Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peninsula Post-acute during CMS and state inspections, most recent first.
Missing Initial Temperatures on Cool Down Log: The kitchen failed to document the initial temperatures for 3 food items on the SPECIAL COOL DOWN LOG. The DoD reviewed the log and verified that pudding, cream square, and salad had no initial temperatures recorded before later cooling to 35 F, 38 F, and 39 F. The DoD stated the items were room temperature but acknowledged there was no evidence of that and that the initial temperatures should have been checked and documented per the facility's cooling P&P.
Rodent droppings were observed in the dry goods storage room during an observation with the DON, along with four snap-type rodent traps on the floor. The DON stated she was unaware of any rodent problem in the kitchen or storage area and believed the traps may have been placed as a preventive measure. Review of the facility's Pest Control policy stated the facility maintains an ongoing pest control program to keep the building free of insects and rodents.
A resident with dementia, repeated falls, abnormal gait, and a known subdural hematoma experienced a fall and was later observed by family to become increasingly lethargic, less responsive, more unsteady, and with poor intake. Despite these changes and the resident’s eventual transfer to the hospital, where a left holohemispheric chronic SDH was identified and neurosurgery performed, the DON did not initiate a formal investigation of the incident as an unusual occurrence. The Medical Director agreed that the case should have been formally investigated to assess nursing practices, and the facility’s Unusual Occurrence Reporting policy addressed reporting but not formal investigation of such events.
Care Plan Not Updated After Urinary Catheter Discontinued: A resident with obstructive and reflux uropathy and BPH no longer had a urinary catheter, but the catheter care plan remained active in the EHR. The LVN and DON both confirmed the plan had not been discontinued to reflect the resident’s current status, and the LVN stated the care plan was not person-centered. The facility policy required comprehensive, person-centered care plans with measurable objectives and revisions when resident conditions change.
Oxygen Therapy Provided Outside Physician Order: A resident with COPD, acute and chronic respiratory failure with hypoxia, and syncope/collapse received oxygen at 2 lpm via nasal cannula connected to an unlabeled humidifier and oxygen concentrator. An LVN stated the humidifier was unlabeled with date and initials and could be used by another resident if unlabeled. The DON reviewed the order for oxygen at 2-3 lpm for SOB, chest pain, and O2 sat less than 90% and confirmed it did not include a humidifier.
Failure to follow a prescriber order for lidocaine patches. An LVN observed an old patch on a resident’s back, removed it, and applied only one new lidocaine 4% patch even though the order required two patches to be applied for pain relief. The LVN stated she did not read the order in its entirety, and the DON acknowledged the ordered dose was not administered and that the prior patch was present before the new one was applied.
An opened and undated multi-dose vial of Novolin N for a resident was found in the medication storage room refrigerator. The ADON stated the vial should have been dated when opened, and the DON acknowledged the vial was undated. Facility policy required opened multi-dose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise, and the Novolin N label stated opened vials should be discarded after 42 days.
The facility failed to ensure food safety and sanitation, with fish served at improper temperatures, improper thawing methods, and unlabeled, expired items in a resident's refrigerator. Hand hygiene and glove use were not followed, and kitchen equipment and food carts were inadequately cleaned, risking foodborne illness for 56 residents.
A long-term care facility experienced a 25% medication error rate due to improper administration practices. An LVN left medications at a resident's bedside without observing intake, and an RN administered Repaglinide during a meal instead of before. Additionally, insulin was administered without proper blood sugar checks, and the technique used was inconsistent with professional standards. These actions were contrary to facility policies and prescriber orders.
The facility failed to properly label and store medications, including allowing a resident to keep medication at the bedside without an order, using undated medication bottles, and storing expired biologicals. Controlled drugs and a resident's money were improperly stored in a medication cart, and a cart was left unlocked and unattended. These actions violated the facility's policies and procedures.
The facility failed to serve green beans in accordance with the approved menu, using a 1/3 cup scoop instead of the required 1/2 cup scoop. This error affected 49 residents who were supposed to receive regular textured green beans, potentially impacting their nutritional intake. The issue was confirmed by dietary staff during an interview.
The facility failed to provide palatable food for a lunch meal, affecting 34 residents who received meatballs and pureed green beans. Food temperatures were not measured before service, resulting in meatballs being served below the required temperature. Additionally, pureed green beans were found to be excessively salty compared to their regular counterparts, indicating a failure to adhere to recipe guidelines.
