Dining Area Sanitation Deficiencies
Penalty
Summary
Food service safety standards were not met during observations of the kitchen and dining areas for a census of 129. During the initial kitchen tour, the Manitowoc ice machine was opened and the plastic water curtain/splash shield covering the ice grid was observed with calcium buildup on the inside, despite the machine having been serviced about 10 days earlier. The observation also noted two large breaks in the floor in front of the ice machine, measuring approximately 3 inches by 10 inches, and the Dietary Supervisor stated the floor had been like that for 5 to 6 years. In dry storage, food labeling was inconsistent with the facility’s storage guidelines. A bag of pasta had a prep date of 5/15/26 and a use-by date of 12/15/26, a second opened bag of pasta had a prep date of 5/6/26 and a use-by date of 12/6/26, and a third bag of pasta had a prep date of 5/19/26 and a use-by date of 12/19/26. A large opened bottle of vinegar was also observed with a prep date and use-by date of 4/24/26. The facility’s storage instructions and food storage policy were reviewed during the observation. In the walk-in freezer, a box of beef patties had been opened and the bag containing the patties was left open, exposing the food to the air. During lunch meal service, the middle dining room was being used for haircuts while residents were being set up for the meal. A male resident was observed receiving a haircut with electric clippers, and the hair stylist stated haircuts had been moved into the dining room about a year earlier. The RD and ADON both stated that haircutting in the dining room prior to lunch was a cross-contamination or infection control issue.
Infection Control Failures With PPE, Hand Hygiene, and Respiratory/Monitoring Equipment
Penalty
Summary
Staff failed to follow infection prevention and control practices for multiple residents during care and equipment handling. Resident 15 had diagnoses including dysphagia and a gastrostomy tube and was on Enhanced Barrier Precautions related to the G-tube. During observation, staff entered the room with a face mask and gloves but no gown while providing care, and the CNA later stated she changed the resident’s brief. The Infection Preventionist stated that staff caring for residents identified with the yellow dot for EBP were expected to use gown and gloves for high-contact care such as brief changes. During wound care for Resident 115, who had type 2 diabetes and a stage 3 pressure ulcer of the right buttock, the treatment nurse was observed removing gloves and putting on a new pair of gloves without performing hand hygiene in between on two occasions. The nurse stated she performed hand hygiene before glove use and before and after handling clean or soiled dressing. The Infection Preventionist stated hand hygiene should be practiced before and after removing gloves and that the facility follows CDC guidance and its hand hygiene policy. Several residents had equipment stored or cleaned in a manner that did not match facility expectations. Resident 16, who had COPD and chronic respiratory failure with hypoxia and was cognitively intact, had oxygen nasal cannula tubing lying on top of personal items on the wheelchair rather than stored in a bag. Resident 93, who had type 2 diabetes and was cognitively intact, had a glucometer cleaned with an alcohol pad after blood glucose testing; the nurse stated this was not the proper way to clean it and said a disinfectant wipe should have been used, especially because the resident was in contact isolation. Resident 44, who had COPD, asthma, respiratory failure with hypoxia, morbid obesity, and pulmonary fibrosis, had a nebulizer machine on the floor and tubing stored in a nightstand drawer. Resident 128, who had COPD, heart failure, respiratory failure with hypoxia, obstructive sleep apnea, morbid obesity, and asthma, had oxygen tubing on the floor while oxygen was set at 2 liters per minute; staff stated the tubing should be in a bag when not in use and that tubing on the floor was contaminated.
Failure to Follow Inhaler Order and Pre-Meal Blood Glucose Timing
Penalty
Summary
Resident 78, who was admitted with diagnoses including COPD and asthma, had a physician order for fluticasone furoate-vilanterol inhaler 1 puff by mouth daily for COPD with instructions to rinse the mouth after use. During a concurrent observation and interview, a licensed nurse administered the inhaler but did not instruct the resident to rinse his mouth afterward. The nurse stated she forgot to give that instruction, and the DON stated the physician orders should have been followed. Resident 93, who was admitted with Type 2 DM and had an order for insulin lispro injection per sliding scale with meals, was observed eating breakfast when the nurse was preparing to check a blood glucose level to determine the insulin dose. The nurse confirmed the blood glucose check should have been done about 30 minutes before the resident began eating breakfast. The DON stated the blood glucose check should be done 30 minutes before a meal to determine the insulin dose and that an accurate result would not be obtained if the resident was eating.
Failure to Provide Proper Foot Care
Penalty
Summary
Proper foot care was not provided for 2 of 27 sampled residents. Resident 15 had diagnoses including hereditary ataxia and hemiplegia/hemiparesis following a CVA, and the MDS indicated memory problems and dependence on staff for personal hygiene. Although the physician order allowed podiatry, an observation showed the resident’s toenails were long, and a later observation with an LN confirmed the toenails were thick and long and needed trimming. The LN stated she had not received a report about the toenails, and the MRA stated there was no documentation from Social Services regarding podiatry care and no podiatry care had been provided. Resident 63 had multiple diagnoses including a left femur fracture, COPD, CKD, and chronic pain, and the MDS showed moderate cognitive impairment. During observation, the resident’s toenails were approximately one centimeter longer than the toes, appeared thickened, and the left first toenail was curving into the second toe. The resident stated the toenail was starting to cut into the second toe, that the toenails needed to be cut, and that they had not been cut since admission. The resident also stated she had not been seen by a podiatrist while in the facility. Record review showed Resident 63 had a physician order to see podiatry and a care plan intervention to refer to podiatry for nail care as needed, but the resident had not been seen by podiatry. The SSD stated the resident had not been added to the podiatry list because nursing had not referred her, and the DON acknowledged the resident had not received podiatry services. Facility policies required nail assessment, routine nail care, and referral of residents needing foot care to qualified professionals, but these actions were not carried out for the two residents.
