Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Pioneer House during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, documented as lacking decision-making capacity and assessed as high risk for elopement, refused the wander management system (WMS), yet the care plan did not include specific interventions to monitor safety, address the mental illness diagnosis, or reduce elopement risk. Progress notes showed the resident was restless, agitated, and on high elopement risk, but staff did not document monitoring strategies. When the resident was discovered missing, an LPN did not announce Code Pink, administration was not notified for more than two hours, and police were notified several hours later, contrary to facility policy requiring immediate Code Pink, prompt administration notification, and police notification if the resident was not located after 30 minutes. Staff interviews confirmed the absence of WMS use, difficulty monitoring residents leaving the floor, and lack of a Code Pink announcement, while the DON acknowledged the missing care plan interventions and the failure to follow the elopement procedures.
A resident with extensive burn wounds and homelessness was discharged without arrangements for home health nursing, food, or transportation for follow-up care. The facility did not contact community resources, provide written instructions, or ensure the resident could manage her medical needs post-discharge. Staff interviews confirmed the lack of individualized discharge planning and failure to meet the resident's health and safety needs.
A resident receiving Olanzapine for schizophrenia had no schizophrenia diagnosis documented in the EMR or MDS, and the same resident was observed without a prescribed cervical collar even though the order required it at all times. In addition, one resident with a PEG tube had no documented weights for several months despite an order for routine monitoring, and another resident on dialysis did not have daily weights entered in the EHR as ordered.
Failure to provide nail care and ADL assistance: Two residents with significant neurologic impairments were observed with untrimmed fingernails containing dark debris, and staff confirmed the nails had not been cleaned or trimmed as expected. One resident required full assistance with personal hygiene, and both residents had care plans directing staff to assist with ADLs and keep fingernails short.
Failure to provide accessible fluids to a resident at risk for dehydration. A resident with MS who required set-up assistance for drinking was repeatedly observed without water within reach, with the bedside table out of reach on multiple occasions. The resident stated she was thirsty and wanted water, and a CNA confirmed there was no water available. Intake records showed very limited fluid intake, and the DON stated staff were expected to offer water for hydration and comfort.
Improper medication storage and expired medications were found during observation and interview. An LPN observed nasal spray and eye drops stored with oral meds on a med cart, and a clear plastic bag labeled only with a resident's first name contained an inhaler and a nasal spray. In the med supply closet, multiple vitamins and anti-diarrhea meds were expired. The DON confirmed the items should not have been stored together and the expired meds should have been discarded.
Unsafe food storage and sanitation practices were observed in the kitchen. A trash can by the handwashing sink was left without a liner and contained used items, clean utensils were found with food debris and stored in a dirty tray, and several pitchers and pans were stacked wet in clean storage. A leaking refrigerator evaporator, a leaking coffee station faucet, and a food processor leak were also observed, along with reused wiping cloths, continued food prep without handwashing or glove changes, and sanitized cups stored too close to the handwashing area.
A facility failed to follow infection control practices for two residents. One resident received a tube feeding bolus with an unlabeled syringe, and two staff members provided direct care without wearing gowns while the residents were on EBP. The residents’ care plans called for adherence to EBP, and the facility policy identified tube feeding device care and wound care as high-contact activities requiring gown and glove use.
Pest control program failed to prevent a cockroach infestation in the kitchen, dining hall, and nearby areas. A resident reported a cockroach on her body and another resident saw cockroaches in the dining hall, while a DA said roaches were entering via meal carts. Surveyors observed cockroaches under the sink, on the dining hall counter wall, and near the dining area entrance, and records showed live German cockroaches and harborage in the kitchenette.
Controlled medication records were not accurately reconciled for two residents with PRN opioid orders. For one resident, Hydromorphone was documented on the MAR but not the CDR, and another dose was documented on the CDR but not the MAR. For the second resident, Oxycodone was documented on the MAR but not the CDR, and another dose was documented on the CDR but not the MAR. The DON confirmed the missing documentation and stated the CDR should be signed and accurate.
A resident with severe cognitive impairment and a history of wandering was not wearing a required wander guard device for multiple shifts, despite physician orders and care plan directives. Staff failed to ensure the device was in place or to document its absence, resulting in the resident leaving the facility unsupervised and being found by law enforcement miles away without the device.
A resident with severe cognitive impairment and a history of aggression wandered unsupervised, entering other residents' rooms and physically assaulting two residents, resulting in pain, injury, and fear. Staff and residents reported that the aggressive resident was not adequately monitored, despite known risks and prior incidents, and the facility failed to protect residents from abuse as required by policy.
A resident with encephalopathy and dysphagia was not provided the therapeutic diet ordered by their physician, receiving a pureed meal instead of the prescribed soft and bite-sized texture. This discrepancy was confirmed by facility staff, including a CNA, LN, and the DON, highlighting a failure to adhere to the facility's policy on therapeutic diets.
