Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Saylor Lane Healthcare Center during CMS and state inspections, most recent first.
The facility was cited for multiple failures in food safety and sanitation, including improper cleaning of the ice machine and freezer, use of damaged equipment such as a worn can opener and grooved cutting boards, improper storage of wet pans, and dietary staff lacking knowledge of correct dishwashing procedures. Additionally, a dietary aide was observed with long artificial nails handling food contact surfaces, all of which had the potential to cause food contamination for all residents receiving meals from the kitchen.
A dumpster located outside the facility was observed with deformed lids that did not close securely, leaving a gap and allowing flies to access the trash inside. Staff confirmed the issue and acknowledged that the dumpster should be tightly sealed, in accordance with facility policy and FDA Food Code requirements.
Nursing staff did not label a gastrostomy tube flush bag with the date and time, failed to document pain assessments before and after administering narcotic pain medication, withheld blood pressure medications based on unverified CNA-obtained vitals, and administered a hazardous chemotherapeutic drug without personal protective equipment. These actions were not in accordance with facility policy or professional standards.
A resident with multiple respiratory and cardiac conditions received oxygen at a higher flow rate than ordered, with no documentation of titration or physician notification, and the nasal cannula was not changed weekly as required. Staff confirmed the oxygen settings and tubing change schedule were not followed, contrary to facility policy and physician orders.
The facility failed to accurately document and account for controlled substances for a resident prescribed tramadol, with discrepancies between the CDR and MAR. Required shift-to-shift controlled drug counts were missing signatures from nursing staff, and a narcotic emergency kit was not replaced promptly after use. Additionally, a resident with diabetes missed a scheduled dose of Ozempic due to lack of medication availability and absence of documented communication with the family.
A resident with diabetes received insulin glargine according to physician orders that required staff to notify the physician or NP if blood sugar readings were below 100 or above 300 mg/dl. On multiple occasions, the resident's blood sugar exceeded 300 mg/dl at the time of scheduled insulin administration, but there was no documentation that the physician or NP was notified. Additionally, while monitoring for hypoglycemia was ordered, there were no parameters for monitoring hyperglycemia, and facility policy for documentation and reporting was not followed.
A medication error rate above 5% was observed when a nurse failed to prime insulin pens before administering insulin lispro to two residents. The nurse was unaware of the priming requirement, which is specified in both manufacturer instructions and facility policy. The DON confirmed that staff are expected to prime insulin pens prior to dosing.
Surveyors found that refrigerated medications, including insulin and flu vaccine, were stored at 28°F, which is below the required range of 36°F to 46°F. The DON confirmed the improper temperature, and facility policy as well as manufacturer instructions specify that these medications should not be frozen and must be discarded if frozen. The deficiency was identified during an inspection of the medication storage room refrigerator.
Dietary aides were unable to accurately describe or demonstrate proper manual and machine dishwashing procedures, including correct sanitizer concentrations and immersion times, despite having attended in-service trainings and being marked as competent. This failure had the potential to place nearly all residents at risk for foodborne illness due to improper sanitization of dishes.
Five residents on mechanical soft diets received smaller portions of meatballs than required, and one resident on a fortified diet did not receive the necessary added gravy and margarine during a lunch meal service. The cook did not follow the facility's menu guidelines for portion sizes and fortification, as confirmed by the RD and facility documentation.
Multiple infection control breaches were observed, including staff handling ready-to-eat food with bare hands, clean linen touching contaminated surfaces, improper cleaning of a shared glucometer, lack of hand hygiene between different medication routes, and failure to change a nebulizer face mask weekly. These actions involved several residents with complex medical needs and were confirmed by staff interviews and policy reviews.
A licensed nurse failed to verify the placement of a PEG tube before administering a bolus feeding to a resident with diabetes and GERD, despite physician orders and facility policy requiring this step. The resident, who was cognitively impaired and dependent on tube feeding, experienced intermittent coughing during the feeding. Facility leadership confirmed that verifying tube placement is the expected standard of practice.
The facility did not maintain documentation of COVID-19 vaccination status for seven staff members, including nurses, CNAs, a laundry aide, and a cook. During interviews and record reviews, it was confirmed that these records were missing despite facility policy requiring vaccination status to be assessed and documented for all employees.
A resident with a history of behavioral outbursts due to Huntington's Disease threw a walker and struck another resident in the rehab room, with staff and other residents present. Despite prior orders to monitor such behaviors, the event was not reported as abuse and was instead treated as a behavioral incident, contrary to the facility's abuse prevention policy.
A resident with Huntington's Disease threw a walker at another resident, striking the individual's knee in the rehab room. The incident was witnessed by the DOR and a PTA, both of whom recognized it as abuse and reported it internally. However, the DON classified the event as a behavioral outburst and did not report it to the Department, contrary to facility policy requiring immediate reporting of abuse allegations.