Oxygen Signage and BiPAP Mask Fit Deficiencies
Penalty
Summary
Respiratory care was not provided in accordance with professional standards for a resident with myasthenia gravis and COPD when the resident was observed receiving continuous oxygen by nasal cannula without oxygen warning signage posted by the room door. The resident had been admitted with oxygen use documented in nursing notes, and during multiple observations the resident remained on 2 to 3 liters per minute of oxygen while no signage was present. Nursing staff confirmed that oxygen-in-use signage should have been posted, and the DON stated that oxygen warning signs must be placed on the door when oxygen is in use. Record review also showed the resident’s oxygen order had been discontinued before the new order was entered, while staff stated the resident was already using oxygen when readmitted. Respiratory care was also not provided as ordered for a resident with COPD, heart failure, respiratory failure with hypoxia, OSA, morbid obesity, and asthma who was prescribed BiPAP with a large nasal mask. The resident had severe cognitive impairment and was observed with the BiPAP machine on the nightstand and the mask in a bag, stating the mask was too small and that the resident had not been wearing it. The resident again demonstrated that the mask did not fit and reported having told staff it was too small. Nursing staff stated the resident did not wear the BiPAP on their shift and that the RN needed to reassess the mask if it was too small. The RN supervisor later examined the mask and acknowledged it was too small and would not work, stating a new mask needed to be ordered. The DON acknowledged the mask may not fit the resident, and the DOA stated he had been notified that the BiPAP did not fit and needed a new mask, adding that the resident may not have had the proper mask for over a year. The facility policy required noninvasive ventilation to be provided per physician orders and current standards of practice, with equipment that fits over the nose or mouth.
Fluid Restriction for Dialysis Resident Not Followed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related care for a resident with end stage renal disease and dependence on renal dialysis when the resident’s ordered fluid restriction of 1000 mL per 24 hours was not followed. Resident 5 was admitted in March 2026, had intact cognition on the 4/6/26 MDS, and did not exhibit behaviors of rejection of care. A physician order dated 4/23/26 specified a 1000 mL/24-hour fluid restriction. A review of the resident’s fluid intake from 4/22/26 through 5/22/26 showed multiple days when intake exceeded the ordered limit, including 1120 mL, 1460 mL, 1290 mL, 1560 mL, 2400 mL, 1700 mL, and other amounts over 1000 mL. During interview and record review, the DON confirmed the resident received more than 1000 mL on multiple days, stated the resident was very non-compliant and became angry when reminded, and confirmed there were no staff notes documenting the non-compliance. The DON also confirmed the non-compliance was not included in the care plan and stated the lack of documentation and care planning would make it appear the resident was not monitored and that the fluid restriction order was not followed.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had annual performance reviews for CNA 3, CNA 4, and CNA 7. During an interview, the Director of Staff Development stated he was responsible for conducting CNA performance evaluations and said he had not conducted a performance evaluation since he started last December. During a concurrent interview and record review, the Payroll Action Forms showed CNA 3 was hired on 12/12/23, CNA 4 was hired on 10/17/23, and CNA 7 was hired on 8/1/21. The Director of Staff Development stated he could not find the annual performance evaluations for these three CNAs. The Director of Nursing stated CNA performance evaluations were done annually and that the Director of Staff Development was responsible for conducting the reviews. The DON stated the purpose of the performance evaluation was to assess how an employee progressed in knowledge and skills, to ensure the highest practicable care for each resident, and to evaluate attitude toward residents and families, resident care, safety, and completeness of documentation. The facility policy titled Evaluation Process, revised 12/19/2022, stated employees were to receive a formal written evaluation annually and described the process for completing, reviewing, signing, and filing the evaluation forms.
Missing Lower Denture Not Reported or Located
Penalty
Summary
The facility failed to ensure dental services were provided for one resident when the resident's lower denture was missing. The resident was admitted with diagnoses including hypothyroidism and bipolar disorder, and the MDS dated 3/31/26 indicated the resident was cognitively intact with a BIMS score of 15 and required partial or moderate assistance with oral hygiene, including the ability to insert and remove dentures. The resident's inventory of personal effects dated 3/29/26 listed one upper and one lower denture, and the care plan identified a potential for oral/dental health problems related to full dentures with interventions to coordinate dental care and monitor, document, and report signs and symptoms of oral/dental problems needing attention. During observation and interview, the resident was seen with only one denture in a cup and stated the lower denture was broken and that he did not know where it was. The resident later ate lunch without dentures and stated he had trouble chewing at times. A nurse reviewed the inventory and stated he had not received a report that the denture was missing, while a CNA stated she had noticed the lower denture was missing about two weeks earlier and reported it to the charge nurse. The DON stated staff were expected to check whether alert residents were wearing dentures before meals and that if a CNA was made aware dentures were missing, the CNA should report it to the charge nurse and Social Services. The facility policy titled Theft and Loss Program stated that when a personal property item is reported missing, staff should immediately begin a search and complete a Theft and Loss report if not found.
Call Light Not Within Reach of Resident
Penalty
Summary
The facility failed to ensure that a call light device was accessible for 1 of 27 sampled residents, Resident 142, when the resident was not able to reach the device to call for assistance. Resident 142 was admitted in May 2026 with diagnoses including gangrene and necrosis of lung, COPD, diabetes, vascular dementia, and protein-calorie malnutrition. The MDS dated 5/11/26 indicated a BIMS score of 10 out of 15, showing moderate cognitive impairment, and the resident required moderate to substantial assistance with eating, oral hygiene, dressing, and personal hygiene and was dependent for toileting, bathing, bed mobility, and transfers. The care plan for Resident 142 included an intervention to encourage the resident to use a bell to call for assistance. During observation on 5/19/26, the resident's call light was seen hanging from the left side of the bed rail almost to the floor, and the resident stated he could not reach it. A nurse later acknowledged the resident could not reach the call light on the left side and stated it needed to be moved to the resident's right side, where he could press the button. A CNA stated call light devices should be close to the resident, within reach, and placed on the resident's stronger side if needed. The facility policy stated staff will ensure the call light is within reach of the resident and secured as needed.