A resident with multiple health conditions requiring substantial assistance for ADLs was unsafely discharged to a room and board facility without confirming necessary in-home supportive services (IHSS). The facility's SSD and DON failed to verify the availability of IHSS, relying instead on the resident's self-assessment and the room and board representative's understanding. This oversight led to the resident being unable to care for themselves, resulting in hospitalization.
A facility failed to complete and provide an inventory of personal belongings sheet to a resident upon admission, as required by policy. The resident, admitted with anxiety, confirmed that no inventory was conducted, and no copy was given. The DON acknowledged the lack of documentation, which could lead to the resident's belongings being lost or stolen.
A resident with a history of aggression and inappropriate behavior verbally threatened and physically assaulted another resident, causing injury and distress. Another resident experienced multiple episodes of sexual inappropriateness from the same resident. Despite awareness of the resident's behaviors, the facility failed to implement effective interventions to ensure the safety of the affected residents.
A facility failed to document the admission weight of a resident with dysphagia and severe protein-calorie malnutrition, as required by physician orders. The absence of this documentation was confirmed by the ADON, DON, and NC, and the facility could not provide their policy for Admission Assessment despite requests.
A resident, dependent on staff for grooming and hygiene due to cerebral infarction and muscle weakness, did not receive scheduled showers as per their care plan. The resident's care plan required bathing at least twice a week, but records showed only two showers were provided over a specified period. Facility staff confirmed the oversight, acknowledging the failure to adhere to the resident's care plan.
The facility failed to store medications in their original containers for 16 residents, as observed with unlabeled pills in plastic cups in a medication cart. A Licensed Nurse confirmed the safety concern, and the DON highlighted the risk of incorrect identification. Facility policy mandates medications remain in original packaging.
The facility failed to maintain food safety and sanitation standards, affecting 42 residents. Expired and unlabeled food items were found in the kitchen, and there were no temperature logs for certain storage areas. Ice and water dispensers were unclean, and food tray lids were improperly stored on a dirty oven top. The Dietary Manager confirmed these deficiencies.
The facility failed to maintain proper infection control practices, including housekeeping staff not changing gloves, lack of handwashing in the laundry room, and no corrective action for positive legionella tests. LN 1 and CNAs did not perform hand hygiene when passing lunch trays, and LN 1 did not follow Enhanced Barrier Precautions for a resident with spina bifida and paraplegia.
A resident's right to retain personal possessions was violated when their cell phone was taken without permission after they used it to call 911 due to unresponsive staff. The facility failed to investigate or document the incident, and the phone's whereabouts remain unknown, despite policies requiring prompt investigation of such issues.
A resident reported an incident of sexual and physical abuse to an LN, resulting in a bruise, but the facility failed to investigate or report the allegation. Interviews revealed staff were unaware of the abuse protocol, and the DON and ADM were not informed. The facility's policy requires immediate reporting and investigation, which was not followed, leaving the resident feeling unsafe.
A resident was served meals in polystyrene containers with plastic utensils without any documented orders or dietary instructions, leading to feelings of neglect and diminished self-worth. The DON and DM confirmed the lack of orders for this practice, acknowledging it as a dignity issue. The facility's policy on resident rights, which includes the right to a dignified existence, was not followed.
The facility failed to maintain secured handrails in the corridors of Unit A and Unit B, as required by regulations. Observations showed a resident with impaired cognition and difficulty walking using a walker in a corridor without handrails, and two other residents navigating another corridor also lacking handrails. The Maintenance Supervisor confirmed the handrails were removed for painting and repairs, with no timeline for reinstallation. The DON acknowledged the increased risk of falls and injuries due to the absence of handrails and admitted the facility lacked a policy for handrails.
The facility failed to ensure that call lights were within reach for two residents, placing them at risk of not being able to ask for assistance. The call lights were found bundled up in a basket above the bedside dresser, out of reach. Staff confirmed the call lights were out of reach and stated they usually place them within reach for resident safety. The facility's policy indicated call lights should be accessible when residents are in bed.