The facility failed to ensure food safety by not consistently documenting food storage temperature logs and sanitization solution logs. Missing entries were found in the Dry Food Storage Temperature Control Log, Quaternary Ammonium Log, and Cold Storage Temperature Control Log for the month of May 2024, potentially leading to foodborne illnesses for 38 residents.
The facility failed to assess and evaluate the weekly I&O summaries for two residents on fluid restriction, making it difficult to determine their fluid balance and the effectiveness of their fluid restriction orders.
The facility failed to act on the pharmacist's recommendations for a resident's antipsychotic medication monitoring and allowed expired medications to be mixed with current ones in the storage room, leading to unresolved irregularities and potential medication errors.
The facility failed to discard expired flu vaccines, mixing them with non-expired vaccines in the medication refrigerator. A Licensed Nurse confirmed the presence of nine expired syringes from the 2022-2023 season, which should have been discarded according to the facility's policy. This increased the potential for medication errors and compromised drug safety for the residents.
The facility failed to maintain accurate and complete medical records for several residents, leading to potential miscommunication among healthcare providers. Issues included inconsistent documentation of medication administration, failure to properly monitor fluid intake and output, and inaccurate weight records. The DON acknowledged these inaccuracies and the potential confusion they could cause.
The facility failed to maintain an effective infection prevention and control program when a PTA did not wear required PPE while assisting two residents on ESP, and a nasal cannula for another resident was improperly stored, increasing the risk of cross-contamination and infection.
The facility failed to provide proper nail care for two residents, leading to long, unsanitary fingernails with blackish substances underneath. Both residents required assistance with personal care, and the lack of nail care was confirmed through observations and interviews with staff.
The facility failed to follow wound care procedures for two residents, resulting in unlabeled dressings and a stage 3 pressure ulcer not being covered as per physician's orders. The DON confirmed that the dressings should have been labeled and in place according to the facility's policy.
A resident with respiratory failure and COPD did not have an 'oxygen in use' sign on their room door, and their oxygen concentrator was set at 3 lpm instead of the physician-ordered 2 lpm. Both the DON and staff confirmed these discrepancies, which were against the facility's policies.
The facility failed to ensure consistent documentation of a resident's post-dialysis weight and completion of dialysis communication sheets, as required by professional standards, facility policies, and physician's orders. These lapses were confirmed by the DON and an LN, who noted missing or incomplete records on multiple occasions.
The facility failed to protect resident confidentiality when meal tray tickets containing personal information were discarded in the general trash. Kitchen aides were observed throwing away these tickets, and the Dietary Supervisor confirmed this was against policy, which requires shredding of such documents.
Multiple Food Safety and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, or distributed in accordance with professional standards of food safety. Observations revealed that the ice machine was not properly cleaned according to the manufacturer's instructions, with visible black and pink substances present on internal components, and some parts not being removed and sanitized as required. The reach-in freezer was found with sticky brown liquid spills from a soda can explosion that had not been promptly cleaned, and the blade of the can opener was discolored and worn, with the potential for metal shavings to contaminate food. Additionally, two cutting boards had deep grooves, making them difficult to clean and increasing the risk of harboring bacteria, while several metal pans were stacked wet in clean storage areas, contrary to air-drying requirements. Dietary staff demonstrated a lack of knowledge regarding proper manual dishwashing procedures using the 2-compartment sink, including incorrect steps, water temperatures, immersion times, and sanitizer concentrations. One dietary aide was unable to correctly test and identify the proper sanitizer concentration for the dishwashing machine, and used test strips incorrectly during the demonstration. These lapses in knowledge and procedure were confirmed by interviews with the dietary manager and registered dietitian, who acknowledged the importance of proper dishwashing to prevent foodborne illness. Further, a dietary aide was observed with long artificial nails with gem decorations, handling food contact surfaces and clean utensils with bare hands. This was in violation of facility policy and FDA Food Code requirements, which prohibit artificial nails and require short, well-groomed fingernails for food handlers. The report notes that these failures had the potential to cause food contamination and foodborne illness for all residents consuming food from the facility kitchen.
Improperly Sealed Dumpster Creates Environmental Deficiency
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors when the only outdoor garbage dumpster was not securely closed due to deformed lids. During observation, the dumpster was found with both lids bowed away from the edges, leaving a one- to two-inch gap, and several bags of trash inside attracted flies. Staff confirmed that the lids were deformed and did not close tightly, acknowledging that the dumpster should be securely covered. The facility's policy requires dumpster lids to remain closed at all times and for weekly inspections to be documented. The FDA Food Code also mandates that outside receptacles for refuse containing food residue must have tight-fitting lids.
