Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Park Post-acute during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications. The DON and MDSC reviewed records for several residents with dementia, schizophrenia, depression, anxiety, bipolar disorder, and other conditions who were prescribed psychotropic or related medications such as olanzapine, mirtazapine, buspirone, fluoxetine, risperidone, lorazepam, donepezil, and memantine. Multiple consent forms were missing required details such as dosage, frequency, benefits, side effects, alternative treatments, and physician signatures, and some residents had no informed consent on file.
A facility failed to keep call lights within reach for six residents. One resident with dementia, seizures, and anxiety had the call light and bed remote on the floor, another resident with discitis, UTI, DM2, and cervical radiculopathy had the call light by a lower leg, and a resident with quadriplegia had no call light at all. Other residents with falls risk, a fractured humerus and Parkinson’s disease, and a fractured tibia were also observed with call lights positioned out of reach or hidden from view, and staff confirmed the devices were not accessible.
Homelike Environment Not Maintained: A bowel movement was observed in a hallway with a noticeable odor, a resident room had broken blinds and missing floor tiles, another resident's dresser was broken, and staff personal belongings were stored in a resident's room. Staff and leadership confirmed the conditions were not consistent with the facility's homelike environment expectations.
Inaccurate MDS coding affected three residents. One resident receiving dialysis three times weekly was coded as not receiving dialysis, another resident with chronic right upper extremity contractures and daily Tylenol was coded as having no upper-extremity impairment and no pain medication use, and a third resident observed on O2 via NC with active oxygen and hospice orders was coded as not receiving those services. The MDSC confirmed the coding errors.
PASRR screening was not completed accurately for two residents. One resident with autism and a developmental disorder had both Level I screens marked “No” for ID/DD/related condition, so no Level II evaluation occurred. Another resident with schizophrenia had a Level I screen indicating Level II was needed, but the state agency closed the evaluation after facility staff did not respond to communication attempts, and the DON and MDSC confirmed the evaluation was not scheduled.
Respiratory Tubing Not Properly Dated or Stored: Four residents receiving O2 or nebulizer therapy were observed with tubing that was undated, not stored in a protective bag, or lying on the floor. One resident had NC O2 at 4 L/min with no storage bag available, another had NC tubing dated but no bag, a third had O2 tubing on the floor and undated, and a fourth had unlabeled nebulizer tubing not stored in a protective bag. The DON and LPN confirmed the facility’s infection prevention expectations for labeling and storage of respiratory tubing.
The facility failed to store and handle kitchen items per safety standards when two worn pans were kept in the food prep area and a rusted paint scraper was stored with clean utensils in a drawer. The CDM verified both conditions during the kitchen tour, and the RD stated the worn pans and rusted scraper created cross-contamination concerns for food prepared by kitchen staff.
Unlabeled perishable food was found on a resident’s bedside table, and staff confirmed it had been brought in by family without the required name or date labeling. In separate rooms, two residents had EBP facility markers next to their room labels, but no EBP signage was posted at the doors. An LN, the IP, the DSD, and the DON all confirmed the missing signage and stated it was needed to alert staff and visitors and guide PPE use.
A CNA addressed a resident as "Honey" multiple times while providing bedside care instead of using the resident’s preferred name. The resident stated she did not like being called Honey and wanted to be called by her name. The CNA acknowledged the mistake, and the DON stated that addressing residents by their preferred names is necessary to preserve dignity.
Late Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments for two residents within the required timeframe. One resident’s annual assessment remained in progress and was overdue due to staffing difficulties, and another resident’s admission assessment remained in progress while the facility waited for a hospice CTI that had not been documented as requested. The MDSC stated the delays affected the development of the residents’ comprehensive care plans, including ADLs, cognition, mood and behaviors, medication, skin care, activity preferences, and discharge goals.
A facility failed to keep resident areas free from accident hazards. A resident at high fall risk had a regular mattress stored upright in the room and used as a fall mat, which the LN, IP, RHD, and DON all identified as unsafe. Another resident with HF and vascular dementia had a physician order for fall mats on both sides of the bed, but staff only had one mat in place and the care plan did not reflect the ordered intervention. In a third room, a metal strip protruded from the wall at knee height near a resident’s bed and bathroom door; staff confirmed it had caught clothing and had not been entered into the maintenance log.
A resident with hemiplegia, reduced mobility, and severe cognitive impairment had both half side rails raised, but the RNA stated the resident was totally dependent for bed mobility and could not use the rails. The side rail screening tool was inaccurate because it listed reasons for rail use that the resident could not perform, and the resident had no physician order for side rails, which the LN and DON stated was required.
A resident with anxiety disorder and PTSD had a PRN alprazolam order that lacked a stop date. The DON confirmed the order was not appropriate because PRN meds needed a stop date for reassessment, and the PC stated PRN psychotropic orders should generally be limited to 14 days unless the provider documents a rationale for extended use. The facility policy also stated PRN psychotropic orders are limited to 14 days.
Medication cart 4 had storage and labeling deficiencies when an LPN found three insulin pens and one insulin vial without open dates and loose, unidentifiable pills in medication drawers. The LPN confirmed the missing open dates and the presence of the pills, and the DON stated insulin pens and vials were expected to have open dates so staff would know when to discard them. Facility policy required medications to remain in their original packaging or dispensing system and to be properly labeled.
A resident with severe dementia, documented wandering risk, and an active wander guard order eloped during the night through an unalarmed and unlocked laundry exit door located outside the main patient care area. The resident’s care plan identified elopement risk and called for frequent checks, redirection, and use of a wander guard, but on the night of the incident the resident was left in an activities room under CNA supervision while the assigned nurse assisted an x-ray technician and then went on break. No door alarms sounded, and staff discovered the resident missing only after the roommate inquired about her whereabouts. Police later located the resident in a nearby private home, and EMS transported the resident to a hospital, where an acute NSTEMI and acute altered mental status were diagnosed.