Failure to Properly Position Residents During Feeding Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with eating were properly positioned during feeding, as specified in their care plans and the facility's meal assistance policy. One resident, with diagnoses including COPD and GERD and severe cognitive impairment, was observed being fed while lying on their left side with the head of bed lower than 30 degrees, contrary to care plan instructions to keep the head of bed elevated at 30-45 degrees and avoid lying down during and after meals. The staff member confirmed feeding the resident in this improper position. Another resident, dependent on staff for eating and with a diagnosis of dysphagia, was observed being offered food while in a supine position with the head of bed lower than 30 degrees, despite care plan instructions to maintain the head of bed at 30-45 degrees during feeding. The staff member acknowledged attempting to feed the resident in this position and stated that residents should be upright when eating. Facility policies reviewed also required residents to be positioned upright during meals, but these were not followed during the observed incidents.
Failure to Properly Witness and Document Destruction of Non-Controlled Medications
Penalty
Summary
The facility failed to ensure that discontinued non-controlled prescription medications and those remaining after a patient's discharge were destroyed in accordance with policy and regulatory requirements. Specifically, the destruction of these medications was not consistently witnessed and signed by two licensed nurses, as confirmed by a review of the non-controlled medication disposition logbook. Multiple entries in the logbook showed either only one nurse's signature or no signatures at all, indicating that the required process was not being followed on several occasions and with multiple medications. Interviews with the Infection Preventionist, Pharmacy Consultant, and Director of Nursing all confirmed that the destruction of non-controlled medications should be witnessed and signed by two licensed nurses. The facility's own policy also requires that the destruction of unused, contaminated, or expired prescription drugs be witnessed and documented in accordance with state laws, including signatures from the appropriate staff. The lack of proper documentation and witnessing of medication destruction created a potential risk for diversion or misuse of non-controlled medications.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. During medication administration observations, two errors were identified out of 30 opportunities involving two residents. In one instance, a nurse administered Insulin Lispro to a resident with type 1 diabetes mellitus before the resident received their meal, despite the physician's order specifying administration before meals. The resident's blood sugar was checked and insulin was given, but the meal tray was delayed, and the resident did not begin eating until nearly an hour after the insulin was administered. The pharmacy consultant confirmed that Insulin Lispro should be given before meals to avoid hypoglycemia, and the nurse did not follow the physician's order in this case. In another instance, a nurse administered pantoprazole to a resident at 9:20 a.m., although the medication was scheduled for 7:30 a.m. per the physician's order and the Medication Administration Record. The pharmacy consultant stated that pantoprazole should be administered within one hour before or after the scheduled time to maintain its efficacy. The facility's policy also requires medications to be administered within 60 minutes of the scheduled time unless otherwise ordered. These actions demonstrate a failure to follow physician orders and facility policy regarding medication administration timing.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. An opened, unlabeled glucose gel tube was found in a medication cart, with confirmation from nursing staff and the pharmacy consultant that the gel was intended for single use only and should have been disposed of immediately after administration. The lack of labeling and improper storage created a risk that the gel could have been administered to more than one resident. Additionally, a discharged resident's medications, including an opened pill bottle with loose pills, were found stored in a plastic bag in the medication room, contrary to facility policy and professional standards. The infection preventionist confirmed that these medications were kept for up to seven days in case the resident returned, but acknowledged that open medication bottles posed a risk for drug diversion and were not suitable for return to the resident. Further, the refrigerator in the North medication room was found to be operating at 51 degrees Fahrenheit, above the recommended temperature range for medication storage. The refrigerator contained insulin vials, emergency medication kits, and vaccination vials. Both the infection preventionist and pharmacy consultant confirmed that storing medications at this temperature could compromise their efficacy and safety. Facility policies reviewed by surveyors required proper labeling, storage, and timely disposal of medications, as well as maintenance of appropriate refrigerator temperatures, but these were not followed in the instances observed.
Improper Food Storage, Labeling, and Use of Dented Cans
Penalty
Summary
Surveyors observed multiple failures in food storage and labeling practices within the facility's kitchen and storage areas. In the freezer, several opened food items, including garlic bread, pork sausage links, and fish fillets, were found without labels indicating the open and use by dates. Similarly, in the walk-in refrigerator, opened containers of mustard and honey mustard dressing were not labeled with open or use by dates. In the dry storage room, items such as corn meal and cake mix were found with lapsed use by dates, while soy sauce and a white powder were missing open and use by date labels, with the latter also having an unreadable name label. Additionally, four dented cans containing various food products were stored alongside non-dented cans, and one dented can of tomato soup was observed being prepared for use. Interviews with the Dietary Manager, kitchen staff, and the Registered Dietician confirmed awareness of the facility's policies requiring proper labeling and removal of expired or damaged food items. Staff acknowledged that perishable foods should be labeled with the product name, open date, and use by date, and that dented cans should not be used due to safety concerns. The facility's own policies and FDA Food Code guidelines were reviewed, supporting the need for these practices to prevent foodborne illness. The observed failures in labeling, storage, and handling of food items had the potential to compromise food safety for the facility's residents.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several observed deficiencies. Personal belongings of residents, such as rings, phone chargers, hearing aids, compact discs, eyeglasses, and keys, were found stored in medication carts alongside pharmaceutical products, including controlled medications. Multiple licensed nurses confirmed the storage of these items in the medication carts, stating it was done to keep the items safe. The Infection Preventionist did not initially recognize this as an issue, but the Pharmacy Consultant and Director of Nursing both acknowledged that storing personal items with medications could lead to cross-contamination and was not in line with facility policy. In another instance, two certified nursing assistants provided direct care, specifically bed baths, to a resident with a history of multidrug-resistant organism infection and an unhealed stage 4 pressure ulcer, without wearing the required personal protective equipment (PPE) gowns. Both CNAs acknowledged that enhanced barrier precautions, including gowns, should have been used due to the resident's condition and the presence of a feeding tube and wound. The care plan and facility policy confirmed the need for PPE during high-contact care activities for residents on enhanced barrier precautions. The Director of Nursing and Infection Preventionist both confirmed that the expectation was for staff to wear gowns, masks, and gloves in these situations. Additionally, a nurse practitioner was observed not wearing a facemask in a hallway, despite the facility's active respiratory infection precautions and a directive from the Director of Nursing that all employees must wear masks. The nurse practitioner acknowledged the requirement. Facility policy also indicated that appropriate PPE, including masks, should be used to decrease the risk of transmission during respiratory infection outbreaks.