Failure to Prevent Elopement and Follow Elopement Procedures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement measures to prevent an avoidable elopement for a resident with schizoaffective disorder who was assessed as high risk for elopement and lacked decision-making capacity. The resident’s Wandering Risk Assessment identified a high elopement risk, and physician orders and admission documentation indicated the resident did not have capacity to understand choices and make decisions. The care plan documented that the resident was non-compliant with the wander management system (WMS) and was a fall risk, but it did not include nursing interventions for monitoring safety or reducing elopement risk, nor did it address the resident’s schizoaffective disorder or how related behaviors would be monitored. Progress notes documented that the resident refused the WMS and was on high elopement risk, with restlessness and agitation, but staff did not document monitoring interventions or best practices to keep the resident safe from elopement. On the date of the incident, a licensed nurse documented at 7:35 p.m. that the resident was not found in the facility, but there was no documentation that a Code Pink was announced as required by the facility’s elopement emergency procedures. The same nurse documented at 10:05 p.m. that the DON was notified the resident had left the facility, indicating an administration notification delay of more than two hours. A later progress note at 3:17 a.m. showed the DON faxed notification to the police department, exceeding the policy requirement to notify police if the resident is not located after 30 minutes. Staff interviews revealed that residents outside smoking after the main entrance doors locked at 5 p.m. needed to ring a doorbell for re-entry and that one CNA could not tell when residents left the floor if busy elsewhere and confirmed the resident did not wear a WMS and no Code Pink was heard. The DON confirmed the resident lacked capacity, was high risk for elopement, that the care plan did not address the mental illness diagnosis, and that there were no interventions for monitoring safety when the WMS was not worn. The facility’s policies required identification of residents at risk for wandering/elopement, inclusion of safety strategies in the care plan, and initiation of the elopement/missing resident emergency procedure, including announcing Code Pink, notifying administration, and notifying police if the resident was not located after 30 minutes.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was homeless and required ongoing care for multiple burn wounds. The resident, admitted with third-degree burns covering 20-29% of her body, muscle wasting, mobility disorders, and MRSA carrier status, was discharged without proper arrangements for home health nursing services, food, or transportation to follow-up medical appointments. The case manager/social worker did not contact homeless shelters or home health agencies, nor did she provide the resident with written discharge instructions or information for follow-up care. The resident was only verbally informed of her discharge the day before and was not advised of her right to appeal the discharge. The discharge plan was not individualized or reviewed with the resident, and the facility did not ensure that the resident's needs and preferences were met. The administrator attempted to secure a motel room for three nights but did not make a reservation or arrange for food, nursing care, or a long-term shelter solution. There was no documentation of a discharge plan or communication with the resident regarding the plan. The facility's own policy required a discharge summary and plan to be developed and reviewed with the resident and family at least 24 hours before discharge, but this was not followed. Interviews with facility staff, including the DON and wound nurse, revealed a lack of awareness and preparation for the resident's discharge needs. The wound nurse acknowledged that the resident would not be able to care for wounds on her back and had not provided any education or training for wound care. The facility's failure to coordinate post-discharge care, secure appropriate shelter, and provide necessary information and resources resulted in a discharge process that did not address the resident's health and safety needs.
Missing Diagnoses, Unfollowed Collar Order, and Incomplete Weight Monitoring
Penalty
Summary
The facility failed to maintain accurate clinical documentation and follow physician orders for three residents. Resident 20 had diagnoses including spinal cord injury in the neck area and fractures of the neck and lower back spine, but the medical record and MDS did not include a diagnosis of schizophrenia even though the resident was receiving Olanzapine 5 mg at bedtime for schizophrenia and auditory hallucinations. The resident confirmed awareness of the medication and stated it was used to manage the voices he heard, and facility staff confirmed the diagnosis was missing from both the EMR and MDS. Resident 20 also had a current order to wear a cervical collar at all times due to spinal injury, but was observed lying in bed without the collar in place. The collar was on the bedside table, and the resident stated it had been removed the night before and not reapplied. A nurse confirmed she did not offer the collar to the resident, and the DON confirmed the order was current and that the resident should have been wearing it at all times. Resident 36 had diagnoses including digestive system surgery and malnutrition, with a PEG tube in place and a care plan calling for weights on admission, monthly, and as indicated. The last documented weight was 105.4 lbs. on 7/9/25, and no weights were recorded for August through December. Resident 2 had a diagnosis involving kidney failure and received dialysis twice weekly, with an order for daily weights placed on 10/21/25. The EHR showed the last weight entry on 10/31/25, and the DON and nurse consultant confirmed daily weights were not entered as ordered.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to ensure residents were assisted with activities of daily living to maintain personal hygiene when nail care was not performed for two sampled residents. Resident 33 was admitted with diagnoses including stroke with loss of movement to one side of the body and high blood sugar. Her MDS dated 9/29/25 indicated she could not perform personal hygiene without full staff assistance. During an observation on 12/1/25, Resident 33’s right-hand fingernails were long with thick dried dark matter underneath each nail and dried dark matter around the cuticles. She stated it would be nice if her nails were clean. A nurse later confirmed the nails were not clean and stated nails should be cleaned and trimmed for hygiene and infection control reasons. The resident’s care plan directed staff to keep fingernails short and monitor/document ADL abilities and assist as needed, and the facility’s ADL and fingernail care policies addressed hygiene and prevention of infection. Resident 23 was admitted in May 2025 with diagnoses including hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage affecting the left dominant side. His care plan, revised on 11/3/25, identified him as at risk for altered ADLs and directed staff to provide assistance with ADLs as indicated. On 12/2/25, his left-hand fingernails were observed to be untrimmed and containing a dark brown substance underneath. A later observation on 12/3/25 showed the fingernails still had not been trimmed and cleaned. On 12/4/25, an LPN confirmed nail care had not been provided and stated staff were expected to perform nail care on Sundays.