The facility failed to provide completed contracts for dialysis services and transportation, which were being provided by an external agency. An internal agreement request form for dialysis was not a finalized contract, and the transportation contract lacked the facility representative's signature. The Administrator confirmed the absence of a formal dialysis contract.
The facility admitted more residents than its licensed capacity of 62 skilled nursing beds for 13 days in September. Despite the Fire Marshall's temporary approval for 68 beds, the facility's official license only permits 62 beds, leading to non-compliance with state regulations.
A facility failed to obtain a POLST for a resident upon admission, risking non-compliance with the resident's end-of-life wishes. Despite having a DNR order and no cognitive impairment, the POLST form was missing from the resident's records, as confirmed by an LVN. The resident had multiple medical conditions, and the absence of this documentation could lead to their treatment preferences not being honored.
A resident's MDS was inaccurately encoded with a diagnosis of depression, despite no medical history of the condition. The error was identified during a review of the resident's medical records, which showed diagnoses of spinal stenosis and low back pain but not depression. The MDS Director confirmed the inaccuracy, noting the facility's policy requires accurate certification of assessments.
The facility failed to develop accurate care plans for two residents. One resident's care plan incorrectly indicated Duloxetine was for depression, despite no such diagnosis, while another resident lacked a care plan for indefinite Cephalexin use for UTIs. The facility's policy requires care plans to be developed within specific timeframes, which was not followed, leading to deficiencies in meeting residents' needs.
Two residents experienced deficiencies in insulin administration due to an LVN's failure to follow professional standards and facility policies. The LVN did not inject air into the insulin vial or pinch the skin during injection for one resident, and obtained a glucose reading during a meal for another resident, administering insulin without a prescribed pre-meal glucose check. The ADON confirmed these actions were against facility policy.
A resident with Japanese as their primary language was not provided with adequate translation services, as staff were unaware of resources beyond family members or communication boards. The facility does not subscribe to medical translation services, relying instead on family or translation apps like Google Translate.
A facility failed to monitor a resident on psychotropic medication for behavioral symptoms and side effects. The resident, admitted with schizophrenia, was prescribed amisulpride, and informed consent was obtained seven days late. Monitoring of side effects also started seven days after medication administration, contrary to facility policy.
A resident was administered Acetaminophen beyond the prescribed dosage, exceeding the maximum allowed 3000 mg in 24 hours. The resident, with fractures in the left femur and humerus, received 1000 mg three times daily and additional doses, leading to a significant medication error. Both the LVN and IDON confirmed the error, which could affect liver function.
The facility failed to ensure a kitchen staff member's competency in manual warewashing using the three-compartment sink, omitting the sanitizing step. This deficiency was identified during an observation and interview, where the Dietary Aide incorrectly described the procedure, potentially leading to contamination of food and utensils.
The facility's electronic medical record system failed to provide appropriate diet order options for residents with renal insufficiency, offering only a 'Liberal Renal' diet not defined in the facility's diet manual. This affected three residents, including one with end-stage renal disease on dialysis, potentially leading to inappropriate nutrient levels. The Registered Dietitian and Dietary Supervisor confirmed the discrepancy between the electronic system and the approved diet manual.
A facility failed to follow infection control standards for a resident on enhanced barrier precautions (EBP) due to multiple antibiotic resistances and an indwelling urinary catheter. PT and OT staff were observed providing care without the necessary PPE, specifically gowns, during high-contact activities. The Infection Preventionist confirmed the oversight and noted the absence of signage indicating EBP requirements, contrary to the facility's policy on transmission-based precautions.
The facility failed to ensure that RNs completed assessments for four residents who experienced changes in condition, including falls and severe pain. Instead, LVNs performed the assessments, which is not within their job description. This led to inadequate care for residents with significant medical issues.
A resident with severe cognitive impairment was injured during a transfer from a wheelchair to a bed using a hoyer lift. The resident panicked and flipped upside down, hitting her head on the base of the lift, resulting in severe pain and a bump on the head. Facility policies on safe lifting were not adequately followed.
