Below 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 River Pointe Post-acute during CMS and state inspections, most recent first.
A resident with acute respiratory failure with hypoxia, CHF, ischemic cardiomyopathy, and sleep apnea was ordered oxygen at 1 L/min via NC at bedtime only, but was observed on continuous oxygen with the concentrator set at 5 L/min. An LN acknowledged the order was not followed, another LN said she did not verify the flow rate after taking over care, and the DON confirmed there was no order for continuous oxygen despite documentation showing daytime and nighttime oxygen use.
A resident admitted with sepsis and dry gangrene of a toe underwent an outpatient amputation of the left second toe, after which a podiatrist issued detailed post-surgical orders for activity restriction, limb elevation, bathing precautions, wound care, and signs/symptoms to report. These orders were entered into the electronic order summary but did not populate onto the MAR/TAR due to a coding error, so the treatment nurse and other nurses did not implement or document the ordered post-amputation care. Several nurses reported they either were unaware of the amputation or had no orders on the MAR/TAR to follow, and the DON confirmed there was no documentation that the post-surgical orders were carried out, despite facility policies requiring complete and accurate documentation of treatments and services.
A resident with anxiety, depression, and physical disability but intact cognition experienced misappropriation of property when a CNA repeatedly solicited and received money and used the resident’s debit card for personal purchases. Bank records and text messages showed multiple money requests and transactions tied to the CNA, while facility notes documented the resident’s emotional distress, social withdrawal, and loss of interest in activities following discovery of the financial losses. The resident reported feeling pressured to provide money, stated she had not authorized the extent of withdrawals, and indicated she had not been informed by the facility not to give money to staff, despite staff interviews and facility policy confirming that asking for or accepting money from residents is prohibited and considered potential financial abuse.
A resident with mobility limitations and dependence on staff for shower transfers did not receive scheduled showers as required by their ADL care plan and facility policy. Documentation showed missing or incomplete weekly shower records and only one shower per week over several weeks, despite staff statements that all residents are scheduled for twice-weekly baths with refusals documented. The resident and a family member reported multiple missed showers and that the resident sometimes went an entire week with only one shower, without having requested reduced frequency, contrary to facility expectations for maintaining personal hygiene.
Failure to Protect Confidential Meal Ticket Information: A dietary aide discarded meal tickets containing residents’ names, allergies, adaptive utensil needs, and therapeutic diet orders into a trash bin with food waste. The IDSS confirmed the tickets were thrown away in trash bags and later disposed of in the dumpster, and stated this was a breach of privacy. The RD and ADM also stated the tickets contained PHI and should have been shredded.
Failure to follow pureed diet recipes resulted in excess broth, excess milk, and unmeasured food thickener being added to pureed chicken and noodles for several residents. A cook prepared the items without using the ordered recipe amounts, and the RD confirmed the food was not prepared to the proper consistency for residents on pureed diets and could reduce nutrient value.
Undated dry goods, an expired beverage with an unfastened lid, and an opened frozen food package without an open date were found in dietary storage. Surveyors also observed two wet steam table pans stored on shelves and another pan with brown dried food residue inside, while the IDSS and RD confirmed these conditions did not meet food safety expectations.
A resident admitted with nontraumatic subarachnoid hemorrhage had a POLST in the chart, and the MDSC confirmed an advance directive had been created, but a copy of the advance directive was not present in the medical record. The DON confirmed the missing document and stated staff were expected to obtain and file it with the resident's records, consistent with the facility policy requiring advance directives to be maintained and readily retrievable.
A resident admitted with acute and chronic respiratory failure was discharged, but the discharge MDS was not submitted to CMS in a timely manner and remained overdue by 134 days. The MDSC confirmed the omission, and the DON stated staff were expected to follow the required MDS submission timeframes in the CMS RAI Manual.
Failure to use a communication board for a resident with limited English proficiency. A resident with metabolic encephalopathy and Spanish as his primary language had a care plan directing staff to use a communication board to support communication, but staff did not have the board available and instead spoke in English without clarifying his needs during multiple observations. The LN confirmed the board was not available, and the SSD confirmed staff were not given the board despite the care plan.
A resident with DM and protein-calorie malnutrition had documented dislikes of chicken, turkey, and fish, and her care plan called for appropriate protein alternatives when those foods were served. During lunch, staff placed yogurt on her tray as the protein substitute, but the RD stated it was inadequate for her protein needs; the IDSS identified a vegetarian patty as a suitable alternative, and the yogurt provided only 3 g of protein compared with 7 g in the veggie patty.
A nurse administered TPN to a resident on EBP for a central venous catheter without wearing a gown. The resident had multiple diagnoses including perforated intestine and protein-calorie malnutrition, and the facility policy required gloves and gown for high-contact care for residents with indwelling devices such as central lines.
Two residents did not have call lights kept within reach or usable. One resident with MS, glaucoma, weakness, and a hand contracture could not use a regular call light tied to the bed rail, and the ADM confirmed a touch pad call light was needed. Another resident with acute respiratory failure and a tracheostomy was observed multiple times without the call light within reach, and staff confirmed call lights should be kept within reach so residents can call for help.
A contracted phlebotomist failed to follow contact precautions while drawing blood from a resident with an MRSA sacral wound infection who had physician-ordered contact precautions in place. The phlebotomist entered the room and performed a blood draw without wearing a gown, left the room and handled phlebotomy equipment without changing gloves or performing hand hygiene, then returned to continue the procedure. The phlebotomist was unable to describe required contact precautions and subsequently entered another resident’s room to draw blood without cleaning the equipment, contrary to facility policy and expectations stated by the IP and DON.
Misappropriation of Resident Funds by CNA: A resident with anxiety, depression, and intact cognition was solicited by a CNA for money and had a debit card used for personal purchases. The resident reported repeated requests for money, unauthorized card use, and significant emotional distress, including feeling hurt, betrayed, depressed, and socially withdrawn. Facility records and interviews confirmed the CNA requested and received money and gifts, and the ADM stated staff receiving money or gifts from residents was against policy.
Missed Scheduled Showers: A resident who was totally dependent on shower transfer and had diagnoses including mobility abnormalities and heart failure did not receive showers as scheduled. Shower sheets showed one week with no documented shower and other weeks with only one shower, despite staff stating showers were expected twice weekly and refusals should be documented. The resident stated he had missed multiple showers, felt dirty, and preferred more than one shower per week.
A resident with a known banana allergy experienced an anaphylactic reaction after being served Banana Cream Pie, despite clear documentation of the allergy in their records and meal ticket. The incident required emergency administration of epinephrine, and staff interviews confirmed that established procedures to prevent allergen exposure were not followed.
A resident with upper extremity impairment and cognitive intactness was not assisted with her dentures before breakfast, despite her care plan indicating a need for substantial help. The CNA who served her breakfast was unaware of the resident's dentures, and the DON acknowledged the importance of this assistance for proper nutrition.
Three unlabeled medication cups containing white cream were found on a resident's dresser, with staff confirming the cream was not labeled and should not have been left at the bedside. The resident reported the cream was lidocaine applied by a nurse, and the DON acknowledged this was not acceptable practice according to facility policy requiring medications to be stored in locked compartments.
A resident with severe cognitive impairment, hemiplegia, and a high fall risk was left unsupervised in their room without a 1:1 sitter, as required by their care plan. The resident was found sitting on the edge of the bed with the call light on the floor and no staff present, despite needing assistance with meals and continuous supervision. Staff confirmed the supervision requirement and that the assigned sitter had left the resident unattended.
A resident with intact cognitive function and significant medical needs experienced delays in staff response due to a malfunctioning call light system. When the resident activated the call light, only the light above the room door illuminated, while the corridor call lights failed to activate. Staff confirmed the issue and noted that the system had not been reprogrammed after servicing, and the problem had not been reported to maintenance or leadership.
A resident with cognitive and communication deficits was physically assaulted by another resident known for daily aggressive behaviors, resulting in a bruise and visible fear. Despite care plans addressing the aggressor's history of anger and aggression, staff confirmed ongoing verbal and physical abuse, and the vulnerable resident was not protected from harm.