Failure to Provide Accessible Fluids to a Resident at Risk for Dehydration
Penalty
Summary
The facility failed to ensure that Resident 4 was offered sufficient fluid intake to maintain proper hydration. Resident 4 was admitted with multiple sclerosis, and the MDS dated 11/5/25 indicated she required set-up assistance to drink fluids. Her care plan, revised 11/13/25, identified her as at risk for fluid volume deficit related to impaired mobility and directed staff to offer fluids as tolerated or as indicated by diet order. A review of Resident 4's fluid intake sheet showed only 240 ml on 12/1/25 and 240 ml on 12/3/25. During multiple observations, Resident 4 was found in bed or in her room without water within reach, and her bedside table was not reachable on several occasions. On 12/1/25, she stated she was thirsty and wanted water. On 12/2/25, she again indicated she was thirsty, and CNA 3 confirmed that she did not have water within reach. On 12/3/25, Resident 4 still did not have water available and her bedside table was not within reach. The DON stated that staff were expected to offer water to residents for hydration and comfort, and the facility policy titled Hydration - Clinical Protocol stated staff would provide supportive measures such as providing fluids.
Improper Medication Storage and Expired Medications
Penalty
Summary
Safe medication storage was not maintained for a census of 49 when expired medications were found available for resident use and medications were stored improperly. During a concurrent observation and interview with LN 2, a nasal spray and eye drops were observed stored next to oral medications on the medication cart, and LN 2 confirmed they should not be mixed with oral medications. In the same observation, a clear plastic bag labeled only with a resident's first name contained an oral inhaler and a nasal spray, and LN 2 confirmed these items should not be stored together due to cross contamination. During a concurrent observation and interview with LN 2 in the medication supply closet, multiple vitamins and anti-diarrhea medications were found expired, and LN 2 confirmed they needed to be discarded so residents would not receive expired medications. The DON later reviewed pictures of the expired medications and items stored together in the medication cart and confirmed the medications should not have been stored together and the expired medications should have been discarded because of the potential for cross contamination and infection. The facility policy titled Medication Labeling and Storage stated outdated or deteriorated medications or biologicals are to be returned or destroyed, medications are to be stored in an orderly manner, and medications for external use are to be clearly marked and stored separately from other medications.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
Food was not stored, prepared, and handled in a sanitary manner in the kitchen for residents receiving meals from the facility. During observation, a trash can located by the handwashing sink was found without a plastic liner and contained used gloves, paper towels, and coffee creamer cups. The dietary aide confirmed the condition of the trash can and stated that a liner should have been replaced after the previous shift disposed of trash. The dietary consultant stated that trash cans and bins should not be overflowing, must be kept clean, and should have liners replaced each time trash is removed. Clean kitchen utensils were also found contaminated or improperly stored. Several utensils inside a plastic tray had food debris on them, and the bottom of the tray used to store clean utensils contained visible dirt and food residue. In addition, several plastic pitchers and metal pans were observed stacked while still wet in the clean dish storage area. The dietary consultant confirmed that utensils and kitchenware should be visibly clean before storage and should be completely dry before being stacked and stored. Equipment and nearby storage areas were observed in conditions that affected food handling. Water from a leaking evaporator in a resident food refrigerator was collected in a plastic pan placed on top of the shelf used to store resident food, and the dietary manager stated the evaporator had been broken for some time. During food processor use, liquid leaked from the bowl onto the base and countertop, and the cook wiped the liquid with a cloth taken from another countertop, reused the same cloth when the leak occurred again, and continued food preparation without washing hands or changing gloves. Water was also observed leaking from the hot water faucet at the coffee station onto the shelf where clean resident coffee urns were stored, with a mixture of clear and brown liquid on the shelf beneath the urns. Sanitized coffee cups were placed near the handwashing station directly beneath the soap dispenser, and a white foamy substance was observed on the tray holding the cups; staff confirmed the cups were stored too close to the handwashing area.