Missing Initial Temperatures on Cool Down Log
Penalty
Summary
The facility failed to ensure safe and sanitary food storage conditions when the kitchen did not document the initial temperatures for 3 food items on the SPECIAL COOL DOWN LOG. During a concurrent interview and record review, the Director of Dietary reviewed the log and verified each date and item recorded. The log showed that pudding on 12/24/25, cream square on 12/31/25, and salad on 1/3/26 had no initial temperatures documented, although each item later reached a recorded cooled temperature of 35 F, 38 F, and 39 F, respectively. During the interview, the Director of Dietary stated that these 3 items' initial temperatures were room temperature, but acknowledged there was no evidence that the initial temperatures were actually at room temperature. The Director of Dietary also acknowledged that the initial temperatures should have been checked and recorded in the log to track temperature changes. Review of the facility's policy and procedure for cooling and reheating potentially hazardous or time/temperature control for safety food indicated that menu item, date, time, temperature, and cook's initials are to be noted on the cool down log, and the Director of Dietary acknowledged that the facility had failed to follow this cooling procedure.
Rodent Droppings Observed in Dry Goods Storage Area
Penalty
Summary
The facility failed to ensure that a food storage area was pest free when rodent droppings were observed in the dry goods storage room. During a concurrent observation and interview with the Director of Dietary, four spring-loaded snap-type rodent traps were seen on the floor of the dry goods storage room. When asked about a rodent problem, the Director of Dietary stated she was unaware of any rodent problems in the kitchen or kitchen storage area and explained the traps may have been placed by the pest management company as a preventative measure. Further inspection of a corner of the dry goods storage room revealed approximately 12 small black pellet-like substances on the floor, and the Director of Dietary agreed they appeared to be rodent droppings. Review of the facility's Pest Control policy indicated the facility shall maintain an effective pest control program and keep the building free of insects and rodents.
Failure to Investigate Unusual Occurrence After Fall and Worsening Subdural Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to identify and investigate an unusual occurrence related to a resident with a known subdural hematoma and history of repeated falls. The resident was admitted with multiple diagnoses including dementia, glaucoma, repeated falls, abnormal gait and mobility, and a subdural hematoma. On 1/21/26, a Change in Condition Evaluation documented that around 5:00 AM the resident was found sitting on the floor at the foot of her bed, unable to state what happened, denying head injury and pain, with no new skin tears, normal PERRLA, intact upper and lower extremity movement, and refusal of vital signs at that time. The DON later acknowledged awareness of this fall, the resident’s subsequent transfer to the hospital on 1/31/26, and neurosurgery performed that same day, but stated she did not formally investigate the case as an unusual occurrence. In the days following the fall, the resident’s family member reported noticing the resident becoming lethargic, less responsive, more unsteady, and not eating well, and stated she had to beg staff to transfer the resident to the hospital for evaluation. Hospital records from 1/31/26 documented that the daughter had been notified of the 1/21 fall and had observed the resident becoming more unsteady, lethargic, and with decreased intake over several days, and that the resident presented with altered mental status and less mobility over the past weeks, especially in the last couple of days. The hospital identified a left holohemispheric chronic subdural hematoma and recommended burr hole drainage. During interviews, the DON stated she did not formally investigate the case and, in retrospect, believed she should have, and the Medical Director agreed that the facility should have formally investigated the case to determine if nursing practices needed improvement. Review of the facility’s Unusual Occurrence Reporting policy showed it addressed reporting unusual occurrences but did not address formal investigation to identify deficiencies and develop interventions.
Care Plan Not Updated After Urinary Catheter Discontinued
Penalty
Summary
The facility failed to update a comprehensive, person-centered care plan for Resident 18 when the resident’s urinary catheter had been discontinued, but the catheter care plan remained active in the electronic health record. Resident 18 was admitted with diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS dated 3/6/26 showed a BIMS score of 13, indicating intact cognitive function. During an interview on 3/23/26, Resident 18 stated he no longer had a catheter and that it had been removed. During a concurrent interview and record review on 3/26/26, LVN 3 confirmed Resident 18 did not currently have a urinary catheter and acknowledged that the catheter care plan had not been discontinued to reflect the resident’s current status. LVN 3 stated the care plan was not person-centered and explained that staff rely on the care plan to understand a resident’s needs, goals, and appropriate interventions. During a later interview and record review the same day, the DON also confirmed the urinary catheter care plan remained active despite the catheter having been discontinued and stated it should have been resolved once the catheter was removed. The facility policy stated that comprehensive, person-centered care plans include measurable objectives and timetables and are revised as resident conditions change.