Two residents, one with violent behavior and another with dementia, were involved in a physical and verbal altercation. An LPN witnessed the incident and reported it to a supervisor, but the required abuse report was not filed with authorities as mandated by facility policy and state law.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A CNA was scheduled and worked with an expired certification, as confirmed by employee file review and staff interviews. The DSD acknowledged the lapse in tracking certification renewals, and the DON stated that a system should be in place to prevent such occurrences. This failure resulted in non-compliance with state requirements for CNA certification.
A resident with severe cognitive impairment and a staff member did not have documented evidence of being offered or receiving the COVID-19 vaccine, nor was there documentation of refusal or contraindication. Facility staff confirmed that required procedures for offering and documenting COVID-19 vaccination were not followed for these individuals, despite policy requirements.
Three residents did not receive scabies medications as ordered: one did not receive prescribed Permethrin or Ivermectin, another received Permethrin on two consecutive days instead of once, and a third experienced a delay in Permethrin administration without documentation. The ADON confirmed these deviations from physician orders and facility policy.
A resident with a suspected scabies infection was removed from contact precautions before receiving the prescribed Permethrin cream treatment, contrary to physician orders and facility policy. Staff confirmed that the resident had not received the required medication and that contact isolation was discontinued prematurely, despite the presence of visible rashes.
A resident in an LTC facility was struck on the hand by another resident, resulting in a bruise. The incident occurred when the second resident, who was severely cognitively impaired, entered the first resident's room, leading to a physical altercation. The first resident, who was cognitively intact, attempted to push the second resident's wheelchair out of the room, prompting the strike. The second resident had a history of aggressive behavior and was on psychotropic medications. Facility policies on abuse prevention and altercations were not effectively implemented to prevent this incident.
A CNA failed to wear a protective gown while changing a resident's soiled brief, violating the facility's infection control policy. The resident, admitted with a skin infection and an indwelling Foley catheter, required Enhanced Barrier Precautions to prevent the spread of multi-drug resistant organisms. The Infection Preventionist confirmed the necessity of gown use during high-contact care.
A facility failed to maintain food safety standards, risking contamination for 105 residents. Issues included an unclean ice machine, improperly stored kitchenware, unlabeled and expired food, and incorrect thawing processes. Dietary staff lacked knowledge of dishwashing procedures, and a staff member violated the dress code by not fully covering their hair.
The facility failed to properly dispose of garbage and refuse, as observed with two outside dumpsters that were not adequately closed, and the surrounding area was littered with debris. Observations with the Dietary Supervisor and Environmental Services Manager confirmed that the dumpster lids were open, and there was scattered trash around the area. The Registered Dietitian emphasized the need for closed lids and a clean surrounding area to prevent pests and rodents.
The Dietary Services Supervisor (DS) failed to demonstrate necessary competencies in food safety procedures, including proper thawing of meats, correct sanitizer concentration for dishwashing, and maintaining hair restraint in the kitchen. Observations revealed improper thawing practices and inadequate knowledge of sanitizer use, with expired ServSafe certification. The facility administrator plans to address these issues under the QAPI program.
A Dietary Aide in an LTC facility demonstrated inadequate competency in dishwashing procedures, failing to correctly use test strips and verbalize proper manual dishwashing steps. This posed a risk to 105 out of 108 residents who consumed food from the facility, despite the aide having attended relevant training and holding a valid food handler certificate.
The facility failed to follow the planned menu, resulting in dietary discrepancies for residents. Two residents on large portion diets received fewer meatballs than prescribed, while four residents on renal diets were served pudding instead of cookies. Additionally, residents on low fat and low cholesterol diets received whole milk and margarine, and those on finger food diets were given rice and tapioca pudding instead of the specified items. None of the residents received the parsley garnish as indicated on the menu.
The facility failed to adhere to professional standards for two residents. A resident's medications were left unattended, contrary to policy, without a Medication Administration Assessment or care plan documentation. Another resident's oxygen tubing was found unconnected, resulting in inadequate oxygen delivery. Both incidents were against facility policies, as confirmed by staff interviews.
The facility failed to ensure a safe environment by not having a smoking policy or supervising two residents with respiratory conditions who smoked on the premises. The ADON acknowledged the absence of policies and the risk of accidents, including fire. Additionally, a resident's care plan did not address smoking safety, despite the need for supervision being noted in their assessment.
A facility was found to have a 20.69% medication error rate when a nurse improperly administered medications to a resident with a PEG tube. The nurse crushed and combined medications, failing to flush the tube as required, leading to a blockage and incomplete administration. This was against the prescribed orders and facility policy, posing a risk to the resident's condition.
A resident with a PEG tube received omeprazole in crushed pill form instead of the prescribed liquid suspension, leading to a blockage in the syringe during administration. The facility's policies and physician orders were not followed, posing a risk of PEG tube blockage and absorption issues.
The facility failed to securely store discontinued and destroyed medications, as observed in two medication rooms. Cabinets containing medications were found unlocked, and a biohazard bin with medications was easily accessible. The DON confirmed the lack of security, which contradicts the facility's policy requiring locked storage and limited access to authorized personnel.
The facility failed to implement action plans for an infection control issue as part of their QAPI program, affecting 108 residents. A PIP was initiated, but key tasks such as in-service training, competency checks, and weekly skin sweeps were not documented. Interviews revealed incomplete training and lack of required monthly reviews, contrary to the facility's QAPI policy.
The facility failed to maintain effective infection control, with personal items on the floor, improper PPE use for a resident on Enhanced Barrier Precautions, unlabeled urinals, unsanitized blood pressure cuffs, and soiled linens on the floor. These actions posed infection risks, contrary to the facility's policies.
A resident's room was found to be unsafe and unsanitary, with electrical devices improperly plugged into a power strip, oxygen tubing on the floor, and clutter creating a fire hazard. The room was also unclean, with a sticky substance on the floor identified as feces. These conditions violated the facility's policies on electrical safety and maintaining a homelike environment.
The facility failed to maintain resident rights when four staff members did not wear ID badges, affecting three residents. One resident with moderately impaired cognition and another with intact cognition expressed concerns about not knowing their caregivers due to the absence of ID badges. Observations confirmed that two LNs and two CNAs were not wearing badges, contrary to facility policy requiring ID badges for safety and security.
A resident with multiple medical conditions, including diabetes and osteomyelitis, did not receive prescribed MASD treatment on eight PM shifts. The treatment, which included cleansing and applying zinc oxide, was not documented as completed, contrary to physician's orders and facility policy. This lapse was confirmed by a nurse and acknowledged by the administrator.
A resident in the facility did not have a functional call system in the bathroom, despite having medical conditions that necessitate such a system. The issue was reported to maintenance months prior but remained unresolved. Staff interviews confirmed the absence of a call bell, contrary to facility policy and CMS guidelines.
A facility failed to notify a resident's representative about a room change, potentially causing distress. The resident, diagnosed with gangrene and Parkinson's Disease, was moved without informing the representative, who expressed concern. The DON and SSD confirmed the absence of documentation regarding the notification or reason for the room change, contrary to facility policy.
A resident with gangrene and Parkinson's Disease was neglected in terms of hygiene care, as the facility failed to provide scheduled showers. The resident's representative reported the resident appeared dirty and unkempt. The DON could not find documentation of showers being offered, received, or refused, contrary to facility policy requiring such records.
Improper Oxygen Flow Rate and Continuous Oxygen Use Without Order
Penalty
Summary
The facility failed to ensure safe administration of supplemental oxygen for one resident with diagnoses including acute respiratory failure with hypoxia, congestive heart failure, ischemic cardiomyopathy, and obstructive sleep apnea. The resident’s physician order dated 3/25/26 directed oxygen at 1 L/min via nasal cannula at bedtime every shift for sleep apnea. During observation on 5/19/26, the resident was found in bed with oxygen via nasal cannula and the concentrator set at 5 L/min. The resident stated the setting was “way too much” and reported that oxygen had previously been at 3 L/min, though she did not know when or who increased it. She also stated she was receiving oxygen at night and during the daytime. During interviews and record review, an LN stated the resident was supposed to receive oxygen at 1 L/min at night only and acknowledged the observed continuous 5 L/min setting did not follow the physician order. A second LN stated she had been told the resident was on continuous oxygen but had not checked the concentrator or flow rate after taking over care. The DON reviewed the record and confirmed there was no order for continuous oxygen administration, while nurses’ documentation showed oxygen use during both daytime and nighttime on multiple days in May contrary to the order. The facility policy required verification of a physician order before oxygen administration and adjustment of the delivery device to the proper flow rate.