Infection Control Lapses During Tube Feeding and EBP Care
Penalty
Summary
Proper infection prevention and control practices were not followed for two sampled residents. Resident 23, who was admitted with diagnoses including hemiplegia, hemiparesis following a non-traumatic intracerebral hemorrhage affecting the left dominant side, and dysphagia, was observed receiving a tube feeding bolus with an unlabeled syringe. During the observation, the LN confirmed the syringe was not labeled with a date and stated that tube feeding syringes should be labeled with a date. The IP later stated that tube feeding syringes should be labeled with a date to prevent use beyond 24 hours, which could increase the risk of infection. The facility policy for enteral feedings indicated that administration sets for open-system enteral feedings should be changed at least every 24 hours or as specified by the manufacturer. The facility also failed to follow Enhanced Barrier Precautions for direct care activities involving two residents. Resident 19, who was admitted with pneumonia, had a care plan directing staff to monitor adherence to EBP guidelines, especially gown and gloves during high-contact activities. During observation, a CNA replaced Resident 19's soiled dressing covering a tracheostomy scar without wearing a gown and confirmed he was not wearing one. Resident 23 also had a care plan directing adherence to EBP guidelines, and during the tube feeding bolus observation, the LN did not wear a gown while providing care and acknowledged that she should have worn one. The DON stated that staff were expected to follow EBP guidelines during direct care, and the facility policy identified device care and wound care as high-contact activities requiring gown and gloves.
Pest Control Program Failed to Prevent Cockroach Infestation
Penalty
Summary
The facility failed to implement an effective pest control program to prevent cockroach infestation in the kitchen, dining hall, and surrounding areas. During interviews, a resident reported waking up one night with a cockroach on her body and seeing a large cockroach on the bathroom wall, and another resident stated that cockroaches were crawling on the walls in the dining hall. A dietary aide stated that the facility had undergone a major pest control spray the prior month and that pest control services had been visiting weekly to spray the kitchen, adding that cockroaches were entering the kitchen via the meal carts used to transport trays to and from resident rooms. During observation, the nurse consultant confirmed cockroaches under the kitchen sink behind exposed pipes. A cockroach was also observed crawling along the dining hall countertop wall and then scurrying into an opening between the countertop and wall. Later, a cockroach was observed emerging from behind the medication cart and crawling on the wall near the entrance to the residents' dining area. Facility records showed pest control services on multiple dates in late October and November 2025, and an official inspection report documented 13 live adult German cockroaches between the cabinet edge and countertop in the 6th floor dining room kitchenette, along with fecal focal points and insulation around water pipes under the dishwasher contributing to cockroach harborage.
Controlled Medication Records Were Not Reconciled
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications for two residents who had as-needed opioid orders. For one resident, the Medication Administration Record (MAR) showed Hydromorphone 4 mg was administered at 12:33 a.m., but that dose was not documented on the Controlled Drug Record (CDR). The CDR for that resident also showed one Hydromorphone 4 mg tablet removed from the medication card at 11 p.m. on 11/30/25, but that removal was not documented on the MAR. For the second resident, the MAR showed Oxycodone 5 mg was administered at 3:42 a.m., but that dose was not documented on the CDR. The CDR for that resident also showed one Oxycodone 5 mg tablet removed from the medication card at 3:27 p.m. on 11/29/25, but that removal was not documented on the MAR. During interview and record review, the DON confirmed the missing documentation on both the CDR and MAR and stated she would expect the CDR to be signed and to be an accurate record.
Failure to Ensure Use of Wandering Device for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate supervision and ensure that a resident at high risk for elopement was wearing a required wandering device, as ordered by the physician and outlined in the care plan. The resident, who had severe cognitive impairment with a BIMS score of 4/15, a history of dementia, falls, and spinal fracture, was known to wander and exhibit exit-seeking behaviors. Staff interviews confirmed that the resident was supposed to wear a wander guard on the left ankle, which would trigger an alarm if the resident approached an exit. However, documentation in the Medication Administration Record (MAR) indicated that the resident was not wearing the device for six consecutive shifts prior to the incident. On the day of the incident, the resident was able to leave the facility unsupervised and without staff knowledge. The absence of the wandering device was confirmed by both staff and the resident's responsible party, who reported not seeing the device on the resident prior to the elopement. The resident was later found by law enforcement more than two miles from the facility, without the wandering device, and was returned to the facility. The facility's own policies required identification of residents at risk for wandering and implementation of safety interventions, including the use of a wander guard, but these were not followed in this case. Record reviews and staff interviews further revealed that nurses were expected to check and document the presence of the wandering device each shift, and to immediately replace it if missing. Despite these expectations, there was no documentation or action taken to ensure the device was in place during the period leading up to the resident's elopement. The failure to follow physician orders, care plan interventions, and facility policy directly led to the resident's unsupervised exit from the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two residents experiencing pain, injury, and fear for their safety. One resident with severe cognitive impairment, Alzheimer's disease, and a history of behavioral disturbances was known to wander unsupervised and had prior incidents of aggression. This resident entered another resident's room, touched personal belongings, ate food, and became physically aggressive when confronted, swinging her arms and making physical contact that resulted in redness on the other resident's neck. The affected resident, who had intact cognition and a history of depression and chronic pain, reported feeling abused and expressed fear, leading him to avoid activities and remain in his room for safety. In a separate incident, the same resident with cognitive impairment approached another resident in the dining room, touched her belongings, and slapped her on the back of the head when she tried to intervene. The resident who was struck, who had moderate cognitive impairment, hemiplegia, and mental health diagnoses, complained of pain and expressed feeling unsafe and wanting to leave the facility. Witnesses, including another resident and staff, confirmed the aggressive behavior and noted that the resident responsible for the incidents was not monitored at all times, despite being on special monitoring due to her known wandering and aggression. Staff interviews revealed that the facility did not provide sufficient supervision to prevent the aggressive resident from entering other residents' rooms or causing harm. Multiple staff members and residents reported that the aggressive resident frequently wandered unsupervised and that staff were often too busy to monitor her continuously. The facility's policy stated that residents have the right to be free from abuse, including abuse by other residents, but the observed incidents and staff accounts demonstrated a failure to uphold this standard.