Oxygen Therapy Provided Outside Physician Order
Penalty
Summary
The facility failed to meet professional standards of quality when Resident 18 received oxygen therapy outside the prescriber's order. Resident 18 was admitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and syncope and collapse. The resident's oxygen care plan, initiated on 3/4/26, included interventions to change humidification and oxygen tubing. During observations on 3/23/26, Resident 18 was receiving oxygen at 2 lpm via nasal cannula connected to an unlabeled humidifier and oxygen concentrator. During a concurrent observation and interview, LVN 1 traced the oxygen tubing from the resident to the concentrator and stated the humidifier was unlabeled with date and initials, and that another resident could use it if it was unlabeled. During a later interview and record review, the DON reviewed the physician's order dated 3/3/26, which directed oxygen at 2-3 lpm for shortness of breath, chest pain, and oxygen saturation less than 90%, and stated the order did not include use of a humidifier.
Failure to Follow Lidocaine Patch Order
Penalty
Summary
The facility failed to ensure accurate medication administration when nursing staff did not follow the prescribed order for Resident 52. The physician’s order dated 3/3/26 directed that lidocaine 4% patches be applied to the lower back for pain, with two patches applied to clean, dry skin at 9:00 AM, worn for 12 hours, and removed at 9:00 PM. During a medication pass observation on 3/25/26 at 9:41 AM, an unlabeled patch was seen on the resident’s back, and LVN 2 removed the old patch and applied a new lidocaine 4% patch to the same area. When asked how many patches were applied, LVN 2 stated that one patch was applied. During later interview and record review, LVN 2 confirmed that one patch had been applied and stated she did not read the order in its entirety. She also stated the old patch was expected to have been removed the night before and was not supposed to be there. The DON reviewed the record and acknowledged the order required two lidocaine 4% patches, that not following the order meant the prescribed dose was not administered and may not manage the resident’s pain, and that she was aware the previous patch was present before the new one was administered. The facility policy stated medications are administered in accordance with prescriber orders.
Opened Undated Insulin Vial Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure medications and biologicals were properly stored when an opened and undated multi-dose vial of Novolin N for Resident 41 was found in the medication storage room refrigerator. During a concurrent observation and interview, the Assistant Director of Nursing identified the vial in the refrigerator and stated it should have been dated when opened to confirm it remained usable. During a later interview, the Director of Nursing acknowledged the opened and undated Novolin N vial was found in the medication storage room refrigerator. The DON stated that when a licensed nurse opens a multi-dose vial, it should be labeled with the date, and if the opened vial came from home, it would either be discarded or sent back to the family. The facility policy on medication labeling and storage stated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date, and the Novolin N label information stated opened vials can be stored at room temperature up to 77°F and should be thrown away after 42 days.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment, leading to potential food contamination. During a kitchen observation, the Dietary Supervisor (DS) served fish that was not cooked to the recommended temperature of 145 degrees Fahrenheit, with initial temperatures recorded as low as 109.1 degrees Fahrenheit. Additionally, raw fish fillets were improperly thawed on the countertop, contrary to the facility's policy which requires thawing in a refrigerator, under running water, or in a microwave. The facility also failed to maintain proper labeling and dating of food items in a resident's refrigerator, which contained unlabeled, undated, and expired items such as yogurt, protein drinks, and milk. The DS acknowledged that the refrigerator should be monitored daily to prevent the storage of expired items, but it was only checked weekly. Furthermore, the DS did not follow proper hand hygiene and glove use protocols, as observed when she picked up items from the floor without washing her hands or changing gloves, risking cross-contamination. The kitchen equipment and food carts were not cleaned appropriately, with the microwave and plate warmer found to have visible residue. The cleaning schedule did not include the microwave, and the plate warmer was not cleaned after each use. Food carts were cleaned with an incorrect bleach solution concentration, despite the availability of a quaternary sanitizing solution. These lapses in sanitation practices could lead to foodborne illnesses among the 56 residents receiving food from the kitchen.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 25% error rate during medication administration for four residents. Licensed Vocational Nurse (LVN) 3 left seven medications on Resident 53's bedside table without observing the resident take them, contrary to the facility's policy and procedure. The resident was in a rush and requested the medications be left for later consumption, but there was no order for self-administration, and LVN 3 acknowledged the mistake during an interview. Registered Nurse (RN) 1 administered Repaglinide to Resident 43 during a meal, despite the medication's requirement to be taken 30 minutes before meals as per the prescriber's order and FDA guidelines. This action was inconsistent with the facility's policy that medications should be administered according to prescriber orders and within the specified time frame to ensure optimal therapeutic effect. LVN 3 also failed to follow professional standards for insulin administration for Residents 219 and 24. Insulin was administered without proper blood sugar checks, and the technique used did not align with the facility's policy or the American Diabetes Association's guidelines. For Resident 24, insulin was administered during a meal without a prescribed blood sugar check, and LVN 3 admitted there was no order for pre-meal blood glucose checks, which was confirmed by the Assistant Director of Nursing (ADON).