Failure to Implement and Document Post-Amputation Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement and document a podiatrist’s post-surgical care orders for one resident following an amputation of the left second toe. The resident was admitted with diagnoses including an upper arm fracture and sepsis, had a BIMS score of 15 indicating no cognitive impairment, and was documented as capable of making her own health decisions. A physician progress note indicated the resident had dry gangrene of the left second toe and that outpatient amputation was recommended. A nursing progress note later documented that the resident went out to podiatry, had the second toe amputated, and that new orders were received. The podiatrist’s post-surgical orders, entered into the Order Summary Report on 3/2/26, included activity restrictions (no heavy lifting, pushing, or straining until cleared by the MD), instructions to keep the surgical foot/ankle above heart level as much as possible for two weeks, bathing instructions to avoid getting the cast/bandage wet, and detailed wound care directions to keep the cast/bandage clean, dry, and intact, not to remove it, and to add bandages and call specified hospital numbers if bleeding continued. The orders also included signs and symptoms to report to the physician, such as temperature greater than 100.4°F, excessive pain not controlled with medications, excessive nausea/vomiting, and increased bleeding from the incision site. However, review of the March Treatment Administration Record showed these post-surgical orders were not present on the TAR. Multiple nurses, including the treatment nurse and several licensed nurses who provided care to the resident in March, stated they did not implement the podiatrist’s post-surgical orders because the orders were not present on the MAR or TAR, and one nurse reported not being informed that the resident had the toe amputation. The treatment nurse confirmed that once orders are placed in the TAR, wound care and other nurses carry them out and document them, and acknowledged there was no documentation that the post-amputation orders were implemented between 3/2/26 and 3/10/26, when the resident was transferred to the hospital for abnormal lab results. The DON confirmed that the admitting nurse was responsible for entering orders into the electronic record so they would appear on the MAR/TAR, verified that the post-amputation orders were not on the TAR, and acknowledged there was no documented evidence that the orders had been carried out. The administrator stated that a coding error by the nurse entering the podiatrist’s orders resulted in the orders not appearing on the TAR. Facility policies required that all services and treatments be completely and accurately documented in the medical record and that medication and treatment orders be consistent and effective.
Failure to Prevent CNA Financial Exploitation of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a CNA solicited and obtained money and used the resident’s debit card for personal use. The resident was admitted with anxiety disorder, depression, and limitations of activities due to disability, and had an intact BIMS score of 14. The resident reported a sudden depletion of funds from her bank account after being informed by the bank that her balance was low and that her debit card may have been used inappropriately. Facility staff assisted the resident in reviewing recent bank transactions and identified multiple transactions associated with food delivery services, and text messages between the resident and the CNA showed repeated requests for money. Progress notes and interdisciplinary team documentation indicated that the resident verbalized feeling upset, concerned, and emotionally distressed after discovering the financial transactions. The resident reported difficulty recognizing appropriate financial boundaries with staff, expressed that her trust had been violated, and stated she did not want to see the staff member involved. Over several days, activity and nursing notes documented that the resident was emotional, upset, hurt, disappointed in herself and the CNA, and that she found it hard to understand why someone would do this, making it hard for her to trust others. The resident was noted to be mostly in her room, sleeping much of the day, socially withdrawn, and not interested in activities. Interviews and record review confirmed that the CNA had requested and received money and gifts from the resident multiple times, including ATM withdrawals using the resident’s debit card. Text messages reviewed with the resident showed the CNA requested money on multiple specific dates over several weeks. The resident stated she had allowed the CNA to use her card but had not given permission to take money to the extent that occurred, and she reported feeling pressured to give money and that she had never been told by the facility not to give money to staff. Facility staff, including a nurse, another CNA, social services, and the DON, stated that staff are trained and expected not to ask for or receive money or gifts from residents and that such conduct could constitute financial abuse or misappropriation of resident property. The facility’s abuse prevention policy stated residents have the right to be free from misappropriation of resident property and exploitation and that administration will protect residents from abuse by facility staff.
Failure to Provide Scheduled Showers and ADL Support
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically scheduled showers, for one resident. The resident was admitted in late winter 2026 with diagnoses including walking and mobility abnormalities, need for assistance with personal care, and heart failure. An MDS dated 1/26/26 showed the resident had no memory impairment and was totally dependent on staff for shower transfers. The resident’s ADL care plan, initiated 1/28/26, identified ADL self-care needs and risk for pressure injury and skin breakdown, with instructions that skin discoloration should be noted during baths. Review of shower documentation showed the facility could not produce a shower sheet for the week of 1/14/26, indicating the resident did not receive a shower that week, and subsequent weekly shower sheets dated 1/22/26, 1/26/26, and 2/2/26 each showed only one shower provided that week. Staff interviews confirmed that facility practice and expectation were for residents to receive showers twice weekly, with showers offered on either AM or PM shifts and refusals documented on shower sheets. A licensed nurse stated showers were expected two times per week and could be offered in the evening if a resident was unavailable due to appointments. A CNA reported that all residents were scheduled for baths twice per week, that no residents were scheduled once weekly unless they refused, and that refusals and skipped baths were reported to the nurse and documented. The ADON confirmed that shower sheets were used to document all showers and refusals, and that showers were scheduled twice weekly. In contrast, the resident and a family member reported that multiple showers had been missed, with the resident stating he sometimes skipped an entire week and only received one shower, and that he had not requested to receive only one shower per week. Facility policies on Abuse and Neglect and on ADLs required staff to institute measures to address residents’ needs to minimize neglect and to provide services necessary to maintain grooming and personal hygiene, which were not followed in this case.
Failure to Protect Confidential Meal Ticket Information
Penalty
Summary
The facility failed to maintain privacy for residents when meal tray tickets containing residents’ names, food allergies, adaptive eating utensil needs, and therapeutic diet orders were discarded in the trash. During a concurrent observation and interview on 3/9/26 at 9:54 a.m., the Interim Dietary Services Supervisor was observed overseeing dietary aides cleaning up breakfast trays, and Dietary Aide 1 threw the meal tickets into a trash bin with uneaten food. The Interim Dietary Services Supervisor confirmed that kitchen staff discarded the meal tickets into trash bags that were then disposed of in the facility’s garbage dumpster, and stated she was unaware of another method to dispose of the tickets to protect residents’ private information. She also stated that discarding the meal tickets in the trash was a breach of residents’ privacy. During interviews, the Registered Dietician stated on 3/10/26 at 3:45 p.m. that residents’ privacy was breached by discarding the meal tickets in trash bins because the tickets contained private health information, including allergies and doctor’s orders for therapeutic diets, and should have been fed into a paper shredder. On 3/12/26 at 8:54 a.m., the administrator stated the residents’ private information on the meal tickets could easily be exposed to the public and expected all used meal tickets to be shredded. Facility policies titled Resident Rights and Management of Protected Health Information indicated residents have a right to privacy and confidentiality and that PHI shall not be used or disclosed except as permitted by law.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to follow the recipe for pureed meals for seven residents out of a census of 110 when excess broth, excess milk, and unmeasured amounts of food thickener were added to pureed food items. The lunch menu for 3/11/26 included sweet and sour chicken and sesame noodles, and the facility’s recipes for Pureed (IDDSI Level 4) Meats and Pureed (IDDSI Level 4) Starch specified measured amounts of broth or warm milk and food thickener for 12 servings. During a concurrent observation and interview, a cook prepared 12 servings of chicken and added six cups of broth in increments plus six unmeasured plastic spoonfuls of instant food thickener, then prepared the noodles and added 4.5 cups of milk in increments plus six unmeasured plastic spoonfuls of food thickener. The RD confirmed the cook added double amounts of broth to the chicken, added too much milk to the noodles, and did not properly measure the food thickener. The RD stated the consistency of the food was inadequate for the residents’ swallowing abilities and that residents on pureed diets might not get essential nutrients if the food had excess liquids. The facility’s policy stated therapeutic diets are ordered to alter the texture of a diet, and its food preparation policy stated recipes are specific as to portion yield, method of preparation, and quantities of ingredients, and that poorly prepared food will not be served.