Failure to Provide Correct Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for one of the sampled residents, who was admitted with diagnoses including encephalopathy and dysphagia. The physician's order specified a regular diet with soft and bite-sized texture, but the resident received a meal with a pureed food item and a tray card indicating a mince moist diet. This discrepancy was confirmed during observations and interviews with a Certified Nurse Assistant (CNA), a Licensed Nurse (LN), a kitchen staff member, and the Director of Nursing (DON). The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department, was not followed. The DON acknowledged that the diet provided did not match the physician's order, and the kitchen staff confirmed that the mince moist and soft, bite-sized diets are different orders. This failure had the potential to impact the resident's nutritional status, as the diet provided did not align with the resident's treatment plan and preferences.
Unsafe Discharge of Resident Without Adequate Support
Penalty
Summary
The facility failed to provide a safe discharge for a resident who was discharged to a room and board facility that did not meet their care needs. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and a right leg above the knee amputation, required substantial assistance for activities of daily living (ADLs) such as toileting, showering, dressing, bed mobility, and transfers. Despite this, the resident was discharged without ensuring that the necessary in-home supportive services (IHSS) were in place, leading to the resident living in an unsafe environment. Interviews and record reviews revealed that the Social Service Director (SSD) and the Director of Nursing (DON) did not confirm the availability of IHSS before the resident's discharge. The SSD relied on the resident's self-assessment and the room and board representative's (RBR) understanding that IHSS would be provided, but did not verify this information. The resident's Minimum Data Set (MDS) indicated a need for substantial assistance, yet the discharge plan did not adequately address these needs, resulting in the resident being unable to care for themselves and eventually requiring hospitalization. The facility's policy and procedure for preparing a resident for discharge were not followed, as the post-discharge plan was not adequately developed or confirmed. The SSD did not document discussions with the RBR regarding the resident's functional abilities and the room and board's capacity to provide care. The lack of documentation and confirmation of IHSS services contributed to the unsafe discharge, as the resident was left without the necessary support to manage their ADLs independently.
Failure to Provide Inventory of Personal Belongings
Penalty
Summary
The facility failed to ensure that an inventory of personal belongings sheet was completed and a copy was provided to a resident upon admission. This deficiency was identified for one of the three sampled residents, who was admitted with a diagnosis that included anxiety. The review of the resident's Admission Record indicated that the Inventory of Personal Effects sheet, dated shortly after admission, lacked the resident's signature on the 'Certification of Receipt' portion. Furthermore, there was no documented evidence in the resident's closed record, nurse's notes, or admission record that the resident signed the inventory sheet or received a copy upon admission. During a telephone interview, the resident confirmed that an inventory of belongings was not conducted upon admission, and a copy of the inventory sheet was not provided. The Director of Nursing (DON) acknowledged that the facility could not provide documentation that the resident received a copy of the inventory sheet. The facility's policy and procedure for admitting residents, dated September 2013, required that all personal items be inventoried, recorded, and signed by the resident or a family member, with a copy provided to them. This failure had the potential for the resident's personal belongings to be lost or stolen.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, who had a known history of verbal aggression and sexual inappropriateness. Resident 3 was verbally threatened and physically assaulted by Resident 1, resulting in physical injury and emotional distress. Despite Resident 1's history of aggression, there was no documented evidence that the resident had been referred or evaluated by a psychiatrist as ordered by the physician. Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1. The facility's care plan for Resident 2 did not contain any interventions to ensure the resident's safety, despite the resident's report of feeling uncomfortable and dirty due to Resident 1's actions. The facility's staff, including the Assistant Director of Nursing, were aware of Resident 1's behaviors but failed to take adequate measures to protect Resident 2. Interviews with staff and residents revealed that Resident 1 had a history of inappropriate behavior, including making sexual advances towards staff and residents. Despite this, the facility did not implement effective interventions to prevent further incidents. The facility's policy on safety and supervision of residents was not adequately followed, leading to the failure to protect Residents 2 and 3 from abuse.