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. In one instance, a medicine bottle containing FETILIDE 500 MCG was found in a resident's bedside drawer without an order or assessment allowing the resident to self-administer the medication. The facility's policy requires that residents may only self-administer medications if the attending physician and interdisciplinary planning team have determined it is safe. Additionally, during a medication pass, an LVN prepared Adult Tussin DM for a resident from an opened and undated bottle, contrary to the facility's policy that requires the open date to be marked. Further deficiencies were noted with medication labeling and storage. A registered nurse prepared Sevelamer Carbonate for a resident, but the medication label did not reflect the current order, which had been changed. An inspection of a medication cart revealed an opened and undated multi-dose insulin vial, which should have been discarded 28 days after opening. Controlled drugs of discharged residents and discontinued medications were improperly stored in the medication cart, along with a resident's money, which should have been kept in a safe by social services. The facility also failed to remove expired biologicals from active storage. A bottle of Assure Dose Control Solution was found stored beyond its expiration date. Additionally, a medication cart was left unlocked and unattended in the hallway during a medication pass, violating the facility's policy that requires all medications and biologicals to be stored in locked compartments when not in use. These practices were acknowledged by the staff during interviews, indicating a lack of adherence to the facility's policies and procedures regarding medication management.
Incorrect Scoop Size Used for Serving Green Beans
Penalty
Summary
The facility failed to ensure that meals were plated in accordance with the approved menu, specifically regarding the serving size of green beans. During a kitchen observation, it was noted that an employee used a green scoop, which measures 1/3 cup, instead of the required gray scoop, which measures 1/2 cup, to serve green beans to residents during lunch. This discrepancy was confirmed during an interview with the dietary staff, who acknowledged the incorrect scoop size was used. The facility's menu and tray tickets indicated that 49 residents were to receive regular textured green beans, and the failure to use the correct scoop size had the potential to result in these residents not receiving the prescribed amount of nutrients according to their dietary needs.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food for a lunch meal, specifically meatballs and pureed green beans, which affected 34 residents who received these items according to their diet orders. The facility's policy required that food temperatures be checked before service, with hot entrees needing to be at or over 120 degrees Fahrenheit at delivery. However, during an observation, it was found that the food temperatures were not measured before the trayline started. When temperatures were eventually taken, the meatballs were found to be below the required temperature, with readings as low as 102.2 degrees Fahrenheit. The Registered Dietitian confirmed that the meatballs were cooler than ideal when sampled. Additionally, the pureed green beans were found to be extremely salty and did not taste like green beans, unlike the regular textured green beans which were not overly seasoned. The Registered Dietitian and Dietary Supervisor both confirmed the difference in taste, with the pureed version being notably saltier. This discrepancy in food preparation and taste was not in line with the facility's recipe guidelines, which emphasized preparing tasteful meals and adjusting seasoning as needed.
Incomplete Contracts for Dialysis and Transportation Services
Penalty
Summary
The facility failed to provide a completed written agreement for dialysis services and transportation to dialysis, which were being provided by an external agency. During an interview and record review, it was revealed that the facility had an internal agreement request form for nursing home dialysis transfer, dated May 18, 2021, which was not an actual contract. The Administrator confirmed that this was merely a request for an agreement and not a finalized contract. Additionally, the facility's transportation contract, dated January 1, 2024, was found to be incomplete as it lacked the signature of the facility representative, although it was signed by the Owner/CEO of the transportation agency. The Administrator acknowledged that the contract was not signed by the facility. Furthermore, when the facility's dialysis contract was requested on two separate occasions, the Administrator stated that it was still pending and not available for review, indicating that the facility did not have a formal contract on file for the dialysis services being provided.