Undated food and improperly stored dirty or wet pans
Penalty
Summary
Food was stored and handled in a manner that did not follow professional food service standards. During observation with the Interim Dietary Services Supervisor, a large bin of uncooked macaroni pasta and nine bags of black olives were found undated in dry goods storage. In the refrigerator, a shallow container with an unfastened lid containing diet orange drink was found with an expiration date of 3/8/26, and the IDSS confirmed the lid was not firmly affixed and the drink was expired. An opened, undated package of breaded chicken tenders was also found in the freezer, and the IDSS stated the package should have had an open date so staff would know whether it was appropriate to serve. Food service equipment was also stored in an unsanitary condition. Two small steam table serving pans were observed wet while stored on shelves, and the IDSS stated they should have been air dried before storage. During meal preparation, a steam table pan was found with brown jelly-like splotches inside the bottom of the pan, and the IDSS and C 1 identified it as dirty with dried food. The RD stated food should have received dates and, if opened, use-by labels, and that expired or undated food compromised food safety; the RD also stated heating pans were supposed to be thoroughly cleaned and dried.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of an advance directive was obtained and maintained in the medical record for one sampled resident. Resident 45 was admitted in October 2024 with a diagnosis of nontraumatic subarachnoid hemorrhage, and the resident's Order Summary Report indicated code status was to follow POLST instructions. During a concurrent interview and record review, the MDS Coordinator confirmed that Resident 45 had a POLST dated 3/3/26 showing an advance directive created on 3/24/21 was available, but a copy of the advance directive itself was not present in the medical record. During an interview, the DON also confirmed that a copy of the advance directive was not in Resident 45's medical records. The DON stated staff were expected to obtain a copy of the advance directive from the resident or resident representative and place it in the medical record. The facility's policy stated that if a resident or representative had executed an advance directive, copies were to be obtained and maintained in the same section of the medical record and be readily retrievable by facility staff.
Late Submission of Discharge MDS
Penalty
Summary
The facility failed to submit a discharge MDS for Resident 42 in a timely manner. Resident 42 was admitted in 10/25 and discharged on 10/17/25 with a diagnosis of acute and chronic respiratory failure. During interview and record review on 3/12/26, the MDS Coordinator confirmed the discharge MDS had not been submitted to CMS and was overdue by 134 days, and stated the discharge MDS was expected to be submitted according to the CMS RAI Manual timeframes. The DON also stated staff were expected to follow the required timeframes for MDS submission. A review of the CMS RAI Version 3.0 Manual dated 10/19 indicated the MDS discharge assessment was to be transmitted to CMS within 14 days of completion.
Failure to Use Communication Board for Resident With Limited English Proficiency
Penalty
Summary
The facility failed to follow the plan of care for one resident who had metabolic encephalopathy, spoke Spanish as his primary language, and had adequate ability to see and hear. His care plan, dated 1/29/26, directed staff to use a communication board to help him express himself and support effective communication so his needs and preferences would be clearly understood and addressed. During observations, the resident appeared anxious and wanted to communicate, but staff did not use a communication board. At lunch, he asked a staff member a question in Spanish while pointing to his tray, and the staff member replied in English without clarifying his request, stating, "just eat." During another observation, a case manager attempted to wake the resident for lunch, and the resident appeared startled and tried to communicate in Spanish, but the case manager continued speaking in English and did not use a communication board to clarify whether he wanted to eat then or later. A licensed nurse confirmed a communication board was not available for staff to use when interacting with the resident. The social services director reviewed the care plan and confirmed staff were not given a communication board despite the plan calling for its use, and the DON stated staff were expected to follow residents' plans of care to support consistent, effective care and better communication.
Inadequate Protein Substitute Provided for Resident Meal Preference
Penalty
Summary
The facility failed to accommodate the food preferences for one resident, who had diagnoses including diabetes mellitus and protein-calorie malnutrition. Her care plan identified her as at risk for weight loss and malnutrition and documented dislikes of chicken, turkey, and fish, with instructions to provide appropriate protein alternatives when those meat dishes were served. Her diet order included a consistent carbohydrate diet with pureed texture and thin liquids. During lunch observation, the resident’s meal ticket reflected her dislikes, but her tray contained only pureed corn and mashed potatoes with gravy, and a yogurt container was placed on the tray as the protein substitute. Staff stated the facility always gave her yogurt as a protein substitute, while the registered dietician stated the yogurt was an inadequate replacement for her protein requirements. The interim dietary services supervisor stated a vegetarian patty would be a suitable protein alternative, and review of the yogurt container showed four ounces provided three grams of protein, while the vegetable patty package showed one patty had seven grams of protein. The facility’s policies stated residents should receive nourishing, well-balanced diets that consider preferences, and substitutions should consider likes and dislikes.
Failure to Use Required PPE During TPN Administration
Penalty
Summary
The facility failed to follow proper infection control measures for one resident who was on Enhanced Barrier Precautions due to a central venous catheter used for total parenteral nutrition. During a concurrent observation and interview, a licensed nurse was observed administering TPN to the resident without wearing a gown, even though the resident was placed on EBP. The nurse stated she should have worn a gown during the TPN administration because the resident was on EBP. The resident was admitted with multiple diagnoses including a perforated intestine and protein-calorie malnutrition. The resident's order summary indicated EBP was in place because of the central venous catheter. The infection preventionist stated staff should follow infection prevention and control measures to prevent the spread of infection and for resident safety. The facility policy on Enhanced Barrier Precautions stated that gloves and gown are applied before high-contact resident care activities and that EBP is indicated for residents with indwelling medical devices such as central lines.
Call Lights Not Kept Within Reach or Usable
Penalty
Summary
The facility failed to ensure call lights were available and usable for two residents. One resident, admitted with diagnoses including MS and glaucoma, was observed in bed with a regular call light tied to the left bed rail. The resident could not find the call light, reported left hand weakness, partial right hand contracture, and impaired vision, and was unable to press the button even when CNA 2 helped place it in the resident’s right hand. CNA 2 confirmed the call light was not within reach, not appropriate, and did not meet the resident’s needs. The ADM later confirmed the call light was not suitable for the resident’s partial right hand contracture and was not placed within reach, and stated a touch pad call light was expected. A second resident, admitted with diagnoses including acute respiratory failure and tracheostomy, was observed on multiple occasions with the call light not within reach. During one observation, a CNA was assisting the resident and did not place the call light within reach. CNA 1 stated the call light needed to be within residents’ reach so they could call for help if needed, and the DON confirmed the call light was not within reach and expected call lights to be within reach. The resident’s care plan directed staff to ensure the call light was within reach, and the facility’s policy stated to provide a touch-sensitive call light if a resident had a contracture and could not press the button and to keep the call light within reach.
Failure to Follow Contact Precautions for Resident on MRSA Isolation
Penalty
Summary
A deficiency occurred when a contracted phlebotomist failed to follow the facility’s contact precaution requirements while providing care to a resident with a documented Methicillin Resistant Staphylococcus Aureus (MRSA) sacral wound infection. The resident had a physician’s order dated 2/9/26 for contact precautions every shift, which required the use of gloves and a gown for all room interactions. During an observation and concurrent interview on 2/19/26 at 8:46 a.m., the contracted phlebotomist drew blood from this resident without wearing a gown. After leaving the room, the phlebotomist touched phlebotomy equipment without changing gloves or performing hand hygiene, then returned to the resident to continue the blood draw. When questioned, the contracted phlebotomist was unable to state what constituted contact precautions or whether a gown was required for direct care. After this interaction, the phlebotomist entered another resident’s room to draw blood without cleaning the equipment. The Infection Preventionist later confirmed that the resident was on contact precautions and that staff performing direct care, such as blood draws, should wear a gown. The DON stated that contact precautions should be followed by all staff, including contracted staff. The facility’s written policy on Isolation - Categories of Transmission-Based Precautions, revised 10/18, specified that staff and visitors will wear gloves and a disposable gown upon entering the room of a resident on contact precautions, change gloves after contact with infective material, remove gloves and perform hand hygiene before leaving the room, and remove the gown before leaving while avoiding contact of clothing with potentially contaminated surfaces.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a CNA solicited, borrowed, and received money from the resident and used the resident’s debit card for personal purchases. The resident was admitted with diagnoses including anxiety disorder, depression, and limitation of activities due to disability, and had a BIMS score of 14 indicating intact cognition. The resident later reported feeling upset, hurt, disappointed, and emotionally distressed after discovering the financial transactions and stated that the staff member had taken thousands of dollars from the bank account through debit card use. The resident’s records documented repeated distress after the incident, including feeling betrayed, depressed, socially withdrawn, and remaining mostly in the room. The resident stated the CNA asked for money multiple times, used the debit card without permission, and made the resident feel pressured and “dumb” for trusting her. The resident also stated the staff member had ruined the resident’s reputation with the bank and that it was hard to trust others. Facility interviews and records confirmed the CNA requested and received money and gifts from the resident, and the facility investigation binder included text messages from the CNA asking for money. The Administrator stated the resident allowed the CNA to use the debit card and loaned money to the CNA, and also stated that staff receiving money or gifts from residents was against company policy. The CNA later confirmed requesting and receiving gifts and money, borrowing money, and making ATM withdrawals, while the facility policy stated residents have the right to be free from misappropriation of property and exploitation.