Failure to Ensure Accessible and Functional Call Light Systems
Penalty
Summary
The facility failed to ensure that the call light system was accessible and functional for five out of 29 sampled residents. In two cases, residents with severe cognitive impairment and significant physical dependencies were found in their rooms with their call light buttons on the floor and out of reach. Staff confirmed that the call light buttons should have been within reach, as documented in the residents' care plans and the facility's policies. Both residents required substantial or maximal assistance with daily activities and were unable to access the call system independently. Another resident, also with severe cognitive impairment and high dependency for daily care, was observed with a broken call light system. The call light wire was on the floor and the button was missing, rendering the system nonfunctional. Staff acknowledged the issue and stated that the resident was capable of using a call light if it were available and working. The DON confirmed that the expectation was for all residents to have a functional call light system. Additionally, two residents did not have an available bathroom call system. The facility's policies require that call lights be accessible to residents in their rooms and that staff ensure the system is within reach and functional. These failures were identified through observation, interview, and record review, and were not in accordance with the facility's own procedures for accommodating residents' needs and ensuring timely response to requests for assistance.
Failure to Initiate Baseline Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who was admitted with a peripherally inserted central catheter (PICC) line for intravenous antibiotic administration. Upon review, it was found that the resident was admitted with a diagnosis of septic arthritis of the right knee and required IV Vancomycin via the PICC line. Despite these needs, there was no care plan in place addressing the care and management of the PICC line following admission. The Director of Nursing confirmed during interview and record review that the resident did not have a care plan for the PICC line, despite facility policy requiring a baseline care plan to be developed and implemented for each resident to ensure effective and person-centered care. The lack of a care plan for the PICC line was verified by both documentation review and staff interview.
Failure to Consistently Provide Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that physician orders for wound care treatments were consistently followed for one resident with multiple complex medical conditions, including morbid obesity, venous insufficiency, and immunodeficiency. Review of the Treatment Administration Records (TAR) for February and March 2025 revealed that several wound care treatments, as ordered by the physician, were not administered on specific days and shifts. The Assistant Director of Nursing confirmed that these treatments were missed and acknowledged that it was the responsibility of the licensed nurse to perform and document the treatments as ordered. The resident's care plan, initiated in early February 2025, specified that wound care should be provided per treatment orders, and the facility's job descriptions and policies required licensed nurses to perform wound treatments according to physician orders. Despite these requirements, documentation showed that wound care was not provided as ordered on at least three occasions. The facility's policies also emphasized the need for qualified staff to deliver care in accordance with professional standards and individualized care plans, but these standards were not met in this instance.
Failure to Apply Ordered Contracture Device to Resident's Hand
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands did not have the ordered contracture device applied to the right hand on multiple occasions. Observations in the resident's room revealed that the contracture device was consistently missing from the right hand, despite care plan and occupational therapy orders specifying that devices should be worn on both hands 24 hours a day. Certified Nursing Assistants, a Licensed Nurse, and a Restorative Nursing Assistant all confirmed during interviews that the device was not in place and acknowledged the expectation for the device to be applied as ordered. Record reviews showed that the resident's care plan and occupational therapy evaluation required continuous use of contracture devices for both hands. Facility leadership, including the Assistant Director of Rehabilitation, Director of Nursing, and Director of Staff Development, confirmed that staff are expected to follow these orders and care plans. The facility's policy also indicated the importance of maintaining or improving residents' abilities through restorative nursing programs, including the use of splints or braces. The failure to implement the ordered contracture device for the resident's right hand constituted the deficiency.
Delayed STAT Urinalysis Collection and Processing for Resident with Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, urinary tract infection (UTI), sepsis, and ESBL resistance exhibited a change in mental status and increased urinary frequency. The resident, who was always incontinent of bowel and bladder and had severely impaired cognition, was observed to be more confused than baseline. A certified nurse assistant notified a licensed nurse, who assessed the resident and contacted the nurse practitioner. A STAT urinalysis (UA) was ordered to rule out a possible UTI, with instructions to collect a urine sample immediately and use straight catheterization if necessary. Despite the STAT order, the urine sample was not collected and picked up in a timely manner. Progress notes indicated that the lab was notified and the order was faxed, but the specimen was not collected until two days later. The laboratory manager confirmed that STAT orders are typically processed within four hours, but in this case, the specimen was only collected and picked up several days after the order was placed. During this period, the resident's confusion worsened, and the resident was eventually sent to an acute hospital for further evaluation due to the deteriorating condition. The facility's agreement with the laboratory service provider required prompt handling of STAT orders, and facility policy mandated timely provision of laboratory services. However, the delay in collecting and processing the urine sample resulted in a failure to provide adequate services for the prevention and early detection of a possible UTI, as evidenced by the abnormal findings in the urinalysis once it was finally completed.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
Staff failed to follow a physician's order for oxygen therapy for one resident with multiple respiratory diagnoses, including respiratory failure, congestive heart failure, and asthma. The resident was admitted in March 2025 and had an intact cognitive status. The physician's order specified oxygen administration at 2-3 liters per minute (LPM) every shift. However, during multiple observations on consecutive days, the resident was found receiving oxygen at 5 LPM via nasal cannula. Both a CNA and a licensed nurse confirmed the oxygen was set at 5 LPM during their respective interviews and observations. The resident's care plan intervention directed staff to administer oxygen as prescribed or per standing order. The facility's policy on oxygen administration required that oxygen be given according to physician orders. The DON confirmed that oxygen should always be administered within the parameters of the doctor's order and acknowledged the potential for negative effects if higher levels are given. Despite these policies and orders, staff did not adjust the oxygen flow to the prescribed rate, resulting in a failure to provide safe and appropriate respiratory care as required.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act upon irregularities reported by the consultant pharmacist for one resident. The pharmacist conducted a monthly medication regimen review and made specific recommendations regarding the administration of an anti-acid medication, a breathing medication, and PRN pain medications. These recommendations included administering the anti-acid medication on an empty stomach, adding 'shake well before each spray' to the breathing medication order, and including a directive to use non-pharmacological interventions before administering PRN pain medications. There was no documentation that these recommendations were implemented in the resident's medical orders or records. The Assistant Director of Nursing confirmed during an interview and record review that the pharmacist's recommendations had not been carried out and acknowledged that they should have been completed. The facility's policy and procedure required staff to act upon all recommendations from the medication regimen review, but this was not followed for the resident in question, who had multiple diagnoses including heart failure, depression, anxiety disorder, and myalgia, and was noted to have intact cognition.