Facility Exceeds Licensed Bed Capacity
Penalty
Summary
The facility failed to operate within its licensed capacity by admitting more residents than permitted. The facility is licensed for 62 skilled nursing beds, as per the State of California, Department of Public Health. However, a review of the Detailed Census Report for September 2024 revealed that the facility admitted 63 to 64 residents on multiple days throughout the month, specifically on September 1, 2, 4, 9, 15, 16, 19, 23, 24, 25, 26, 27, and 29. This resulted in the facility exceeding its licensed capacity for a total of 13 days. During an interview on October 18, 2024, the Administrator acknowledged admitting more residents than the licensed capacity, citing approval from the Fire Marshall for a temporary increase to 68 beds, with plans to further increase to 70 beds pending approval of a facility application submitted on August 6, 2023. Despite this, the facility's official license only permits 62 skilled nursing beds, indicating a failure to comply with the licensing requirements and regulations.
Failure to Obtain POLST on Admission
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) was obtained upon admission for a resident, identified as Resident 219. This oversight was discovered during an interview and record review, where it was noted that the POLST form was missing from the resident's clinical record. The absence of this critical document could potentially lead to the resident's end-of-life wishes not being honored in an emergency situation. The resident was admitted with several medical conditions, including a fracture of the left femur, gait and mobility abnormalities, type 2 diabetes, anxiety disorder, and hypertension. Despite the resident having no cognitive impairment, as indicated by the Minimum Data Set (MDS), and a Do Not Resuscitate (DNR) order being placed, the POLST form was not completed. The Licensed Vocational Nurse (LVN) involved in the review confirmed the absence of the advance directive and/or POLST form in the resident's records. According to the California Emergency Medical Services Authority, the POLST form should be completed by a healthcare provider based on the patient's preferences and medical indications, and it does not replace the advance directive. The lack of this documentation highlights a failure in the facility's admission process to ensure that the resident's medical treatment preferences were properly documented and accessible.
Inaccurate MDS Encoding for a Resident
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) for one of the residents, identified as Resident 20, by incorrectly documenting a diagnosis of depression. This error was discovered during a review of Resident 20's medical records, which included a face sheet, active diagnoses list, and discharge summary. The face sheet, dated October 18, 2024, listed multiple diagnoses such as spinal stenosis and low back pain but did not include depression. During interviews and record reviews with the MDS Director, it was confirmed that depression was not an active diagnosis for Resident 20, nor was it part of the resident's past medical history as per the discharge summary dated September 9, 2024. The MDS assessment for Resident 20, dated September 11, 2024, inaccurately indicated an active diagnosis of depression. This discrepancy was acknowledged by the MDS Director, who confirmed that the assessment did not reflect the resident's actual medical condition. The facility's policy on certifying the accuracy of resident assessments, last revised in November 2019, requires that any person completing any portion of the MDS assessment must sign it to certify its accuracy. This policy was not adhered to in the case of Resident 20, leading to the inaccurate documentation of the resident's condition.
Deficiencies in Care Plan Development for Two Residents
Penalty
Summary
The facility failed to develop an accurate comprehensive care plan for two residents, Resident 20 and Resident 31, which led to deficiencies in their care. For Resident 20, the care plan inaccurately indicated that Duloxetine was prescribed for depression, despite the absence of a depression diagnosis in the resident's medical records. The Interim Director of Nursing (IDON) confirmed that the care plan was incorrect as the medication was actually prescribed for chronic low back pain, a condition documented in the resident's medical history. For Resident 31, the facility did not develop a care plan for the indefinite use of Cephalexin, an antibiotic prescribed for recurrent urinary tract infections (UTIs). The resident's care plan lacked documentation for monitoring the side effects of the medication and the signs and symptoms of UTIs. The Licensed Vocational Nurse (LVN) acknowledged that the care plan for Cephalexin was only added on the day of the interview, although it should have been completed when the medication was initiated. The facility's policy requires that a comprehensive person-centered care plan be developed within seven days of the completion of the required MDS assessment and completed within 21 days of admission. The failure to adhere to this policy resulted in care plans that were not person-centered or specific enough to meet the residents' medical and physical needs.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice and its own policies and procedures in the administration of insulin for two residents. During a medication pass observation, an LVN prepared and administered insulin to Resident 219 without following the correct procedure. The LVN did not inject air into the insulin vial before drawing the medication, which is necessary to prevent a vacuum. Additionally, the LVN administered the insulin injection at a 90-degree angle without pinching the skin, contrary to the facility's policy that requires pinching the site and holding the syringe for 5 to 10 seconds before removal. For Resident 24, the LVN obtained a glucose reading during a meal, which is against the facility's policy that requires blood glucose checks before meals. The LVN then administered insulin without a prescribed glucose check order for pre-meal administration. The LVN acknowledged the absence of a specific order for pre-meal glucose checks in the resident's electronic health record (EHR) and proceeded with the administration based on a sliding scale order. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires blood glucose checks before meals and that insulin should be administered following specific procedures, including injecting air into the vial and pinching the skin at the injection site. The facility's policy and the American Diabetes Association guidelines emphasize the importance of these steps to ensure proper insulin administration and absorption.