Missed Scheduled Showers
Penalty
Summary
The facility failed to ensure that one sampled resident received adequate assistance with ADLs when scheduled showers were not provided. The resident was admitted in late winter 2026 with diagnoses including walking and mobility abnormalities, need for assistance with personal care, and heart failure. The MDS dated 1/26/26 indicated the resident had no memory impairment and was totally dependent on shower transfer. The ADL care plan initiated 1/28/26 noted the resident was at risk for pressure injury development and skin breakdown, and that skin discoloration should be noted during baths. Review of the shower sheets showed that the facility was unable to provide a shower sheet for the week of 1/14/26, and the resident did not receive a shower that week. Additional shower sheets dated 1/22/26, 1/26/26, and 2/2/26 each indicated the resident received only one shower that week. Staff interviews indicated showers were expected twice per week, with refusals to be documented and another attempt made later if needed. The resident and family member stated the resident had missed multiple showers, felt dirty, and sometimes went an entire week without a shower, while the resident said he did not request only one shower per week and preferred more than one.
Failure to Prevent Allergen Exposure During Meal Service
Penalty
Summary
A resident with a documented allergy to bananas, which causes anaphylaxis, was served Banana Cream Pie during a lunch meal. The resident's clinical record, nutritional assessment, and care plan all indicated a banana allergy, and the meal ticket for the day also noted this allergy. Despite these precautions, the resident received and consumed the dessert containing banana, which led to a severe allergic reaction. The incident required immediate medical intervention, including the administration of epinephrine, after the resident exhibited symptoms such as throat closing, shortness of breath, wheezing, agitation, and anxiety. Interviews with facility staff, including the Dietary Supervisor, Administrator, and Director of Nursing, confirmed that the expectation and policy are to prevent residents from being served foods to which they are allergic. The facility's kitchen documentation outlined responsibilities for cooks and dietary aides to ensure trays are correct and substitutions are made for allergies. However, the process failed, and staff were unable to explain how the resident was served the allergen. The facility's policy on food allergies emphasized steps to prevent exposure, but these were not effectively implemented in this case.
Failure to Assist Resident with Dentures Prior to Meals
Penalty
Summary
The facility failed to provide necessary assistance with the use of dentures for one resident who was cognitively intact but had significant upper extremity impairment and required substantial or maximal assistance for oral hygiene, including inserting and removing dentures. The resident's care plan identified a self-care performance deficit and risk for decline in activities of daily living due to generalized weakness, carpal tunnel syndrome, and macular degeneration. The nutritional assessment confirmed the resident had dentures. On the morning of the observed incident, the resident was found in bed without dentures and stated that no one had assisted her with them that morning, despite requesting help from staff around 8:30 a.m. The denture cup was observed on the dresser, unused. A CNA who assisted the resident with breakfast reported not noticing the absence of dentures and was unaware the resident had them. The DON confirmed the importance of offering dentures to the resident, acknowledging that without them, the resident would be unable to chew food. The facility's policy required staff to provide appropriate support and assistance with activities of daily living, including dining, for residents unable to perform these tasks independently and in accordance with the care plan.
Unlabeled Medication Cups Left at Bedside
Penalty
Summary
A deficiency occurred when three unlabeled medication cups containing white cream were found inside a white plastic container on top of a resident's dresser. The resident, who was cognitively intact and had a diagnosis including generalized muscle weakness, stated that the cups contained lidocaine cream brought in by a nurse and that it was applied to her hands twice daily. Multiple staff members, including two CNAs and a treatment nurse, confirmed the presence of the unlabeled cups and noted that the cream should not have been left at the bedside, especially without proper labeling. One CNA expressed concern that a confused resident might mistakenly ingest the cream, and the treatment nurse indicated the cream resembled barrier cream. The Director of Nursing, upon being shown a picture of the cream, acknowledged that it was unacceptable for licensed staff to leave creams or unknown substances at the bedside. A review of the facility's policy confirmed that drugs and biologicals are to be stored in locked compartments. The failure to properly label and securely store the medication at the resident's bedside constituted a breach of the facility's medication storage policy.
Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis following cerebral infarction, and dysphagia, was left unsupervised in his room despite being care planned for one-to-one supervision due to high risk for falls and elopement. The resident had severely impaired cognition and a documented history of falls, with a Morse Fall Assessment score indicating high risk. During observation, the resident was found sitting on the edge of his bed with his call light on the floor and no staff or sitter present, despite requiring assistance with meals and supervision at all times. Staff interviews confirmed that the resident should have had continuous one-to-one supervision, and the assigned sitter was observed exiting the resident's bathroom, leaving the resident unattended. The care plan and staff training records indicated that the expectation was for the resident to never be left unattended, and the DON confirmed that staff are expected to arrange relief if a sitter needs a break. The facility was unable to provide a specific policy for sitter or supervision when requested.
Failure to Maintain Fully Functional Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was fully functional and properly maintained for one resident. When the resident pressed the call light button, the call light above the room door activated, but the corridor call lights located on the wall and above the double door did not illuminate. This incomplete functionality was confirmed through observations, interviews with staff, and review of records. The resident, who was cognitively intact and capable of making health decisions, expressed ongoing concerns about delayed staff response to call lights. Staff interviews confirmed that the corridor call lights did not illuminate when the resident activated the call light, making it difficult for staff to know when assistance was needed unless they were physically near the room. Further investigation revealed that the call light system had not been reprogrammed after servicing, and the issue had not been reported to maintenance or facility leadership. The maintenance request log and call light maintenance log were not provided for review. Staff, including CNAs and the Assistant Maintenance Supervisor, acknowledged the importance of the corridor call lights for timely response and resident safety. The facility's policy required immediate notification and repair of malfunctioning call lights, but the Director of Nursing and other leadership were unaware of the issue until it was brought to their attention during the survey.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive and communication deficits, who was incapable of making her own healthcare decisions, was physically abused by another resident with a history of bipolar disorder and aggression. The incident involved the aggressive resident striking the vulnerable resident on the left side of her forehead with a closed fist, resulting in a visible bruise and a hematoma. The assaulted resident exhibited fear and distress, manifested by crying and avoidance behaviors, particularly when the aggressor was present in the room. Prior to the incident, the aggressive resident had documented daily physical behavioral symptoms directed towards others, including verbal and physical aggression. The care plan for this resident noted a history of uncontrolled anger and poor impulse control, with instructions to assess and anticipate needs and to immediately separate parties involved in confrontations. Despite these documented risks and interventions, the aggressive resident was able to physically assault her roommate, indicating a failure to prevent abuse as outlined in the facility's abuse prevention policy. Multiple staff interviews confirmed the aggressive behaviors, including yelling, cursing, and physical threats towards both residents and staff. The assaulted resident was unable to verbally express herself due to her medical condition but demonstrated fear through nonverbal cues and crying. Staff, including the DON, Social Services Director, and an LPN, all acknowledged the abusive behavior and its impact on the assaulted resident, confirming that the facility did not ensure the resident's right to be free from abuse.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one with violent behavior, restlessness, and agitation, and another with dementia. According to the nurse's notes, one resident was observed striking and being verbally abusive to their roommate, as well as taking items from the roommate's closet. The incident escalated to physical aggression, including kicking and slapping, as witnessed by a licensed nurse. The nurse reported the incident to the direct supervisor but was not instructed to complete the required SOC341 form for suspected dependent adult/elder abuse. During interviews, the licensed nurse confirmed the incident was not reported to the state, and the administrator stated that all cases of abuse, even those between residents with dementia and without injury, should be reported to law enforcement, the ombudsman, and the California Department of Public Health within two hours. A review of the facility's policy indicated that all allegations must be investigated and reported within federally required timeframes. The failure to report this incident constituted a deficiency in mandated reporting procedures.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
CNA Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that nursing care staff met certification requirements as defined under State law and regulation. Specifically, one certified nursing assistant (CNA) was scheduled to work with an expired CNA certification. A review of the CNA's employee file confirmed that the certification had expired, and the CNA continued to work after the expiration date. The Director of Staff Development (DSD) acknowledged during an interview that the certification was not renewed and admitted to the oversight. The DSD recognized the potential impact of this lapse, stating that it could affect everyone and that someone could be harmed. Further interviews revealed that the Director of Nursing (DON) expected the DSD to maintain a tracker or spreadsheet to monitor certification expiration dates and ensure timely renewal before staff are scheduled to work. A review of the relevant Health and Safety Code confirmed that certified nurse assistants are required to be certified to perform basic patient care services. The failure to ensure current certification for the CNA meant that the facility did not comply with professional standards of practice for staffing.