Failure to Label and Date Food Brought in by Families or Visitors
Penalty
Summary
The facility failed to ensure safe and sanitary practices for food brought in by family or visitors for residents. During observations, it was found that food items stored in the resident refrigerator, such as cooked noodles, wild berry jam, and a juice drink, were not labeled with the resident's name, date received, or use-by date. Both the Dietary Manager and a Licensed Nurse confirmed that facility policy and posted signage require all food items brought from outside to be labeled with the resident's name, date received, and a use-by date, and that unlabeled food should be discarded after three days. However, these procedures were not followed, as evidenced by the presence of multiple unlabeled food items for 25 sampled residents. Interviews with staff, including the DON, further confirmed that the expectation is for all food brought in from outside to be labeled and dated to ensure safety and compliance with dietary orders. The facility's written policy also specifies that prepared food must be approved by nursing, labeled, and consumed within three days, with any unconsumed food to be discarded. Despite these clear policies and reminders, the failure to label and date food items brought in by families or visitors resulted in noncompliance with safe food storage practices.
Failure to Follow Prescribed Physical Therapy Frequency
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for a resident. The resident, who was admitted in May 2024, had diagnoses including polyosteoarthritis, fusion of the spine, and chronic pain syndrome. The resident's Minimum Data Set (MDS) indicated a need for partial/moderate assistance with lower body dressing and supervision or touching assistance with transfers and walking. Despite the resident's need for physical therapy (PT) to improve leg functions, the prescribed frequency of therapy sessions was not followed. The resident was supposed to receive therapy five times a week for two certification periods, but several sessions were missed, and the frequency was not adhered to. Interviews with the Physical Therapist Assistant (PTA) and the Director of Nursing (DON) confirmed that the therapy frequency was not followed, which could risk the resident's condition not improving. The facility's policy and procedure for inpatient rehabilitation services emphasized the importance of following the individualized plan of care, including the frequency and duration of treatment. However, the facility did not adhere to these guidelines, as evidenced by the missed therapy sessions and the lack of documentation for any resident refusals. This oversight had the potential to lead to a decline in the resident's range of motion or mobility.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration for Resident 1, as medications were left unattended at the bedside. Resident 1, who was admitted in 2024 with diagnoses of anxiety and chronic pain syndrome, had a care plan that emphasized the need for increased communication about care and medications. However, during an observation, a medication cup labeled with Resident 1's room number was found open and unattended on a food tray, containing approximately nine pills of different colors and sizes. This incident was confirmed by the Director of Nursing (DON) and Licensed Nurse 1 (LN 1), who acknowledged the safety concern of leaving medications unattended. The facility's policies and procedures require that medications be administered within one hour of their prescribed time and that self-administration of drugs is only permitted when approved by the attending physician and interdisciplinary team assessment. However, there was no documented evidence of an interdisciplinary team assessment or a care plan for Resident 1's ability to self-administer medications. Additionally, there were no active physician orders allowing Resident 1 to self-administer medications. The DON confirmed that the self-administration assessment was incomplete, and both the Administrator and DON recognized the safety hazard posed by leaving medications at the bedside.
Resident Abuse Incident Involving Cane
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them with a cane. The incident involved two residents, one of whom was admitted with multiple diagnoses including paraplegia, a Stage 4 pressure ulcer, diabetes, and dementia, and had a moderate cognitive impairment. The other resident, who was cognitively intact, had diagnoses including hemiplegia and hemiparesis following a stroke. The altercation occurred when the second resident hit the first resident on the leg with a cane, resulting in injury and pain. The incident was reported by a CNA who witnessed the event and noted that the first resident had called the second resident a racial slur, which upset the second resident. The CNA reported the incident to a licensed nurse, who conducted a body assessment and noted skin discoloration on the first resident's right lower leg. The interdisciplinary team met to discuss the incident, and the Director of Nursing was informed. The first resident reported severe pain and required pain medication following the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents from abuse and the implementation of procedures to prevent such incidents. The policy defines abuse as the willful infliction of injury resulting in physical harm or mental anguish. Despite these policies, the facility failed to prevent the physical abuse of the resident, as evidenced by the altercation and resulting injury.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of abuse in accordance with section 1150B of the Act. This deficiency involved a resident who alleged that a female staff member grabbed him firmly on the right arm. The resident, who had diagnoses including parkinsonism, care provider dependency, weakness, and depression, reported the incident to his daughter, who then informed the nursing staff. Despite the report, the facility did not initiate the abuse allegation reporting process in a timely manner. The resident's clinical records indicated that he had an intact cognition and required partial assistance with daily activities. An assessment on the day of the incident noted erythema and warmth on the resident's right forearm and wrist, with episodic pain. An x-ray confirmed a fracture in the resident's wrist. The Assistant Director of Nursing acknowledged that the abuse allegation was not reported to the state survey agency within the required timeframe, which delayed the investigation. The facility's policy required immediate reporting of such allegations, but this was not adhered to, resulting in a delayed response to the resident's complaint.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to hire a Director of Food and Nutrition Services with the required qualifications. During an initial kitchen tour, it was observed that there was no certificate or degree in the Food and Nutrition Services office. The Dietary Manager (DM) admitted that she had been working in her role for the past year without completing the process to become a Certified Dietary Manager or receiving the required six hours of Title 22 instruction. This deficiency was further confirmed during an interview with the Consultant Registered Dietitian (CRD), who stated that her role did not include hiring or supervising dietary staff and that her involvement in the kitchen was limited to monthly audits, test trays, and occasional in-services for dietary staff. The job description for the Registered Dietitian indicated that the CRD's responsibilities were not supervisory. The facility's provided Director of Food and Nutrition Services Department documentation stated that the director must meet state requirements. According to the State of California - Health and Safety Code 1265.4, the dietetic services supervisor must meet specific educational requirements, none of which were met by the current DM. This failure to employ a qualified Director of Food and Nutrition Services had the potential to lead to foodborne illness for the 124 residents eating facility-prepared meals.