Deficiency in Language Translation Services
Penalty
Summary
The facility failed to provide necessary language translation services for a resident whose primary language is Japanese. Despite the resident's request for a translator, multiple staff members were unaware of how to access translation resources beyond using family members or a communication board. This lack of awareness and resources was evident during interviews with staff, including a registered nurse and a licensed vocational nurse, who admitted to relying on family or non-verbal communication for translation needs. The Director of Social Services confirmed that the facility does not subscribe to any medical translation services and typically relies on family members or communication boards for translation. In cases where more complex communication is required, staff were advised to use translation applications like Google Translate. This deficiency in providing adequate translation services could hinder proper assessment and communication of the resident's needs.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor a resident on psychotropic medication for behavioral symptoms, side effects, and adverse consequences. Resident 220, who was admitted with diagnoses including schizophrenia, was prescribed amisulpride, a psychotropic medication not available in the USA, and was allowed to use their own supply. The informed consent for the use of this medication was obtained seven days after the resident's admission, contrary to the facility's policy that requires informed consent prior to administration. Additionally, the monitoring of the resident's behavior and side effects did not commence until seven days after the medication was first administered. This delay in monitoring was acknowledged by the Assistant Director of Nursing during an interview. The facility's policy mandates that monitoring should begin as soon as the medication is administered, which was not adhered to in this case. This oversight had the potential to place the resident at risk for adverse health consequences, impacting their mental, physical, and psychosocial well-being.
Resident Exceeded Prescribed Acetaminophen Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident was administered Acetaminophen beyond the parameters ordered by the medical provider. The resident, who was admitted in 2024 with multiple diagnoses including fractures of the left femur and left humerus, had two orders for Acetaminophen. The first order was for 500 mg to be given twice daily with a maximum of 3 grams in 24 hours, and the second order was for 325 mg to be given every 4 hours as needed, also not to exceed 3 grams in 24 hours. On specific dates, the resident received 1000 mg of Acetaminophen three times a day, and additional doses of 650 mg were administered, resulting in the resident exceeding the maximum allowed dosage of 3000 mg in 24 hours. Both the LVN and the Interim Director of Nursing acknowledged that the resident was given Acetaminophen over the prescribed limit, which could potentially affect liver function. The facility's policy on administering medications, dated 2001, indicated that medications should be administered in accordance with prescriber orders.
Failure in Kitchen Staff Competency for Manual Warewashing
Penalty
Summary
The facility failed to ensure the competency of one kitchen staff member in manual warewashing using the three-compartment sink, which is essential for cleaning and sanitizing utensils and food-contact surfaces. This deficiency was identified during an observation and interview with the Dietary Aide (DA) and the Dietary Supervisor (DS). The DA incorrectly described the procedure for using the three-compartment sink, omitting the crucial step of sanitizing. According to the facility's policy, the first compartment is for washing with detergent and hot water, the second for rinsing with clean hot water, and the third for sanitizing with a solution. However, the DA stated that the first sink was for scraping food, the second for washing with soap, and the third for rinsing in plain water, without mentioning the sanitizing step. The DS confirmed that the procedure should include scraping, washing, rinsing, and sanitizing, with the first sink for washing, the second for rinsing, and the third for sanitizing. The failure to ensure the DA's competency in this procedure had the potential to result in contamination of food, utensils, and equipment, which could lead to illness caused by pathogens. This deficiency was noted as affecting one of the eight kitchen staff members responsible for manual warewashing when the dish machine is not operational.