Failure to Offer and Document COVID-19 Vaccination for Resident and Staff
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered and properly documented for both residents and staff, as evidenced by the lack of vaccination status or documentation for one resident and one staff member. Specifically, a resident admitted with cerebral palsy and severe cognitive impairment had no record of being offered the COVID-19 vaccine, no documentation of vaccination, refusal, or contraindication, and no evidence that the required education or consent process occurred. The resident's care plan indicated COVID-19 isolation precautions following a positive test, but the clinical record did not reflect any action regarding vaccination upon admission. The Infection Preventionist confirmed that there was no monitoring system in place for resident COVID-19 vaccinations and acknowledged the omission. Similarly, a certified nursing assistant's employee health file lacked any documentation of COVID-19 vaccination status, offer, or refusal. Interviews with the Infection Preventionist, Director of Staff Development, and Director of Nursing confirmed that the facility's expectation was to offer and document COVID-19 vaccination for all staff upon hire and annually, but this was not done for the staff member in question. Review of facility policies indicated requirements for offering and documenting COVID-19 vaccination for both residents and staff, but these procedures were not followed in the cited cases.
Failure to Follow Physician Orders for Scabies Treatment and Prophylaxis
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for three residents regarding the administration of medications for scabies treatment and prophylaxis. For one resident with schizophrenia and moderate cognitive impairment, the prescribed Permethrin cream was not administered as ordered, and an order for oral Ivermectin was not carried out. The Assistant Director of Nursing (ADON) confirmed that the medication was not signed off in the Medication Administration Record (MAR) and that there was no evidence the treatment was given, despite a physician's order. Another resident with Adult Failure to Thrive and dementia, also with moderate cognitive impairment, received Permethrin cream on two consecutive days instead of the single application as ordered. The MAR showed that staff entered and signed off on two separate orders, resulting in back-to-back administration. The ADON acknowledged this deviation from the order and noted the potential for side effects due to excessive use, confirming that the physician's instructions were not followed. A third resident with severe cognitive impairment and dementia did not receive Permethrin cream in a timely manner. Although the order was received, the medication was administered two days later without documentation explaining the delay. The ADON verified that there was no note or notification to the physician regarding the delay, and facility policy requires medications to be administered according to prescriber orders and within required time frames.
Failure to Maintain Contact Precautions and Administer Scabies Treatment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was suspected of having scabies. The resident was admitted with multiple diagnoses, including schizophrenia and moderate cognitive impairment, and developed a non-improving rash with itching. Physician orders and facility policy required the resident to be placed on contact isolation and to receive Permethrin cream treatment for scabies, with isolation to continue for 24 hours after treatment. However, the resident's contact precaution signage was removed before the resident received the prescribed treatment, and the medication administration record showed that the Permethrin cream was not administered as ordered. Observations confirmed that the resident still had visible rashes and was no longer on contact precautions, despite not having received the required treatment. Interviews with facility staff, including the Infection Preventionist and Assistant Director of Nursing, verified that the resident should have remained on contact isolation until after treatment was completed, in accordance with facility policy. The failure to administer the prescribed treatment and to maintain contact precautions as required constituted a breakdown in the facility's infection prevention and control practices.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit her on the left hand, resulting in a bruise. The incident occurred when the second resident, who was severely cognitively impaired, entered the first resident's room, which was previously her own room. The first resident attempted to push the second resident's wheelchair out of the room, leading to the second resident striking her on the hand. The first resident was admitted to the facility with multiple diagnoses, including a stage 4 pressure ulcer, dementia, and diabetes, and was cognitively intact with a BIMS score of 14 out of 15. The second resident, admitted with metabolic encephalopathy, Horner's syndrome, and dementia, had a BIMS score of 4, indicating severe cognitive impairment. The second resident had a history of aggressive behavior, including striking staff during care, and was on psychotropic medications for these behaviors. Interviews with staff and the residents revealed that the second resident had been following the first resident and had previously been moved to a different room due to incompatibility. The facility's policies on abuse prevention and resident-to-resident altercations were reviewed, indicating that residents should be protected from abuse and that all altercations should be investigated. However, the facility failed to prevent the altercation and protect the first resident from being struck.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident who was admitted with a skin infection and had an indwelling Foley catheter. The resident's care plan included Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs). According to the facility's policy, staff were required to wear gowns and gloves during high-contact activities, such as changing briefs or assisting with toileting, for residents on EBP. During an observation, a Certified Nursing Assistant (CNA) was seen changing the resident's soiled brief without wearing a protective gown, which was a violation of the facility's infection control policy. The CNA acknowledged the requirement to wear a gown to prevent the spread of bodily fluids. The Infection Preventionist confirmed that staff should wear gowns during high-contact care for residents on EBP due to the increased risk of spreading MDROs.
Food Safety Violations in LTC Facility
Penalty
Summary
The facility failed to maintain food safety standards in several areas, leading to potential food contamination risks for all 105 residents. The ice machine was found to be unclean, with white and pink slimy substances and black deposits, indicating inadequate cleaning and maintenance. The Environmental Services Manager admitted to sometimes delegating the cleaning to an outside vendor, who confirmed the presence of hard deposits that could harbor bacteria. The Registered Dietician expected the ice machine to be cleaned per manufacturer's guidelines, but the facility's policy was not followed. Additionally, kitchenware was improperly stored while still wet, and fry pans were found with black flaky debris, indicating they were not clean. The Dietary Supervisor acknowledged the need for air drying and the disposal of old pans. Open food packages were not sealed or labeled correctly, and expired food items were found in storage, posing a risk of contamination. The Registered Dietician emphasized the importance of proper labeling and disposal of expired products, but the facility's policies were not adhered to. Thawing processes were not followed, with food items lacking proper labeling and being stored inappropriately, leading to potential cross-contamination. Dietary staff also failed to demonstrate knowledge of correct dishwashing procedures, including sanitizer concentration testing. Furthermore, a dietary staff member did not have their hair fully covered, violating the facility's dress code. These deficiencies highlight significant lapses in food safety practices, which could lead to foodborne illnesses among the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in multiple instances where the lids of two outside dumpsters were not adequately closed, and the surrounding area was littered with debris. During an observation with the Dietary Supervisor, it was noted that the lid of a garbage dumpster containing trash bags was not tightly closed, and a urinal with brown and yellow liquid was found on the ground next to the garbage bin. The Dietary Supervisor confirmed that the lid was open and should have been tightly closed. Subsequent observations revealed that the gate to the dumpster area was open, and the hatch doors on both the garbage and recycling dumpsters were open. Further observations with the Environmental Services Manager confirmed that the lids of the dumpsters were open, and there was scattered trash around the area. The Environmental Services Manager acknowledged that the area was dirtier than desired and confirmed that the area around the dumpsters should be kept clean. An interview with the Registered Dietitian reiterated the need for the garbage bin lids to be closed at all times and the surrounding area to be kept clean to prevent pests and rodents. The facility's policy and procedure on sanitation indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area, and that the lids are closed, as the trash collection area is a potential feeding ground for vermin and rodents.