A resident was issued a 30-Day Notice of Discharge/Eviction for denial of payment while a Medi-Cal application was still pending, despite facility staff being aware of the pending status and regulations prohibiting discharge under these circumstances. Staff interviews and documentation confirmed the facility's knowledge of the application, and the resident's right to remain was not upheld.
A resident with diabetes experienced severe hypoglycemia and seizures due to the facility's failure to monitor blood glucose levels and manage her diabetic condition properly. The resident's insulin regimen was changed without ensuring BG monitoring orders were in place, leading to a critically low blood sugar level and hospitalization.
The facility failed to maintain food safety and sanitation standards, with issues such as a dietary aide not wearing a hairnet, wet nesting of glasses and containers, expired yogurt available for consumption, and improper dishwasher sanitization. Additionally, dust and debris were found in utensil drawers and on kitchen surfaces, and dented cans were stored improperly, posing risks to resident safety.
A resident in an LTC facility received a lower dose of Lorazepam than prescribed, resulting in significant medication errors. The resident was supposed to receive 1 mg every six hours, but instead received 0.5 mg on multiple occasions, which was incorrectly documented as the full dose. The DON confirmed the error, and the facility's medication administration policies were not followed.
The facility failed to document COVID-19 vaccination education for several residents, as confirmed by the Infection Preventionist and the DON. The facility's policy requires education on vaccine benefits, risks, and side effects before offering it, but this was not documented in the residents' medical records.
The facility failed to ensure safe insulin use for two residents with diabetes. One resident's insulin order lacked parameters for high blood sugar, and frequent high readings were not addressed or reported to the MD. Another resident's insulin use was not monitored by blood sugar measurements. Facility policies on diabetes management were not followed, and staff interviews revealed a lack of awareness and action regarding these issues.
The facility failed to maintain a homelike environment for two residents. One resident had a black rubber strip in her room, posing a tripping hazard, while another had broken blinds. The strip was installed due to broken tiles and had been in place for over a year, with staff acknowledging it as a hazard. The blinds were missing a section, and the resident expressed a desire for replacement. Facility policies emphasize maintaining a dignified and orderly environment, which was not upheld.
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, a medication cart contained an outdated Lantus insulin pen, and at the North station, a treatment cart stored an opened bottle of Sterile Sodium Chloride intended for single use. These lapses were acknowledged by the nursing staff and the Director of Nursing.
The facility failed to document education for immunizations for two residents. One resident's Influenza vaccination record lacked documentation of education, and another resident's records for both Influenza and Pneumococcal vaccines were missing education documentation. The facility's policies require that education about the benefits and potential side effects of vaccines be provided and documented in the resident's medical record.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to inadequate care. One resident with skin integrity issues did not have a care plan initiated until eight days post-admission. Another diabetic resident lacked a care plan, resulting in a fall due to low blood sugar, hospitalization, and seizures. The DON confirmed the absence of necessary care plans, which are crucial for effective treatment and monitoring.
A resident with diabetes was admitted to a facility without proper orders for blood glucose monitoring or emergency diabetic medication. The attending physician did not provide necessary instructions, and the nursing staff failed to implement hospital orders. This oversight resulted in the resident experiencing severe hypoglycemia, leading to a fall, hospitalization, and new onset seizures.
The facility failed to follow its medication administration policy for three residents. An LPN did not sign off medications at the time of administration, another LPN administered morning medications late, and a third LPN left the medication cart unattended with medications on top. These actions were confirmed through record reviews and staff interviews.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents or their responsible parties were fully informed and consented to psychotropic medications for five sampled residents. Resident 2, who had cognitive communication deficit and unspecified dementia, was prescribed olanzapine for dementia and received it daily, but the informed consent form signed by the resident’s representative and the physician did not include required information such as the drug category, dosage, frequency, duration, administration method, caution and warning summary, reason for use and benefits, probable side effects and significant risks, or alternative treatments. Resident 112, who was admitted with radiculopathy of the cervical region, was prescribed mirtazapine for depression and received it daily, but the informed consent form lacked the dosage, frequency, duration, administration method, caution and warning summary, benefits, and alternative treatments. For Resident 8, who had diagnoses including schizophrenia, anxiety disorder, depression, and bipolar disorder, the record showed orders for buspirone, fluoxetine, risperidone, and lorazepam. During review, the informed consent forms for buspirone and fluoxetine were found incomplete because they did not include benefits and common side effects and did not contain the physician’s signature. The MDSC stated informed consent was essential and that the medications could not begin until the attending physician had obtained informed consent. The DON stated licensed nurses were expected to obtain fully completed informed consent forms and that the forms needed to include the medication order, diagnosis or indication, side effects, beneficial effects, and the doctor’s signature. Resident 3, who had schizophrenia with auditory hallucinations, had an order for risperidone, but the DON confirmed there was no informed consent for that medication. Resident 19, who had cognitive communication deficit, dementia, and Alzheimer’s disease, had orders for donepezil and memantine, but the DON verified that informed consent from the resident or responsible party was not obtained. The facility’s policies stated that the attending practitioner was responsible for informing the resident or representative about the initiation, reason for use, and risks of psychotropic medications, and that informed consent was to be obtained prior to initiation and verified by the licensed nurse.