Failure to Document Admission Weight for Resident
Penalty
Summary
The facility failed to follow physician orders for a resident when the resident's weight was not measured at admission. The resident was admitted with diagnoses including dysphagia and severe protein-calorie malnutrition. A review of the resident's Order Summary Report (OSR) dated 10/31/24 indicated an order for an admission weight, which was not documented. During an interview and record review with the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, it was confirmed that there was no admission weight recorded for the resident, and thus no way to track potential weight loss. Additionally, the facility was unable to provide their policy and procedure for Admission Assessment, which should include documentation of a resident's admission weight, despite requests made on 11/26/24 and 11/27/24.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living (ADLs) independently, received the necessary services to maintain grooming and personal hygiene. The resident, admitted with diagnoses including cerebral infarction and muscle weakness, was dependent on staff for grooming and hygiene care and required assistance from one to two staff members for bathing. The resident's care plan indicated a preference for showers and required bathing at least twice a week. However, a review of the resident's bathing tasks revealed that the resident only received showers on two occasions within a specified period, with no bathing tasks completed for over a week. During an interview and record review, facility staff, including the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, confirmed the resident's dependency on staff for hygiene needs and acknowledged the failure to provide showers as scheduled. The facility's policy on supporting ADLs emphasized the necessity of providing appropriate care and services for residents unable to carry out ADLs independently.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. During an observation and interview with a Licensed Nurse (LN) at Medication Cart 1, it was found that there were three 30 mL plastic cups in the top drawer, each containing two or more unlabeled and unidentified items. The LN confirmed that the plastic cups were not labeled and contained various pills, including a pink pill, a red liquid-gel pill, two orange-colored pills, and seven red and white liquid-gel pills. The LN acknowledged that medications should not be removed from their original packaging, citing this as a safety concern. In a subsequent interview with the Director of Nursing (DON), it was confirmed that medications are not to be removed from their original packaging, as this poses a safety hazard. The DON emphasized that the next nurse taking over the medication cart would not know what these pills are, highlighting the potential for incorrect identification and misuse. A review of the facility's policy and procedure on Medication Labeling and Storage indicated that medications and biologicals should be stored in their original packaging, and only the issuing pharmacy is authorized to transfer medications between containers. The policy also states that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and medications may not be transferred between containers.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner for 42 residents. During an inspection, an expired half-gallon of milk, opened salad dressing, and creamer containers without open dates were found in the kitchen refrigerators. Additionally, full egg crates were found without received or expiration dates labeled. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled and the expired milk discarded. Furthermore, there were no temperature monitoring logs for the resident food freezer section and the dry storage room, which the Dietary Manager confirmed should have been in place. The inspection also revealed that the ice and water dispensers in the dining room were not clean, with white and brown residue observed on the surfaces. The Dietary Manager confirmed the unclean state of the dispensers. Additionally, lids used for covering prepared food on the steam table were stored on top of an unclean oven top, which was observed to have a dusty sticky residue. The Dietary Manager acknowledged the unclean surface and the improper storage of food tray lids. These findings indicate a failure to adhere to the facility's policies and procedures for food safety and sanitation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to potential cross-contamination and infection risks. Housekeeping staff were observed dipping contaminated gloves into mop bucket sanitizing solution without changing gloves, which was confirmed by the housekeeper and the infection preventionist as cross-contamination. Additionally, the laundry room lacked a handwashing station, and staff did not use gowns when handling dirty laundry, failed to sanitize equipment after handling dirty laundry, and did not perform hand hygiene after glove removal or between resident room visits. Contaminated clothes hangers were also hung back on the clean linens cart. The facility was unable to provide evidence of timely corrective action following positive legionella tests in the water systems. A review of the facility's water management plan revealed a positive legionella testing report, but no evidence of corrective action or retesting was available. The infection preventionist confirmed that interventions and retesting were expected but not documented. Licensed Nurse 1 and Certified Nursing Assistants 2 and 3 did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays. Additionally, LN 1 did not follow Enhanced Barrier Precautions when providing wound care for a resident with spina bifida and paraplegia, who had nephrostomy tubes and a sacral wound. The infection preventionist confirmed that staff should have worn gowns during high-contact care activities, as indicated by the Enhanced Barrier Precautions policy.