Dietary Services Supervisor Lacks Competency in Food Safety Procedures
Penalty
Summary
The Dietary Services Supervisor (DS) at the facility failed to demonstrate the necessary competencies and oversight required for the food and nutrition services, which could potentially lead to foodborne illness among the residents. During an observation, it was noted that the DS was unable to verbalize the proper procedure for thawing meats using the refrigeration method. Additionally, the DS did not have proper knowledge about the correct concentration of the sanitizer for the dishwashing machine and the manual dishwashing process using a three-compartment sink. Furthermore, the DS did not have his hair fully covered by a hair restraint while in the kitchen. During an inspection of the walk-in refrigerator, it was observed that there were three-level carts with boxes of food, some of which were wet and leaking. The DS confirmed that these items were for thawing but could not determine when they were pulled from the freezer due to the absence of dates. The facility's policy requires thawing meat in a refrigerator with proper labeling and separation to prevent cross-contamination, which was not adhered to. Additionally, the DS was unable to verify the correct concentration of the sanitizer for both the dishwashing machine and the manual dishwashing process, as per the facility's policy. The DS's employee file revealed that his ServSafe certification had expired, and his last performance evaluation was conducted by a previous administrator. The facility administrator acknowledged the issues found in the kitchen and planned to address them under the Quality Assurance and Performance Improvement (QAPI) program. The facility's job description for the DS includes responsibilities such as ensuring compliance with dietary procedures and conducting in-service training, which were not effectively carried out as evidenced by the deficiencies observed.
Inadequate Competency in Dietary Aide Poses Risk
Penalty
Summary
The facility failed to ensure that a Dietary Aide (DA 1) possessed the necessary skills to safely perform food and nutrition services. During an observation and interview, DA 1 demonstrated an incorrect understanding of the dishwashing process using a dishwashing machine. DA 1 incorrectly stated that the sanitizer concentration should be 200 ppm, while the facility's policy indicated it should be between 50-100 ppm. DA 1 also used a used test strip to check the sanitizer concentration, which showed no color, and only after being instructed by the Dietary Services Supervisor (DS) did DA 1 use a new test strip, which read 50 ppm. This was within the correct range, but DA 1's initial misunderstanding and incorrect demonstration highlighted a lack of competency. Additionally, DA 1 was unable to correctly verbalize the manual dishwashing process using a three-compartment sink. DA 1 stated that the sanitizer immersion time was 10 seconds with a concentration of 50 ppm, which was incorrect according to the facility's policy and the sanitizer bottle instructions, which required a 60-second immersion time and a concentration of 150-400 ppm. Despite having attended in-service training and holding a valid ServSafe food handler certificate, DA 1's inability to correctly demonstrate and verbalize these processes posed a risk to the 105 out of 108 highly susceptible residents who consumed food from the facility.
Menu Non-Compliance in Dietary Service
Penalty
Summary
The facility failed to adhere to the planned menu for lunch on November 6, 2024, resulting in several dietary discrepancies. Two residents on large portion diets received five meatballs instead of the prescribed six, as observed by the Registered Dietitian (RD) during meal service. The facility's menu indicated that a large portion should consist of six meatballs, but the cook provided only five, which the RD acknowledged as insufficient for residents requiring extra protein. Additionally, four residents on renal or CKD5 diets were served tapioca pudding instead of the specified cookie. The facility's diet manual for renal diets restricts protein and phosphorus intake, recommending cookies over puddings. The RD confirmed that the menu was not followed, potentially impacting the dietary management of these residents' kidney conditions. Further discrepancies were noted for residents on low fat and low cholesterol diets, who received whole milk and margarine instead of fat-free milk and no margarine. Residents on finger food diets were served rice and tapioca pudding, contrary to the menu's specification of diced potatoes and mousse on graham crackers. Moreover, none of the 105 residents received the parsley garnish as indicated on the menu. These failures were acknowledged by the RD and Dietary Supervisor, who confirmed that the menu was not followed during the tray line meal service.
Failure to Adhere to Medication and Oxygen Administration Policies
Penalty
Summary
The facility failed to meet professional standards of quality care for two residents. For Resident 11, medications were left unattended on the bedside table, contrary to the facility's policy. Resident 11, who was admitted with acute and chronic respiratory hypoxia and Type 2 Diabetes with polyneuropathy, reported that nurses routinely left medications for self-administration without supervision. Interviews with the Licensed Nurse, Assistant Director of Nursing, and Director of Nursing confirmed that this practice was against facility policy, which requires a Medication Administration Assessment and documentation in the care plan for self-administration. However, no such assessment or care plan documentation was found for Resident 11. For Resident 5, the oxygen tubing was found unconnected to the oxygen machine, resulting in the resident not receiving oxygen as prescribed. Resident 5, who had chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed to be pale and breathing rapidly. The Licensed Nurse confirmed the disconnection and noted the resident's oxygen level was at 82 percent, below the prescribed level. The facility's policy requires medications and treatments to be administered safely and as prescribed, which was not adhered to in this case.
Lack of Smoking Policy and Supervision in Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for its residents, specifically in relation to smoking policies and supervision. Two residents, one with asthma and nicotine dependence and another with COPD and nicotine dependence, were observed smoking unsupervised on the facility premises. The facility did not have a smoking policy and procedure in place, and the Assistant Director of Nursing (ADON) acknowledged the absence of such policies despite being aware that some residents smoked. This lack of policy and supervision posed potential risks for accidents, including resident injury and fire. Additionally, the facility did not have a smoking care plan for a resident who was non-compliant with care and safety recommendations. The resident's smoking assessment indicated the need for a care plan to ensure safety while smoking, including supervision. However, the care plan did not address smoking or interventions for safety. The ADON confirmed the absence of a care plan for smoking and acknowledged the associated risks. The facility also failed to provide a policy and procedure for care planning when requested.
Medication Administration Errors via PEG Tube
Penalty
Summary
The facility was found to have a 20.69% medication error rate during a medication pass for one resident, significantly exceeding the acceptable threshold of 5%. During the observation, a licensed nurse prepared and administered medications to a resident with a PEG tube without following the prescribed orders. The nurse crushed and combined multiple medications, including omeprazole, aspirin, and Cardizem, and administered them through the PEG tube without flushing it before and after each medication. This resulted in large particles of omeprazole blocking the syringe, preventing the complete administration of the medication. The nurse acknowledged the error and the risk of blockage and air entering the PEG tube due to improper crushing and administration of medications. The resident's medical record indicated specific physician orders for the administration of each medication, including the requirement to flush the feeding tube with water before and after each medication. The facility's policy and procedure for administering medications through an enteral tube also emphasized the need to administer each medication separately and to flush between medications. The failure to adhere to these protocols resulted in a medication error, with the potential to affect the resident's clinical condition. The Assistant Director of Nursing confirmed the expectation for adherence to physician orders and acknowledged the risks associated with improper medication administration.
Medication Error with PEG Tube Administration
Penalty
Summary
The facility failed to ensure that Resident 88 was free from significant medication errors when he received omeprazole in crushed pill form instead of the physician-ordered liquid suspension through his PEG tube. Resident 88, who was admitted with multiple diagnoses including cerebral infarction and GERD, had a care plan indicating the use of a PEG tube. During a medication pass, a licensed nurse crushed omeprazole along with other medications and administered them through the PEG tube, resulting in large particles of omeprazole blocking the syringe and preventing full administration. The physician's orders specified the use of omeprazole oral suspension, and there were no orders allowing substitution with a delayed-release tablet. The facility's policy and procedure documents also indicated that enteric-coated and sustained-release medications should not be crushed. The Assistant Director of Nursing confirmed that the expectation is to follow physician orders and that incorrect administration poses a risk of PEG tube blockage and absorption issues.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store discontinued and destroyed medications in locked compartments, as required by professional principles and the facility's own policy. During an observation and interview with a licensed nurse, it was found that a cabinet in the medication room was unlocked and contained multiple packets of medications, bottles of pills, and liquid medications. The nurse confirmed that the cabinet was kept unlocked. Additionally, another cabinet with double doors was also found unlocked, containing approximately 160 packets of medications and bottles of liquid medications. Further observations revealed that a large blue Medi Waste Disposal Biohazard bin in the medication room was unsecured and easily accessible, containing multiple pills, bottles, and liquid medications. The Director of Nursing confirmed that the discontinued medications and the biohazard bin were not secured, allowing staff access to these medications. The facility's policy and procedure on medication storage, revised in November 2020, indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner, with access limited to authorized personnel.