Call lights not kept within residents’ reach
Penalty
Summary
The facility failed to accommodate the needs of six sampled residents by not keeping their call lights within reach. Resident 28, who had diagnoses including dementia, seizure disorder, and anxiety disorder, was observed sleeping in bed with the call light and bed remote on the floor beside the lower right side of the bed. A nurse confirmed the device had fallen out of reach and stated it was unacceptable for the call light to be out of reach. Resident 112, who had diagnoses including discitis of the lumbosacral region, urinary tract infection, diabetes mellitus type II, and radiculopathy of the cervical region, was observed lying in bed with the call light next to the left lower leg. The resident yelled for nursing staff and asked for the call light. A CNA stated the resident could not reach it because of where it was placed and that the resident had confusion and the call light should have remained accessible. Resident 72, who had diagnoses including major depressive disorder and quadriplegia, was observed sleeping in a low bed without a call light device. A nurse confirmed the resident did not have a call light to use and stated that having no call light was an emergency. Resident 114 was observed with the call light caught between the right side bed rail and the bed frame, and a CNA stated it was not within reach. Resident 115, who had diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, Parkinson’s disease, and a history of falls, had the call light attached to the bed rail behind the resident’s back, and the resident stated the call light could not be found. Resident 117, who had diagnoses including a fracture of the left tibia and urinary retention, was observed with the call light hanging from the right bed grab rail toward the floor, and the resident stated the call light could not be found and that the resident yelled for help or tried to do things without staff assistance when unable to locate it.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for three residents when a brown bowel movement was observed on the floor in the South Hall with a noticeable odor. During observation, staff were seen walking around the bowel movement, and the Social Services Assistant confirmed the odor and stated it could have been unpleasant for residents, staff, and visitors. The Infection Preventionist later stated that a bowel movement in the hallway presented an uncomfortable odor that was not homelike for residents. In one resident room, broken window blinds and missing floor tiles were observed next to one resident's bed. The resident stated the blinds had been broken for some time, that they looked bad, and that no one had told her when they would be fixed. The Maintenance Supervisor confirmed the broken blinds and missing floor tiles in the room. In another resident room, a tall dresser used by a resident to store clothing and personal items was observed with a missing drawer knob and a broken bottom drawer front panel laying on the floor of the dresser. The resident was unaware whether the dresser would be fixed or replaced, and the Maintenance Supervisor confirmed the dresser was broken and should have been replaced. In a third resident's room, staff personal belongings, including a gray hooded sweater and a fanny pack, were observed hung on a hook labeled CNA on the back of the restroom door. The resident stated staff should not place their belongings in her room because it was her home, and staff interviews confirmed that personal items were supposed to be stored in the employee break room, not in the resident's room.
Inaccurate MDS Coding for Dialysis, ROM, Pain, Oxygen, and Hospice
Penalty
Summary
The facility failed to ensure that Resident 7 had an accurate MDS when the assessment was coded as if dialysis services were not being received, even though the resident had diagnoses including end stage renal disease and dependence on renal dialysis and had physician orders for dialysis services at a local dialysis center, including a Monday/Wednesday/Friday hemodialysis schedule. The MDS section for special treatments and procedures left dialysis blank. During interview and record review, the MDSC confirmed the resident should have been coded as receiving dialysis and stated the MDS would need correction and the care plan review should ensure the dialysis service was fully identified in the clinical record. The facility also failed to accurately code Resident 39’s MDS regarding functional impairment and pain management. Resident 39 had a chronic right upper extremity contracture with decreased range of motion in the right shoulder, elbow, hand, and fingers, and the encounter summary documented that this condition was present on admission. The resident was observed demonstrating decreased ability to move the right upper extremity and stated he completed exercises on his own and did not want therapy. CNA 5 stated the resident had difficulty moving the right hand due to contractures in the fingers. The MDSC confirmed that section GG had been coded as no impairment in an upper extremity and that pain management was coded as no for routine or PRN pain medication, even though the resident had contractures and was receiving daily Tylenol. The facility further failed to accurately code Resident 89’s MDS for oxygen and hospice services. Resident 89 had diagnoses including COPD and heart failure and was observed wearing a nasal cannula delivering oxygen at 2L. The resident stated the oxygen helped with anxiety caused by shortness of breath. LN 9 confirmed the resident had active physician orders for oxygen use, including oxygen via nasal cannula at 2 through 5L as needed for SOB or wheezing and another order for continuous oxygen to keep oxygen saturation above 90%, and stated the resident generally kept oxygen on at all times. The MDSC confirmed that oxygen and hospice services were marked as not being received when they should have been coded as yes.
PASRR Screening and Level II Evaluation Not Completed Accurately
Penalty
Summary
The facility failed to ensure that two sampled residents had properly completed PASRR screening and, when indicated, a PASRR Level II evaluation. One resident was admitted with a diagnosis that included developmental disorder of scholastic skills and had cognitive impairment documented on the MDS, including short-term and long-term memory problems, impaired recall, and severely impaired cognitive skills for daily decision making. However, both PASRR Level I screening documents marked “No” for ID/DD/related condition even though the resident’s records and diagnoses indicated autism and a developmental disorder. A Level I determination letter stated that a Level II mental health evaluation was not required. During interview and record review, LN 2 stated the PASRRs should have been marked “Yes” because the resident had autism and a developmental disorder. LN 2 further stated that because the PASRRs were not completed accurately, the resident did not proceed to a PASRR Level II evaluation. The DON also reviewed the PASRRs and stated both were completed inaccurately and did not identify the resident’s developmental disorder. The DON stated the resident was at risk for not receiving adequate care and services. A second resident was admitted with diagnoses including schizophrenia, anxiety disorder, depression, and bipolar disorder. The facility’s PASRR Level I screening identified schizophrenia, marked psychotropic medication use, and indicated a Level II case state. A notice from the state department stated a Level II mental health evaluation was not scheduled because facility staff were unresponsive to two or more attempts at communication within 48 hours of the Level I screening. The DON stated she oversaw PASRR and the MDSC oversaw the process, and the MDSC confirmed the Level II evaluation was required but was not scheduled because staff had not responded to communication attempts.