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an initial kitchen tour, several items were observed without proper labeling, including containers of graham crackers, whipped toppings, butterscotch pudding, cabbage, croissants, spaghetti noodles, and vegetable burgers. The Dietary Manager confirmed that these items did not have the proper labels and acknowledged that improper labeling could lead to foodborne illnesses. Additionally, expired foods such as cake mix, ground cloves, and thyme leaves were found in the dry food storage area, which the Dietary Manager also confirmed could lead to foodborne illnesses. Perishable salads, including egg and tuna salad, were found to be stored at unsafe temperatures above the recommended 41 degrees Fahrenheit. The Registered Dietitian verified these temperatures and suggested that they might be due to food delivery issues. The facility's policies and procedures clearly state that perishable foods should be held at a temperature of 41 degrees Fahrenheit or less to prevent foodborne illnesses. Furthermore, several food items were found uncovered or improperly stored, including an opened bag of cake mix, an unlabeled container of bacon, and open boxes of pork and fish patties with ice crystals and freezer burn. Additional observations revealed an ice buildup in the walk-in freezer, which the Maintenance Supervisor attributed to the door not being closed tightly. Cutting boards with debris and a rusted can opener with a missing metal tip were also found, both of which could lead to contamination. The facility's policies emphasize the importance of cleaning and sanitizing equipment to prevent contamination, but these practices were not followed, as confirmed by the Dietary Manager. These failures collectively had the potential to lead to foodborne illnesses among the 124 residents who received facility-prepared foods.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that three residents were assisted with nail care as part of their Activities of Daily Living (ADLs). Resident 91, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed with long fingernails and a blackish substance underneath them. Certified Nurse Assistant (CNA) 1 confirmed the condition of Resident 91's nails and acknowledged that the blackish substance could cause an infection. There was no documentation indicating that Resident 91 had refused ADL care, including nail care, in the clinical records or progress notes. Resident 4, who had intact cognition but required moderate assistance with personal hygiene, was also observed with long fingernails and a brownish substance underneath them. Resident 4 expressed a desire to have his nails trimmed and cleaned. CNA 1 confirmed the condition of Resident 4's nails, and the clinical records showed no documented refusals of ADL care. Additionally, the SKIN INTEGRITY/SHOWER SHEET indicated that Resident 4's nails were not clipped on a recent date, despite being signed off by the Licensed Nurse (LN) on duty. Resident 46, who was dependent on assistance for personal hygiene and had severe cognitive impairment, was observed with jagged fingernails with sharp edges and a blackish substance underneath them. LN 1 confirmed the condition of Resident 46's nails and stated that the sharp edges could cause skin injury and the blackish substance could be an infection control issue. The clinical records for Resident 46 also showed no documented refusals of ADL care, and the SKIN INTEGRITY/SHOWER SHEET indicated that Resident 46's nails were not clipped on a recent date, despite being signed off by the LN on duty. The Infection Preventionist and the Director of Nursing both emphasized the importance of maintaining clean fingernails for infection control and hygiene.
Inaccurate Signing of Controlled Drug Record Forms
Penalty
Summary
The facility failed to ensure that pharmacy services were maintained when controlled drug record forms were inaccurately signed for a census of 126 residents. During a review of the controlled drug record forms for five discharged residents, it was found that the nurse who received the controlled medications signed the section indicating 'Doses discharged with Patient' instead of the correct section. This error suggested that the controlled drugs were given to the residents at discharge, which was not the case as the controlled drugs are supposed to be destroyed by the nurse. The Director of Nursing (DON) verified this discrepancy during an observation and interview, acknowledging that the incorrect signing could result in the diversion of controlled drugs. The facility's policy titled 'Controlled Substance Administration and Accountability' dated 12/19/22, requires that the entire amount of controlled substances obtained or dispensed is accounted for, and that two licensed staff must witness any disposal or destruction of a controlled substance and document it on the Drug Disposition Record. The policy also mandates that any discrepancies which cannot be resolved must be reported immediately. The failure to adhere to this policy was evident in the inaccurate signing of the controlled drug record forms, which had the potential to result in the diversion of the residents' medication.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled correctly, leading to several deficiencies. Loose pills were found in the South wing medication cart, and opened vials and a bottle of perishable medications in the North wing medication room were not dated with open or expiration dates. Additionally, packets of medicated powder in the North wing treatment cart did not have expiration dates, and an opened inhaler and glucose strips in the North wing medication cart were not dated. Expired and discontinued medications were also found in the North wing medication cart, and a bag containing medications for a resident was found in the nursing office closet, which was not temperature controlled. Prescription eye ointment was found in a resident's room at the bedside without an open date. During the inspection, Licensed Nurses (LNs) verified the presence of loose pills, undated vials, and expired medications. The Director of Nursing (DON) acknowledged these issues during interviews. The facility's policies on labeling and storing medications were reviewed, indicating that all medications and biologicals should be labeled according to federal and state requirements and stored under proper temperature controls. The policies also specified that multi-use vials must include the date they were initially opened and that expired or discontinued medications should be destroyed according to facility policy. The deficiencies observed had the potential for medication misuse, drug diversion, and diminished medication effectiveness. The facility's failure to adhere to its policies on medication labeling and storage was evident in multiple instances, including loose pills in medication carts, undated and expired medications, and improper storage of medications. These actions and inactions by the facility staff led to the identified deficiencies, posing risks to resident safety and care quality.