Inadequate Diet Order Options for Renal Patients
Penalty
Summary
The facility failed to ensure that its electronic medical record system provided physicians with appropriate diet order selections for residents with renal insufficiency or failure, consistent with current standards of practice and the terminology used by the approved diet manual. This deficiency was identified during a review of the facility's policy and procedure on therapeutic diets, which indicated that the terminology of physician-ordered diets should match that used by the Food and Nutrition Services department. However, the facility's electronic system only offered a 'Liberal Renal' diet option, which was not defined in the facility's diet manual and did not align with the specific dietary needs of residents with renal conditions. The deficiency affected three residents who were prescribed a renal diet. For instance, one resident's physician ordered a 'Liberal Renal' diet, which included an extra bowl of gravy and low potassium, but there was no approved guidance for this term. Another resident with end-stage renal disease on dialysis was prescribed a 'CCHO, Liberal Renal' diet with double protein and no concentrated sweets, which did not conform to the standards of practice. The Registered Dietitian and Dietary Supervisor confirmed that the 'Liberal Renal' diet was not in the diet manual, and the electronic medical record did not provide options consistent with the facility's approved diet manual, potentially leading to inappropriate nutrient levels for the residents involved.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards for Resident 19, who was on enhanced barrier precautions (EBP) due to multiple antibiotic resistances and the presence of an indwelling urinary catheter. During an observation, Physical Therapist (PT) 1 and Occupational Therapist (OT) 1 were seen providing care to Resident 19 without wearing the necessary personal protective equipment (PPE), specifically gowns, which are required for high-contact activities under EBP. This oversight occurred despite the resident's condition, which included quadriplegia and a neurogenic bladder, necessitating the use of a Foley catheter. The Infection Preventionist (IP) confirmed that staff should wear gowns and gloves when performing activities such as dressing, bathing, or transferring residents on EBP. However, during the observed session, PT 1 and OT 1 were only wearing gloves while repositioning and assisting Resident 19 with exercises and transfers. The IP acknowledged the absence of appropriate PPE and noted the lack of signage indicating the EBP requirements for Resident 19. The facility's policy on transmission-based precautions, revised in September 2022, supports the use of additional PPE for residents with risk factors for multi-drug resistant organisms (MDROs), which was not followed in this instance.
Failure to Ensure RN Assessments for Residents with Changes in Condition
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed an assessment for four sampled residents when they experienced a change in condition. Resident 1, who had diagnoses including a left ankle wound, congestive heart failure, and osteopenia, was found hanging upside down from a hoyer lift and later complained of severe head pain. Despite this, an LVN, rather than an RN, assessed the resident, who was later diagnosed with a neck fracture. Similarly, Resident 2, with diagnoses including sepsis, diabetes, and heart failure, had an unwitnessed fall, but no RN assessment was completed. Resident 3, with a fractured femur, hypertension, and osteomyelitis, also experienced a fall without an RN assessment. Resident 4, with osteoarthritis, atrial fibrillation, and fibromyalgia, was found lying on the floor after a fall, again without an RN assessment. During an interview, the Director of Nursing stated that LVNs perform assessments on residents with changes in conditions, which contradicts the facility's job description for LVNs. The job description for LVNs includes tasks such as catheterization, tube feedings, and taking vital signs but does not include performing resident assessments. This practice of allowing LVNs to perform assessments instead of RNs led to a failure in providing appropriate care and assessment for residents experiencing significant changes in their conditions.
Failure to Prevent Injury During Transfer
Penalty
Summary
The facility failed to prevent an injury to a resident during a transfer from a wheelchair to a bed using a hoyer lift. The resident, who had severe cognitive impairment and required extensive assistance for daily activities, was being transferred by two CNAs. During the transfer, the hoyer lift's wheels were obstructed by wound vacuum tubing on the floor. One CNA left the resident's side to move the tubing, causing the resident to panic, scream, and flip upside down, hitting her head on the base of the hoyer lift. The resident experienced severe pain and sustained a bump on the back of her head. The incident was observed by an occupational therapist who responded to the resident's scream and found her hanging upside down from the hoyer lift. A vocational nurse assessed the resident and decided to transfer her to the bed. The resident complained of severe pain and was noted to have a small bump on her head. The facility's policies on safe lifting and movement of residents, as well as the use of mechanical lifting devices, were reviewed and found to include guidelines for assessing the resident's condition and ensuring their comfort during transfers. However, these guidelines were not adequately followed, leading to the resident's injury.
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What surveyors actually found near you
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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 Burlingame
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millbrae Care Center | 1 mi | ★★★★★ | 24 | 0 |
| San Bruno Skilled Nursing | 3.4 mi | ★★★★★ | 18 | 0 |
| Brookside Skilled Nursing Hospital | 5.2 mi | ★★★★★ | 10 | 0 |
| San Mateo Medical Center D/p Snf | 6.2 mi | ★★★★★ | 4 | 0 |
| Linda Mar Care Center | 6.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.