Respiratory Tubing Not Properly Dated or Stored
Penalty
Summary
The facility failed to ensure that oxygen tubing and nebulizer breathing treatment tubing were changed, stored, and kept off the floor for four residents receiving respiratory therapy. During observations, Resident 54 was in bed with nasal cannula oxygen at 4 L/min; the tubing was undated and there was no protective bag available for storage when not in use. Resident 89 was also observed in bed with nasal cannula oxygen at 2 L/min; the tubing was dated 1/19/26, but there was no protective bag available, and the resident stated he had not seen a storage bag for the tubing. Resident 97 was observed in bed with an oxygen concentrator next to the bed; the concentrator was off, the oxygen tubing was lying on the floor, the tubing was undated, and there was no protective bag available. Resident 115 had an order for albuterol sulfate nebulizer treatments as needed for shortness of breath. During observation, the resident had a nebulizer device on the bedside table with breathing treatment tubing that was unlabeled and not stored in a protective bag. The licensed nurse stated that the unlabeled tubing prevented staff from knowing when it should be replaced and that failure to store it in a protective bag increased the risk of cross-contamination. The Director of Nursing stated nursing staff were required to label breathing treatment tubing with the first-use date and store it in a protective bag to prevent the spread of infection. Facility records and interviews showed that the facility policy required oxygen cannulae and tubing to be changed every seven days and stored in a plastic bag when not in use, and that nebulizer circuits were to be stored in a plastic bag marked with the date and resident's name between uses. The DON stated the night shift was assigned to change and label oxygen tubing and storage bags on Sunday nights, but also stated there had not been an audit to determine whether orders were present for all residents with oxygen therapy. The observations for these four residents showed tubing that was undated, improperly stored, or lying on the floor, contrary to the facility's stated respiratory infection prevention procedures.
Food Storage and Utensil Sanitation Deficiency
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with safety standards when two worn pans were kept in the food prep area and a rusted paint scraper was stored with clean utensils in a drawer. During the initial kitchen tour, the certified dietary manager verified that the two pans were worn in appearance and that the rusted scraper was stored with clean utensils. The facility census was 94 residents eating facility prepared meals. During interviews, the registered dietitian stated that worn pans should not have been kept in the kitchen and that using worn pans when cooking food could have caused cross contamination in food prepared by kitchen staff. The registered dietitian also stated the rusted paint scraper could have caused cross contamination with the clean utensils and potentially could have affected food prepared in the kitchen. The certified dietary manager stated the worn pots and pans should not have been in the kitchen and that the rusted scraper was a cross-contamination risk and could have potentially been used by kitchen staff.
Unlabeled Perishable Food and Missing EBP Door Signage
Penalty
Summary
Resident 103 had multiple small containers of perishable food on the bedside table in the room. The resident’s record showed diagnoses including sepsis, diabetes mellitus type II, muscle weakness, hypo-osmolality, hyponatremia, and primary central nervous system lymphoma. During observation and interview, the resident stated the food belonged to her, and an LN confirmed the food had been brought by family and was not labeled with the resident’s name or the date it was prepared or received. The LN stated that perishable food left in a resident’s room without refrigeration must be consumed within two hours or discarded, and that without a date staff would not know when it must be discarded. The CDM stated that perishable food brought in from outside sources must be labeled with the resident’s name, room number, date received, and discard date, and that residents’ perishable food should be stored in the refrigerator if it could not be finished. The DON also stated that perishable food from outside sources must be labeled with the resident’s name, room number, date received or prepared, and discard date. Resident 128 and Resident 127 each had an orange-white safety cone facility marker next to the room name label, indicating Enhanced Barrier Precaution status, but no EBP signage was posted at the door. LN 2 stated that the signage was needed to alert residents, staff, and family members and to remind staff to wear PPE during close contact or direct care. The IP stated the marker indicated staff and visitors needed to be aware of EBP and that the door signage was important so everyone knew and followed the necessary precautions. The DSD confirmed the marker was present for Resident 127 but no EBP signage was posted, and the DON stated it was unacceptable for residents with an EBP marker not to have EBP signage by the door.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not honoring her preferred form of address. During bedside care, a CNA addressed the resident as "Honey" three times. The resident was later interviewed and stated that she did not want to be called Honey, explaining that it was not part of her name and that she preferred to be called by her name. The resident involved was admitted with diagnoses including muscle weakness, reduced mobility, and dementia. During an interview, the CNA acknowledged calling the resident Honey multiple times while providing care and stated that she should have treated the resident with respect and dignity and used the resident's name instead. The DON also stated that calling the resident Honey was not acceptable when it was not the resident's preference and emphasized the importance of addressing residents by their names to preserve dignity.