Failure to Maintain Resident's Right to Personal Possessions
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal possessions, specifically a cell phone, was maintained. The resident, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, reported that their cell phone was taken away after they used it to call 911 due to unresponsive nursing staff at night. The resident was unaware of the current location of the cell phone. Interviews with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON) confirmed that the resident was admitted with a cell phone and chargers, but the SSD admitted to not following up on the whereabouts of the phone after it was reportedly taken by firefighters. The facility's policies and procedures, which were reviewed, indicate that residents are allowed to retain personal possessions and that any complaints of misappropriation should be promptly investigated. However, the SSD and the Director of Nursing (DON) both acknowledged that they did not know the current location of the resident's cell phone, and no documentation was found regarding the outcome or location of the phone. The facility's failure to investigate and document the incident violated the resident's rights as outlined in their policies and procedures.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident, identified as Resident 21, who reported an incident of sexual and physical abuse to a Licensed Nurse (LN). Resident 21, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, expressed feeling unsafe and neglected within the facility. The resident reported to LN 4 that two CNAs were involved in the alleged abuse, which resulted in a bruise on the resident's hand. Despite being a mandated reporter, LN 4 did not take appropriate action to report the sexual abuse allegation, considering it a non-emergency situation. Interviews with facility staff revealed a lack of understanding and execution of the facility's abuse reporting protocol. CNA 4 indicated she would report incidents to a nurse or supervisor but was unsure about the availability of an abuse binder. LN 2 stated she would notify the DON and ADM, check the policy for abuse reporting, and inform the state authorities, but was unaware of the location of the abuse binder. The DON and ADM were not informed of the incident and were unaware of the abuse allegation until the surveyor's review. The facility's policy requires all reports of abuse to be immediately reported to the administrator and relevant authorities, with thorough investigations conducted by management. However, the policy was not followed in this case, as the ADM, who is the abuse coordinator, was not notified, and no investigation was initiated. The failure to adhere to the policy resulted in the incident not being reported or investigated, leaving Resident 21 feeling unsafe and unsupported.
Resident Served Meals in Polystyrene Containers Without Justification
Penalty
Summary
The facility failed to provide an environment that supported the quality of life for one resident, identified as Resident 21, by serving meals in polystyrene containers with plastic utensils. This was observed during a visit to Resident 21's room, where the resident expressed dissatisfaction and a lack of understanding as to why meals were served in this manner. The resident felt neglected and expressed feelings of hopelessness, indicating a negative impact on their self-worth and well-being. Upon review of Resident 21's records, it was confirmed by both the Director of Nursing (DON) and the Dietary Manager (DM) that there were no physician orders or dietary instructions specifying the use of polystyrene containers and plastic utensils for this resident. The DON acknowledged that this practice was a dignity issue, potentially making the resident feel singled out. The facility's policy on Resident Rights, which emphasizes the right to a dignified existence and participation in care planning, was not adhered to in this instance.
Absence of Secured Handrails in Facility Corridors
Penalty
Summary
The facility failed to ensure that the corridors in Unit A and Unit B had firmly secured handrails, as required by the California Code of Regulations. This deficiency was identified through observations, interviews, and record reviews. During an observation, a resident with severely impaired cognition and difficulty walking was seen using a walker in the Unit A corridor, which lacked secured handrails. The resident confirmed the absence of handrails and expressed that having them would enhance safety by providing support for balance. Further observations revealed that two residents were seen navigating the Unit B corridor, which also lacked secured handrails. The Maintenance Supervisor confirmed that the handrails had been removed over three weeks prior for painting and repairs, with no clear timeline for reinstallation. The Director of Nursing (DON) acknowledged that the handrails had been absent for over a month and admitted to not having a specific date for their return. Additionally, the facility did not have a policy or procedure in place regarding handrails. The absence of handrails in the facility's corridors posed a potential risk of increased falls and injuries for residents using these areas. The DON, who started working at the facility after the handrails were removed, agreed that the lack of handrails heightened the risk of falls and injuries. The facility's failure to comply with the regulation requiring firmly secured handrails in corridors was evident, as confirmed by the observations and interviews conducted during the survey.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents, placing them at risk of not being able to ask staff for assistance. Resident 2, who has dementia, a history of falling, and glaucoma, and Resident 4, who has dementia, chronic kidney disease stage 3, and hypertension, were observed to have their call lights bundled up and placed in a black basket above the bedside dresser, out of their reach. During an interview, a Certified Nurse Aide confirmed the call lights were out of reach and stated that they usually place the call lights within reach so that residents feel safe and can call for assistance. The Administrator also confirmed that staff are expected to always place the call lights within reach of the residents. The facility's policy and procedure on answering call lights indicated that call lights should be accessible to residents when in bed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 685 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mid-town Oaks Post-acute | 1.6 mi | ★★★★★ | 27 | 0 |
| River Bend Nursing Center | 2.2 mi | ★★★★★ | 31 | 0 |
| Mckinley Park Care Center | 2.2 mi | ★★★★★ | 31 | 0 |
| Saylor Lane Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
| University Post-acute Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.