Failure to Implement Infection Control Action Plans
Penalty
Summary
The facility failed to implement action plans in their Quality Assurance and Performance Improvement (QAPI) program for an identified infection control issue affecting a census of 108 residents. A Performance Improvement Project (PIP) was initiated on 8/16/24 to address this issue, with review dates set for 9/16/24, 10/16/24, and a planned completion date of 11/16/24. However, there was no documented evidence that key tasks were completed, including in-service training for the nursing department, 100% competency skills checks for current and new staff, and weekly skin sweeps. Additionally, findings from these audits were not reported in the Quality Assessment and Assurance (QAA) monthly meetings as required. Interviews with the Infection Preventionist (IP) and the Administrator (ADM) revealed that some training was completed, but there was no documentation to support the completion of the required competency skills checks or weekly skin sweeps. The ADM confirmed that no monthly meetings or reviews were conducted in September or October 2024, as stipulated in the PIP. The facility's policy and procedure for the QAPI program, dated February 2020, mandates monthly committee meetings to review reports, evaluate data, and monitor QAPI-related activities, which were not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Personal items belonging to a resident were found on the floor, which the resident expressed dissatisfaction with, and staff acknowledged as an infection control risk. Additionally, staff failed to wear the required personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions, despite the presence of a sign indicating the need for gown and glove use. Further deficiencies were noted with the improper labeling and storage of urinals for two residents, which posed a risk of cross-contamination. The urinals were not labeled with resident identifiers or dates of initial use, and there was no documented evidence that the residents used urinals for incontinence. Additionally, a blood pressure cuff was not sanitized between uses on different residents, which was acknowledged by the staff as a risk for spreading infection. Lastly, linens and a soiled incontinence pad were observed on the floor of a resident's room, which the resident admitted to discarding. Staff interviews confirmed that such practices were not acceptable and posed an infection control issue. The facility's policies and procedures emphasized maintaining a safe and sanitary environment, which was not adhered to in these instances.
Unsafe and Unsanitary Conditions in Resident's Room
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, identified as Resident 66, who was admitted with multiple diagnoses including obstructive sleep apnea, acute respiratory failure, and a history of falling. During an observation, it was noted that electrical devices such as a CPAP machine, a personal fan, and a laptop were plugged into a power strip located under the bed, surrounded by loose electrical cords and other items, creating a fire hazard. The power strip was used with medical devices, which is against the facility's policy. Additionally, oxygen tubing was found lying on the floor, further contributing to the unsafe environment. The room was also found to be unsanitary, with unclean floors and clutter that made cleaning difficult, increasing the risk of bacterial growth and infection. A dark, sticky substance was observed on the floor, which the resident identified as feces that had been present for several days. The facility's policies on electrical safety and maintaining a homelike environment were not adhered to, as evidenced by the clutter and unsanitary conditions in the resident's room. These deficiencies had the potential to cause preventable falls and unsafe living conditions for the resident.
Failure to Wear ID Badges Compromises Resident Rights
Penalty
Summary
The facility failed to ensure the rights of residents were maintained when four employees did not wear identification badges, affecting three of six sampled residents. Resident 2, who was admitted in October 2024 with diagnoses including leg ulcers, heart failure, and muscle weakness, had a BIMS score indicating moderately impaired cognition. During an interview, Resident 2 expressed not knowing his nurse or CNA due to the absence of ID badges. Similarly, Resident 5, admitted in September 2024 with conditions such as stimulant dependence and bipolar disorder, also had a moderately impaired cognition and voiced concerns about not knowing the names of the staff attending to her. Resident 6, with intact cognition, shared similar concerns about not being able to identify her caregivers. Observations confirmed that several staff members, including two LNs and two CNAs, were not wearing ID badges while on duty. LN 2, CNA 5, CNA 6, and LN 3 all admitted to not wearing their badges, citing reasons such as forgetting them or leaving them in personal belongings. The facility's policy, revised in January 2008, mandates that all employees wear identification badges to promote safety and security. The administrator acknowledged the importance of this policy, emphasizing that it is crucial for residents to identify the staff caring for them.
Failure to Administer MASD Treatment as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and its own policies for one resident. The resident, who was admitted in October 2024, had several medical conditions including osteomyelitis of the vertebra, diabetes mellitus, muscle weakness, and severe obesity. The resident was at risk for developing pressure ulcers and had moisture-associated skin damage (MASD). A physician's order was in place for the treatment of MASD, which included cleansing the affected area with normal saline, patting it dry, applying zinc oxide every shift, and monitoring for any signs of infection or skin breakdown. However, the Treatment Administration Record (TAR) indicated that the MASD treatment was not administered on eight PM shifts throughout October 2024. This was confirmed by a licensed nurse who acknowledged the lack of documentation for the treatment on those shifts. The facility's policy and procedure, as well as CMS guidelines, require that wound care be performed according to accepted medical standards, which was not adhered to in this case. The administrator also confirmed that physician's orders for treatments should be followed.
Deficiency in Resident Call System in Bathroom
Penalty
Summary
The facility failed to provide a functional resident call system in the bathroom for one of the residents, identified as Resident 7. This deficiency was identified through observation, interview, and record review. Resident 7, who was admitted in October 2024, had medical conditions including atrial fibrillation, major depressive disorder, and muscle weakness. Despite being capable of making her own health decisions, Resident 7 did not have a working call system in her bathroom, which was confirmed during an observation on October 28, 2024. The call light in Resident 7's room was noted to be constantly on and broken, a situation that had been reported to maintenance as early as May 7, 2024, but remained unresolved. Interviews with various staff members, including a Licensed Nurse, the Director of Environmental Services, a Certified Nurse Assistant, and the Administrator, confirmed the absence of a functional call system in Resident 7's bathroom. Although the Director of Environmental Services mentioned that a call bell was provided to the resident, Resident 7 and the Certified Nurse Assistant confirmed that no such bell was present in the bathroom or at the bedside. The facility's policy requires a resident call system to be available, and the Centers for Medicare & Medicaid Services guidelines mandate that the call system must be accessible from each toilet, bath, or shower. The lack of a functional call system in Resident 7's bathroom was a clear violation of these guidelines and policies.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify the representative of a resident regarding a room change, which had the potential to cause psychosocial distress to the resident and concern to the representative due to the lack of notification. The resident, who was admitted in mid-2024 with diagnoses including gangrene and Parkinson's Disease, was moved to another room without informing the representative. During a phone interview, the representative expressed upset and concern over not being informed or given a reason for the room change. The Director of Nursing and the Staff Services Director both confirmed that there was no documentation in the resident's chart indicating the reason for the room change or that the representative was notified. The facility's policy requires that family and visitors be informed of room changes and that such information be recorded in the resident's medical record.
Neglect in Resident Hygiene Care
Penalty
Summary
The facility failed to protect a resident from neglect by not providing showers as scheduled. The resident, who was admitted with diagnoses including gangrene and Parkinson's Disease, was observed by their representative to appear dirty, with messy hair covered in food, resembling a homeless person. During a review of the resident's bathing tasks and shower sheets, the Director of Nursing (DON) could not find documentation that the resident had been offered, received, or refused a shower during a specific period. The facility's policy required documentation of the date and time of showers or reasons for refusal, but this was not adhered to, leading to uncertainty about whether the resident received proper hygiene care.
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What surveyors actually found near you
We read the 656 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River City Post Acute | 0 mi | ★★★★★ | 45 | 0 |
| Mountain Manor Senior Residence | 0.1 mi | ★★★★★ | 2 | 0 |
| Whitney Oaks Care Center | 1.7 mi | ★★★★★ | 6 | 0 |
| American River Center | 1.8 mi | ★★★★★ | 12 | 0 |
| Casa Coloma Health Care Center | 1.8 mi | ★★★★★ | 1 | 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.