Late Comprehensive MDS Assessments
Penalty
Summary
The facility failed to ensure that federally required comprehensive MDS assessments were completed within the required timeframe for two sampled residents. Resident 18 had an annual comprehensive assessment with an ARD of 12/18/25, but the assessment was still in progress and 28 days past due when reviewed on 1/28/26. Resident 18’s record showed diagnoses including type 2 diabetes mellitus, reduced mobility, hypertension, chronic kidney disease stage 3, chronic pain syndrome, anxiety, major depressive disorder, dementia, and a history of venous thrombosis and embolism. Resident 54 also did not have the required admission comprehensive MDS completed within 14 days of admission. The record showed Resident 54 was admitted on 12/19/25 with diagnoses including heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, hepatic encephalopathy, and vascular dementia. The MDS assessment calendar showed an ARD of 12/30/25, and the assessment remained in progress and 27 days past the required completion date when reviewed on 1/28/26. During interview, the MDSC stated Resident 18’s annual assessment was late due to staffing difficulties in the department. For Resident 54, the MDSC stated the admission assessment was late because the facility was waiting for a completed CTI from the hospice provider, and acknowledged that the request for the document had not been documented. The MDSC also stated that the incomplete annual and admission comprehensive assessments affected the development of the comprehensive care plans for both residents, including areas such as ADLs, communication, cognitive function, mood and behaviors, medication, skin care, activity preferences, and discharge goals.
Accident Hazards Not Correctly Managed
Penalty
Summary
The facility failed to ensure that three sampled residents were kept free from accident hazards. Resident 2 was admitted with diagnoses including gait and mobility abnormalities, cognitive communication deficit, and dementia. During observation in Resident 2’s room, a regular bed mattress was stored upright against the wall in the room pathway and was being used as a fall mat. The LN stated the mattress was used because Resident 2 was at high risk for falls, but also stated that storing it upright created a safety hazard and could tip or fall. The IP also stated the mattress made the pathway unsafe because it was unstable and not secured. Resident 2 stated the mattress was placed on the floor next to the bed at night and staff removed it before he got out of bed. The RHD and DON both stated that a regular mattress was not appropriate for use as a fall mat and that placing it against the wall created a safety concern. Resident 54 was admitted with heart failure and vascular dementia. Observation showed a fall mat next to only one side of the bed, while the room tag indicated a fall precaution. CNA 5 confirmed Resident 54 was at risk for falls and dependent for ADLs, and stated the resident became anxious and tried to get out of bed unassisted. CNA 4 stated the fall mat should have been placed on the other side of the bed as well. LN 7 confirmed that Resident 54 had a physician’s order for fall mats on both sides of the bed and for the nurse to confirm placement every shift, but only one fall mat was present at the time of review. LN 7 stated the mat had been moved after a fall from the opposite side of the bed and confirmed the resident was only supposed to have one mat at that time, despite the physician’s order for both sides. The DON confirmed the TAR showed staff initials indicating the floor pad was in place, but also stated that if one was missing it should have been replaced and that the care plan did not include the intervention for fall mats on both sides of the bed. Room [ROOM NUMBER] near Resident 7’s bed had a 6-inch metal strip, about 1/4 inch wide, protruding from the wall in a loop-like fashion at knee height next to the bathroom door. CNA 7 confirmed the strip had been there for a while and stated her clothing had gotten caught on it while providing care. CNA 7 said it should have been entered in the maintenance log, but it had not been. The MS confirmed the strip presented a potential for injury and stated staff had not reported it to him. Review of the maintenance log showed no entries for repairs needed in that room. The DSD stated she needed to provide more training to nursing staff on reporting maintenance concerns and keeping the facility in good repair.
Inaccurate Side Rail Assessment and Missing Physician Order
Penalty
Summary
The facility failed to accurately assess and obtain a physician’s order for the safe use of bed rails for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the left non-dominant side, unsteadiness on feet, cognitive communication deficit, other reduced mobility, and developmental disorder of scholastic skills. The resident’s MDS indicated short-term and long-term memory problems, impaired recall, and severely impaired cognitive skills for daily decision making. During observation, the resident had the left and right half side rails raised. The RNA stated the resident was totally dependent on staff for bed mobility and repositioning and could not follow instructions to hold or use the side rails. The side rail screening tool documented that the resident required three staff members for repositioning and transfers, had poor safety awareness, could not follow instructions, had no means of communication, and demonstrated poor concentration and confusion, yet it also listed reasons for side rail use that involved the resident holding the rails and scooting up in bed. An LN stated the resident did not have the ability to hold the side rails, making the documented reasons inaccurate and the side rails unsafe. The resident also did not have a physician’s order for side rails, and the DON stated that side rails require a physician’s order and accurate assessment.
Unnecessary Psychotropic Medication Order Without Stop Date
Penalty
Summary
The facility failed to ensure that one sampled resident prescribed psychotropic medication was free from unnecessary drugs when the resident’s PRN alprazolam order did not have a stop date. The resident had diagnoses including an anxiety disorder and post-traumatic stress disorder. During a concurrent interview and record review, the DON confirmed that the alprazolam order was given on a PRN basis and that the medication start date was 12/2/25, but the order did not include a stop date. The DON stated the order was not appropriate because a PRN medication needed a stop date so the medication could be reassessed for continued appropriateness. During an interview, the Pharmacist Consultant stated that PRN medication orders should have had a 14-day stop date unless the provider documented an explanation for extended PRN use of alprazolam. The facility policy titled Medication Orders stated that PRN orders for psychotropic drugs are limited to 14 days, and if the prescribing practitioner believes extended use is appropriate, the rationale and duration must be documented in the resident’s medical record. The report states the resident was at risk of experiencing unnecessary side effects such as constipation and drowsiness.
Medication Cart Storage and Labeling Deficiencies
Penalty
Summary
Medication storage and labeling practices were not maintained on medication cart 4. During a concurrent observation and interview with LN 10, three insulin pens and one insulin vial stored in the top left drawer did not have open dates indicated on them. LN 10 confirmed the missing open dates and stated they should have been present. The DON later stated that insulin pens and insulin vials were expected to have an open date listed on the medication container so staff would know when to discard the medication. During the same observation, LN 10 also confirmed there were loose, unidentifiable pills in the medication drawers of cart 4, including two pills on the bottom of drawer 2 and four pills on the bottom of drawer 3 on the right-hand side. LN 10 stated keeping the pills secure was for accountability and to ensure the correct number of medications were given to residents. The facility policy required medications to be stored in their original packaging or dispensing system, with only the issuing pharmacy authorized to transfer medications between containers, and required proper labeling of all medications.