Failure to Prepare and Serve Nutritious and Safe Food
Penalty
Summary
The facility failed to prepare and serve food that conserved nutritive value, flavor, and appearance, and served food at unappetizing temperatures. During an initial kitchen tour, it was observed that vegetables were being heated for over two hours, which can lead to nutrient loss. Additionally, pureed meals were prepared without measuring ingredients, and pureed food was prepared in a dirty food processor bowl. These actions were observed during multiple visits to the kitchen, where it was noted that the cook did not follow the facility's recipes and used unmeasured amounts of ingredients, including water instead of broth or milk, which diluted the flavor and nutrition of the food. A test tray confirmed that the pureed tortellini was bland compared to the regular product. The food processor bowl used for pureeing was also found to be dirty, with a tan residue from previous use, posing a risk to residents with sensitivities such as gluten intolerance. During interviews with the Consultant Registered Dietitian (CRD) and Dietary Manager (DM), it was confirmed that the food processor bowl should have been cleaned before preparing another recipe to avoid cross-contamination. The CRD also stated that broth or milk should be added to pureed foods to maintain flavor and nutrition, and adding water could dilute these qualities. The facility's provided recipes and critical control points for food safety were not followed, leading to the potential for poor intake, malnutrition, and weight loss among the 124 residents eating facility-prepared meals.
Failure to Accommodate Food Allergies and Preferences
Penalty
Summary
The facility failed to accommodate food allergies and preferences for six residents, leading to potential health risks. Resident 100, who had a preference for ice cream, was given cake instead, and often did not receive coffee with meals. Resident 26, with a sensitive stomach and a preference to avoid garlic, received food containing garlic and was not allowed to have sausage, which she liked. Resident 34, who disliked carrots and salads, was served green beans for 12 consecutive meals and complained about the food being too salty. The cook was observed adding unmeasured amounts of salt to food, and the dietary manager was unaware of this practice. Resident 57, on a consistent carbohydrate diet, reported receiving less desirable options and frequently being served chicken tenders, which she disliked. Resident 97 mentioned that alternative items were not always available and that the soup was often watery. Resident 89, with a seafood allergy, received shrimp and tuna fish on her meal trays despite a warning sign behind her bed. She also reported that hot food was often served cold or lukewarm. A test tray confirmed that the food temperature was below the acceptable level. The facility's policy and procedure indicated that resident preferences should be documented and reviewed when planning menus, and that the resident council should be included in menu planning. However, the CRD and DM did not attend resident council meetings, believing they were not allowed to. Resident council notes highlighted ongoing issues with food quality, diet adherence, and meal timing, indicating that the facility was not meeting its own standards for accommodating resident preferences and dietary needs.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program for a census of 126 residents. A clean-linen delivery cart and two clean linen storage shelves were found with thick layers of dust in the laundry room. The laundry staff confirmed that there was no log for cleaning the cart, and the Maintenance Supervisor acknowledged that there was no schedule for cleaning the carts. The Infection Preventionist and the Director of Nursing both stated that dirty linen carts and storage shelves could transfer dirt or germs to clean linen, potentially spreading infections to residents. Resident 27's nasal cannula was not labeled with the date it was first used, which is necessary to ensure it is changed every 7 days to prevent infection. Licensed Nurse 8 confirmed the missing label and stated that the nasal cannula should be changed weekly. The Director of Nursing reiterated that staff should label the nasal cannula with the date it was changed to prevent infection control issues. Resident 682 had an empty IV medication bag and IV tubing that were not labeled with the date and nurse's initials. The Assistant Director of Nursing confirmed the missing labels and stated that without knowing when the tubing was last changed, it should not be reused due to infection control concerns. Similarly, Resident 131's IV tubing was not labeled with the date, time, and nurse's initials, as confirmed by Licensed Nurse 11 and the Assistant Director of Nursing. Lastly, Resident 19's urinary catheter drainage bag was found touching the floor, which the Assistant Director of Nursing and the Director of Nursing confirmed could cause an infection. The facility's policies and procedures were not followed in these instances, leading to potential risks of infection and cross-contamination among residents.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment, specifically the ice machine and oven, were in safe operating conditions. During an initial kitchen tour, the Maintenance Supervisor revealed that the ice machine had issues with randomly shutting off. Additionally, the right side of the oven was found to be non-functional. On a subsequent visit, the ice machine was again not working, preventing the use of the ice bath method for thermometer calibration. Furthermore, meal preparation and timing had to be adjusted due to the malfunctioning oven. These deficiencies were observed and reported by the survey team, highlighting the facility's failure to maintain equipment in good repair as required by the US Food and Drug Administration's 2022 Food Code section 4-501.11.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the right for privacy and dignity for Resident 33, who had severe memory impairment and was totally dependent on staff for all activities of daily living. During an observation, two staff members provided care to Resident 33 with the door open and privacy curtains not pulled, exposing the resident's lower body to the hallway. This lack of privacy was confirmed by the Medical Record Assistant and the Director of Nursing, who both acknowledged that dignity and privacy should always be maintained during resident care. Licensed Nurse 12, who was involved in the care, admitted to not pulling the curtain or closing the door, stating it was an oversight. The facility's policies on patient privacy and provision of quality care, which were reviewed, clearly indicated that residents should be clothed or appropriately draped during care to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to these policies resulted in a deficiency in maintaining Resident 33's dignity and privacy.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, Resident 588 and Resident 28, by not ensuring their call lights were accessible. Resident 588, who had moderate cognitive abilities and required partial assistance with ADLs, was observed on multiple occasions with the call light on the floor and out of reach. Despite the care plan indicating that the call light should be within reach, staff did not comply, resulting in Resident 588 being unable to call for help when needed. This was confirmed by both the CNA and the MDS Coordinator during their observations and interviews. Resident 28, who had moderate cognitive abilities and was dependent on ADLs, was also not provided with an appropriate call light type. Despite having hand contractures and being unable to use the standard call light, no alternative call light system was provided. This was confirmed by the MDS Coordinator and CNA, who acknowledged that Resident 28 was unable to use the call light due to his condition. The facility's policy indicated that special accommodations should be made for residents with unique needs, but this was not done for Resident 28.