Elopement of Cognitively Impaired Resident Through Unalarmed Laundry Exit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent an elopement for a resident with severe cognitive impairment and known wandering risk. The resident was admitted with encephalopathy, delirium, gait and mobility abnormalities, need for assistance with personal care, and dementia. A Brief Interview for Mental Status (BIMS) score of 1 indicated severe impairment in thinking and memory. The resident’s care plan, initiated months earlier, identified risk for wandering or elopement related to exit-seeking behavior, a focus on wanting to go home, dementia, and aimless wandering, with goals to prevent elopement and maintain safety. Interventions included frequent checks of the resident’s whereabouts, redirection when approaching exit doors, assessment for a wander/elopement alarm, and application of a wander guard as ordered. An active order for wander guard placement due to exit-seeking behavior was in place. On the night of the incident, documentation showed that the resident was last seen by the night shift CNA walking up and down the hallway at approximately 2:35 a.m., and the resident’s roommate later came out to inquire about the resident when she was no longer in the room. Staff then determined the resident was not in the building and began searching the premises. The assigned nurse (LN 3) reported being responsible for 30 residents that shift and stated that around 1:50 a.m. she accompanied an x-ray technician to assist with other residents, leaving the resident under the supervision of the CNA in the activities room because the resident did not want to remain in bed. LN 3 remained with the x-ray technician until about 2:30 a.m. and then took her scheduled lunch break, assuming the resident remained under CNA supervision. LN 3 later became aware the resident was missing when the roommate asked about her whereabouts and initially believed the resident was still in the building because no door alarm had sounded. Interviews and record review revealed that the resident eloped through a laundry room exit door that was not alarmed and that a second laundry door, which was supposed to be locked from the inside when staff left the area, had been left unlocked. The Administrator stated that prior to the elopement, all exit doors except the laundry door were alarmed, and that staff had forgotten to lock the second laundry door on the night of the incident. The Interdisciplinary Team note documented that the resident, who was alert and ambulatory at the time of exiting, left through a door that did not have an alarm and was outside the patient care area, and that the wander guard did not alarm for this door. Police records indicated that officers responded to a missing person call, searched the surrounding area, and later received a call from a community member reporting an unknown female in her home wearing a yellow gown; officers identified this person as the resident. Due to extreme cold weather, the resident’s age, and health conditions, EMS transported the resident to a hospital, where she was diagnosed with an acute NSTEMI and acute altered mental status, with elevated troponin and treatment including heparin and cardiac monitoring. Facility policies on wandering, elopement prevention and management, and safety and supervision of residents required identification of residents at risk for unsafe wandering or elopement, inclusion of detailed monitoring plans in the care plan, provision of adequate supervision, and maintenance and utilization of electronic monitoring and door alarm systems when deemed appropriate. Policies also described that a missing resident is considered a facility-wide emergency and outlined notification procedures for the Administrator, DON, legal representative, physician, and law enforcement if a resident is not located. Despite these policies and the resident’s documented risk factors and care plan interventions, the resident was able to leave the building through an unalarmed and unlocked laundry exit without staff knowledge, remained missing for several hours during nighttime and early morning hours, and was ultimately found offsite and transported to the hospital, where an acute cardiac injury (NSTEMI) was diagnosed.
Improper Discharge Notice Issued During Pending Medi-Cal Application
Penalty
Summary
The facility failed to comply with transfer and discharge requirements when it issued a 30-Day Notice of Discharge/Eviction to a resident and the resident's responsible party due to a denial of payment, despite the resident having a pending Medi-Cal application. Documentation in the social services notes confirmed that the facility was aware the Medi-Cal application was under review at the time the notice was issued. The responsible party also acknowledged that the application was still pending and not yet active. Interviews with facility staff, including the Social Service Director and Social Services Assistant, confirmed that the resident had a right to remain in the facility while the Medi-Cal application was pending or under appeal. The Administrator later confirmed that Medi-Cal coverage was approved retroactively. Reference to state advocacy guidance indicated that facilities are prohibited from discharging residents with timely Medi-Cal applications pending eligibility determination, and that an appeal suspends a finding of nonpayment. The issuance of the discharge notice under these circumstances constituted a failure to meet regulatory requirements.
Failure to Monitor Diabetic Resident Leads to Severe Hypoglycemia and Seizures
Penalty
Summary
The facility failed to provide quality care to Resident 596, a diabetic patient, who experienced a series of critical events due to inadequate monitoring and management of her condition. Resident 596 was admitted with a diagnosis of diabetes and was on insulin and oral anti-diabetic medications. However, the admitting nurse did not include blood glucose (BG) testing parameters in the resident's orders, and the attending physician did not ensure BG monitoring orders were in place after changing the resident's insulin regimen. This oversight led to a lack of BG monitoring, which is crucial for managing diabetes effectively. On 9/20/24, Resident 596 suffered an unwitnessed fall due to critically low blood sugar levels, resulting in injuries and seizures. The licensed nurse on duty failed to implement emergent nursing interventions to assess the resident's BG level after the fall and did not inform Emergency Medical Services (EMS) of the resident's diabetic status or her last insulin dose. Consequently, Resident 596 was found with a blood glucose level of 20, significantly below the normal range, and was admitted to the intensive care unit (ICU) for treatment of severe hypoglycemia and seizures. The attending physician acknowledged the system failure, admitting that she did not write orders for BG monitoring or a sliding scale for insulin administration. The physician also recognized the risk of death, seizures, or hypoglycemic events due to the lack of proper diabetic management. The facility's policies and procedures for managing diabetes and medication administration were not followed, contributing to the resident's critical condition and subsequent hospitalization.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service and safety, as evidenced by multiple deficiencies observed in the kitchen area. A dietary aide was seen not wearing a hairnet, which is essential to prevent hair from contaminating food. Additionally, drinking glasses and food containers were found wet nested, a practice that can promote bacterial growth. Clean fruit cups were stored under a dishwasher with water dripping onto them, and expired yogurt was available for resident consumption, all of which pose significant risks to food safety. The dishwasher was not functioning within the required parameters, with its water temperature below the necessary 120 degrees Fahrenheit and the parts per million of the dishwashing solution below the accepted standard. This failure in maintaining proper sanitization levels could compromise the cleanliness of dishes used by residents. Furthermore, two utensil drawers contained dust and debris, and two dented cans of corn were found in the food storage area, both of which are against the facility's sanitation policies. The kitchen environment itself was not maintained in a sanitary condition, with three fans in the food preparation area and the counter above the stove top covered in dust and debris. These conditions could lead to contamination of food prepared for the 89 residents receiving meals from the facility. The facility's policies on sanitization and food storage were not followed, as evidenced by these observations, which could potentially lead to foodborne illnesses among residents.
Medication Administration Error for Anti-Anxiety Medication
Penalty
Summary
The facility failed to administer an anti-anxiety medication, Lorazepam, correctly to a resident, resulting in significant medication errors. The resident was prescribed Lorazepam 1 mg to be taken every six hours for agitation with behaviors, starting from late April 2024. However, during May and September 2024, the resident received a lower dose of 0.5 mg on multiple occasions, which was incorrectly documented as 1 mg in the Medication Administration Record (MAR). Specifically, the resident received the incorrect dose 18 times in May and once in September, as evidenced by discrepancies between the Controlled Drug Record (CDR) and the MAR. The Director of Nursing confirmed that the resident did not receive the medication as ordered by the physician, acknowledging the administration of only half the prescribed dose. The facility's policies on controlled medication administration and specific medication administration procedures were not followed, as the documentation did not accurately reflect the amount administered. This failure in adhering to the facility's guidelines and physician's orders had the potential to cause increased anxiety and emotional distress for the resident.
Failure to Document COVID-19 Vaccination Education
Penalty
Summary
The facility failed to provide documented evidence of education regarding COVID-19 vaccinations for four sampled residents and one unsampled resident. During a review of the clinical records, it was found that the records for these residents did not contain documentation indicating that education on the benefits, risks, and potential side effects of the COVID-19 vaccine was provided. This lack of documentation was confirmed during an interview with the Infection Preventionist, who acknowledged that the section titled 'Education Provided to Resident/Family' was not checked in the medical records of the affected residents. The Director of Nursing explained that providing education to residents before administering or refusing a vaccination is crucial as it gives them sufficient information about the medication, including its risks and benefits, allowing them to make an informed decision. The facility's policy on COVID-19 vaccination, revised in October 2023, mandates that residents and staff be educated about the vaccine before it is offered, and that the resident's medical record should include documentation of this education. However, this policy was not adhered to in the cases of the identified residents.
Failure to Ensure Safe Insulin Use for Diabetic Residents
Penalty
Summary
The facility failed to ensure the safe use of insulin for two residents with diabetes, leading to potential unsafe insulin and antidiabetic drug use. Resident 1's insulin order lacked parameters for addressing high blood sugar levels, and there was no documentation of additional treatments or interventions despite frequent high blood sugar readings. The medical doctor was not notified of these high readings, and the resident's care plan, which required notification of the doctor for blood sugar levels above 400, was not followed. Interviews with staff and the medical doctor revealed a lack of awareness and action regarding the resident's high blood sugar levels. Resident 596's diabetic medication and insulin use were not monitored by blood sugar measurements, indicating a failure in monitoring and managing the resident's diabetes. The facility's policies on managing diabetes and medication administration were not adhered to, as evidenced by the lack of intervention for high blood sugar levels and the absence of a sliding scale for insulin administration. The Director of Nursing acknowledged that the nursing staff should have contacted the doctor to obtain parameters for managing blood sugar variations.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, Resident 382 and Resident 3, as observed during a survey. For Resident 382, the floor tiles in her room were replaced with a black rubber strip, which was not uniform with the rest of the rooms and posed a tripping hazard. The Responsible Party for Resident 382 expressed concerns about the strip, having tripped over it in the past. The Maintenance Director confirmed the strip was installed due to broken tiles and had been in place for over a year. The Certified Nurse Assistant also noted the strip as a potential hazard, especially for wheelchairs. The Administrator and Director of Nursing were unaware of the strip's presence and acknowledged it was not in line with the facility's homelike environment policy. For Resident 3, the deficiency involved broken blinds in her room, which had been missing a section for some time. Resident 3 expressed a desire for the blinds to be replaced, describing them as looking "shaggy." The Director of Staff Development and the Director of Nursing both confirmed that blinds should be well-fitting and not broken to maintain a homelike environment. The facility's policies on resident rights and maintenance emphasize the importance of maintaining a dignified and orderly environment, which was not upheld in these instances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, Medication Cart #4 contained an outdated Lantus insulin pen, which had been opened and was beyond its use date of 28 days after opening. This was acknowledged by Licensed Nurse 5 during an inspection. Additionally, at the North station, the treatment cart stored an opened bottle of Sterile Sodium Chloride, which is intended for single use and should have been discarded after use. Licensed Nurse 6 confirmed that the bottle should have been disposed of. The Director of Nursing acknowledged these findings, stating that the insulin pen should have been discarded after 28 days and that single-use products should be discarded after use. The facility's policy on medication storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedure. These lapses in medication storage practices could result in residents receiving expired or unusable medications.