Failure to Complete Comprehensive Assessment for Resident
Penalty
Summary
The facility failed to ensure a comprehensive assessment was performed in accordance with the regulatory time frame for one of the sampled residents, Resident 681. Resident 681 was admitted in late 2018 with diagnoses including stroke, muscle weakness, malnutrition, and difficulty swallowing. The admission MDS for Resident 681 was not completed, as verified by multiple staff members, including Licensed Nurse 11, the MDS Coordinator, and the MDS Director. The MDS was due on March 5, 2024, but remained incomplete and overdue as of March 21, 2024. During observations and interviews, Resident 681 was found to be alert and verbal but minimally responsive, expressing a desire to go back to sleep and later stating relief at surviving the previous day. The MDS Director confirmed that the interdisciplinary team assessment, which is crucial for creating an individualized care plan, was delayed due to pending input from social services. The Resident Assessment Instrument (RAI) process, which ensures residents receive the highest quality of care, was not followed as required, leading to the deficiency.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) for two residents within 48 hours of their admission, as required. Resident 681, admitted with diagnoses including stroke, muscle weakness, malnutrition, and difficulty swallowing, had an incomplete BCP dated 3/15/24, with missing assessments in the Dietary/Nutritional Status and Social Services sections. Observations and interviews revealed that Resident 681 was minimally responsive and had not received a complete assessment, which was confirmed by the MDS Coordinator and Licensed Nurse 11. The MDS for Resident 681 was also incomplete and overdue. Similarly, Resident 6, admitted with diagnoses including hip joint surgery aftercare, left artificial knee joint and infection, anxiety, depression, and need for continuous supervision, had an incomplete BCP dated 3/4/24. The Social Services section was not completed, and the limb prosthesis was not checked. Observations and interviews indicated that Resident 6 had experienced an unwitnessed fall and expressed dissatisfaction with the food quality. The MDSD and DON confirmed the incomplete BCP and acknowledged the failure to meet the 48-hour requirement for completing the BCP.
Failure to Follow Restorative Nursing Program Frequencies
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for two residents. Resident 107, who was admitted with multiple fractures and muscle weakness, did not receive the prescribed restorative nursing program (RNA) exercises three times a week as required. Despite the care plan indicating specific exercises and frequencies, the resident only received exercises on a few occasions over a 30-day period. Both the Director of Rehabilitation (DOR) and the Minimum Data Set Coordinator (MDSC) confirmed the discrepancy and acknowledged that the RNA program frequency was not followed, which could potentially result in muscle weakness and decline in mobility for Resident 107. Similarly, Resident 44, who had diagnoses including paraplegia and a malignant neoplasm of the frontal lobe, also did not receive the prescribed RNA exercises three times a week. The resident reported not having her standing-up therapy exercises for about three weeks. The care plan specified that the resident should have sit-to-stand exercises with maximum assistance three times a week. However, the resident only received these exercises on a few occasions over a 30-day period. The DOR confirmed the inconsistency, and the Restorative Nursing Aide (RNA) noted that there were often not enough staff available to perform the exercises as required. The Director of Nursing (DON) emphasized the importance of following the RNA program frequency to prevent a decline in function. The facility's policy on the Restorative Nursing Program also indicated that the frequency of activities should be documented and followed. The failure to adhere to the prescribed RNA program frequencies for both residents had the potential to impair their mobility and result in a decline in their range of motion.
Failure to Maintain Safe Environment in Smoking Area
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for one of 43 sampled residents, specifically Resident 57, due to an uneven pathway leading to, from, and inside the designated smoking area. Resident 57, who has diagnoses of Spinal Stenosis, abnormalities of gait and mobility, and Major Depressive Disorder, reported feeling unsafe navigating the pathway in her wheelchair. She had previously reported her concerns to the Activities Director (AD) a few months prior to the survey. The AD acknowledged awareness of the cracks but was not aware of any plans to repair them, confirming that the cracks could cause accidents and injuries. The Maintenance Supervisor (MS) was initially unaware of the cracks but confirmed the need for repairs upon reviewing photos and conducting an observation. The Director of Nursing (DON) also agreed that the uneven sidewalks and cracked concrete posed a safety concern. The facility's Smoking Agreement and policies on Resident Smoking and Accidents and Supervision emphasized the importance of maintaining a safe environment for residents, which was not upheld in this instance.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for Resident 18, whose physician's order for oxygen therapy was not followed. Resident 18, who had diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and dementia, was observed using an oxygen concentrator set at 5 liters per minute (LPM) instead of the prescribed 2 LPM. The Assistant Director of Nursing (ADON) confirmed this observation. A review of Resident 18's clinical records indicated no documentation that the oxygen was titrated to maintain oxygen saturation greater or equal to 90%, as required by the physician's order. Licensed Nurse (LN) 9 confirmed the absence of such documentation and stated that the physician's orders should always be followed. The Director of Nursing (DON) acknowledged that the physician's order for oxygen therapy should have been followed and that any changes in oxygen settings should be thoroughly documented and assessed. The facility's policy and procedures for oxygen administration also emphasized the importance of adhering to physician's orders and documenting any changes in the resident's condition. The failure to follow the physician's order for oxygen therapy had the potential to result in unsafe delivery of oxygen to Resident 18, which could lead to respiratory problems.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 753 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitney Oaks Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Eskaton Village Care Center | 0.6 mi | ★★★★★ | 13 | 0 |
| American River Center | 1.1 mi | ★★★★★ | 11 | 0 |
| College Oak Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 14 | 1 |
| Mountain Manor Senior Residence | 2.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.