Failure to Document Vaccine Education for Residents
Penalty
Summary
The facility failed to provide documented evidence of education for immunizations to two residents, Resident 14 and Resident 23. For Resident 14, the Influenza vaccination record dated 9/29/23 did not have the education box checked, and the Infection Preventionist (IP) confirmed there was no documentation of education provided regarding the vaccine. Similarly, for Resident 23, the Influenza vaccination record dated 12/13/23 also lacked documentation of education, and the IP acknowledged this omission. The facility's policy requires that education about the benefits and potential side effects of the influenza vaccine be provided and documented in the resident's medical record. Additionally, Resident 23's record for the Pneumococcal Polysaccharide (PPSV 23) vaccine, dated 5/6/21, also did not have the education box checked, and the IP confirmed the absence of documented education. The Director of Nursing (DON) emphasized the importance of providing education to residents before administering or refusing a vaccination to ensure they have sufficient information about the risks and benefits. The facility's policy mandates that education about the pneumococcal vaccine be provided and documented, and any refusal of the vaccine should be recorded in the resident's medical record.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents, leading to significant deficiencies in care. Resident 545 was admitted with multiple diagnoses, including enterocolitis due to C. Diff, dementia, and generalized muscle weakness. Despite the presence of redness in the right groin, left groin, and perirectal area upon admission, the baseline care plan addressing these skin integrity issues was not initiated until eight days later. This delay in care planning was confirmed by the Director of Nursing (DON) during a review of the resident's medical records. Resident 596, who was admitted with a diagnosis of diabetes, did not have a diabetic baseline care plan developed to manage her condition and medications, including insulin and oral antidiabetic drugs. The admitting nurse failed to enter the necessary orders for hypoglycemia and hyperglycemia protocols. As a result, Resident 596 experienced a fall due to low blood sugar, leading to hospitalization and subsequent adverse events, including seizures. The DON confirmed that a diabetic care plan was not in place, which was crucial for directing the care of the resident. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to meet the resident's immediate needs. However, the lack of timely care plans for both residents resulted in inadequate monitoring and management of their conditions. The DON acknowledged the importance of care plans in creating a pathway of care and ensuring effective treatment, which was not achieved in these cases.
Failure in Diabetic Care Management Leads to Resident Hospitalization
Penalty
Summary
The attending physician (AP) failed to provide necessary orders for routine blood glucose monitoring and adequate oversight for a diabetic resident, identified as Resident 596. Upon admission, the resident had a diagnosis of diabetes and was receiving multiple medications for its management. However, the admitting orders from the hospital, which included instructions for blood glucose monitoring and parameters for notifying the physician in case of significant changes, were not implemented by the facility. The AP did not include these orders in the resident's Order Summary Report, nor did they provide orders for emergency diabetic medication administration or parameters for managing hypoglycemia or hyperglycemia. The nursing staff, under the direction of Licensed Nurse (LN) 3, failed to ensure the admitting orders were accurately entered into the system. Although LN 3 stopped the NPH insulin as per the AP's verbal instructions, there were no written orders to guide the nursing staff on blood glucose monitoring or emergency interventions. The AP's notes, which were faxed to the facility days later, did not include necessary orders for managing the resident's diabetes effectively. Consequently, the resident's blood glucose levels were not monitored adequately, and no emergency protocols were in place to address potential hypoglycemic or hyperglycemic events. As a result of these oversights, Resident 596 experienced a severe hypoglycemic event, leading to a fall and subsequent hospitalization. The resident was found with a critically low blood glucose level and suffered new onset seizures, which were attributed to the severe hypoglycemia. The facility's Medical Director and Director of Nurses acknowledged the lack of appropriate orders and monitoring, highlighting the risk posed to the resident due to the absence of a structured diabetes management plan.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to follow its policy and standards of practice for medication administration for three residents. Licensed Nurse (LN) 2 did not sign off medications at the time of administration for Residents 1, 2, and 3. Medications for these residents were signed off hours after they were due, which was confirmed through a review of the Medication Administration Audit Report (MAAR) and interviews with LN 2 and other staff members. LN 2 admitted to administering medications on time but signing them off later when she had time, which contradicts the facility's policy and places residents at risk for medication errors. Additionally, LN 6 administered morning medications late to Resident 1. The MAAR indicated that medications scheduled for 7 AM were administered between 8:56 AM and 9:04 AM. LN 6 confirmed during an interview that the medications were passed late. The Director of Nurses (DON) emphasized the importance of timely medication administration to ensure the therapeutic effect of the medications. Furthermore, LN 4 left the medication cart unattended with medications on top during a medication pass. This occurred when LN 4 was interrupted by a resident's family member. LN 4 acknowledged the mistake and explained the importance of securing medications to prevent unauthorized access. The DON reiterated the importance of securing medications to ensure resident safety. The facility's policy mandates that medications be administered within one hour of their prescribed time and that the medication cart be kept closed and locked when out of sight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tracy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tracy Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 18 | 0 |
| Guardian Care And Rehabilitation Center | 12.3 mi | ★★★★★ | 29 | 0 |
| Harvest Crossing Post Acute | 12.4 mi | ★★★★★ | 3 | 0 |
| Lincoln Square Post Acute Care | 15.9 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Rehab And Care Center | 16.2 mi | ★★★★★ | 1 | 0 |
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