Failure to Follow Professional Standards in Medication Administration and Safety
Penalty
Summary
Nursing staff failed to follow professional standards in several areas, as observed and documented during the survey. For one resident with a gastrostomy tube, the flush bag used for hydration was not labeled with the date and time it was hung, contrary to facility policy and staff expectations. Both a licensed nurse and the nurse consultant confirmed that the flush bag should have been labeled, and the facility's policy on enteral feedings required documentation of the date and time. In another instance, a nurse did not document a pain assessment before or after administering a scheduled narcotic pain medication to a resident, despite stating that the assessment was performed. The Director of Nursing confirmed that staff are expected to document pain assessments before and after administering pain medication to ensure effectiveness and proper pain management. Additionally, during medication administration, nurses withheld blood pressure medications based on vitals obtained by CNAs without verifying or rechecking the measurements, even when the readings were outside the parameters set by physician orders. The DON stated that vitals should be obtained within 30 minutes of medication administration and that it was acceptable to use CNA-obtained vitals if within this timeframe, but did not expect nurses to verify them. Furthermore, a nurse prepared and administered a hazardous chemotherapeutic medication without wearing gloves or any personal protective equipment, stating she was unaware of special handling requirements and did not see such instructions in the physician's order. The DON acknowledged that special handling instructions were not entered for this medication and that staff are expected to consult the pharmacy if unfamiliar with a medication's handling requirements. OSHA guidelines require safe handling for all hazardous drugs, regardless of administration route.
Failure to Follow Physician Orders and Infection Control for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident by not following the physician's order for oxygen therapy and not adhering to the required schedule for changing the oxygen nasal cannula. The resident, who had diagnoses including congestive heart failure, COPD, pleural effusion, and malignant neoplasm of the pleura, was observed receiving oxygen at a flow rate of 4.5 liters per minute (lpm) via nasal cannula, despite a physician's order specifying continuous oxygen at 3 lpm with titration to maintain oxygen saturation above 92%. Multiple observations confirmed the oxygen was set at 4.5 lpm, and there was no documentation of titration or communication with the physician regarding adjustments, as required by the order. Additionally, the resident's physician's order required the oxygen tubing and nasal cannula to be changed once a week and labeled accordingly. However, the nasal cannula in use was labeled with a date more than two weeks prior, indicating it had not been changed as ordered. Staff interviews confirmed awareness of the requirement to change the nasal cannula weekly for infection control, but this was not done for the resident in question. Facility policy and procedures for oxygen administration and infection prevention were not followed, as staff did not verify or adhere to the physician's orders for oxygen flow rate, titration, and documentation, nor did they ensure timely replacement of the nasal cannula. These failures were confirmed through staff interviews and review of facility policies, which outlined the expectations for oxygen therapy and infection control practices.
Deficiencies in Controlled Substance Accountability and Medication Availability
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substances for a resident with a physician's order for tramadol. There were discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR), with instances where medication was removed from the cart but not documented on the MAR, and vice versa. Both the licensed nurse and the Director of Nursing confirmed that facility policy required documentation on both records immediately after administration, and that these discrepancies were present for the resident in question. Additionally, the facility did not consistently obtain signatures from both off-going and on-coming nurses on the controlled drug shift-to-shift count records for multiple medication carts. Several shifts were missing required signatures, which are necessary to confirm that controlled medication counts were completed and that no discrepancies were identified during shift changes. Both nursing staff and the Director of Nursing acknowledged that this was not in accordance with facility policy, which mandates special handling and record keeping for controlled substances. The facility also failed to replace a narcotic emergency kit (e-kit) in a timely manner after it was opened, as required by policy. The opened kit was found with a red plastic tie and logs indicating medication had been removed, but the kit had not been reordered from the pharmacy. Furthermore, a resident with diabetes did not receive a scheduled dose of Ozempic because the medication was pending delivery from the pharmacy, and there was no documentation that the family had been contacted to supply the medication, despite the expectation that such communication should occur and be documented.
Failure to Notify Physician of Elevated Blood Sugar and Inadequate Monitoring for Insulin Administration
Penalty
Summary
A resident with multiple diagnoses, including diabetes type 2, was prescribed insulin glargine with specific physician orders to notify the physician or nurse practitioner if fingerstick blood sugar (FSBS) readings were below 100 or above 300 mg/dl. The resident's medical records showed several instances where FSBS readings exceeded 300 mg/dl at the time insulin was scheduled to be administered. Despite these elevated readings, there was no documentation that the physician or nurse practitioner was notified as required by the orders. Additionally, the resident's orders included monitoring for signs and symptoms of hypoglycemia, but there were no documented parameters or orders for monitoring hyperglycemia. The facility's policies required prompt reporting of abnormal blood sugar results and appropriate documentation, but these procedures were not followed in this case. The Director of Nursing confirmed the lack of documentation and monitoring for hyperglycemia, as well as the absence of required notifications to the physician or nurse practitioner.
Failure to Prime Insulin Pens Results in Medication Error Rate Above Threshold
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass observation, with two errors out of 36 opportunities involving two residents. During the observed medication administration, a licensed nurse prepared insulin lispro pens for both residents but failed to prime the pens before dialing the prescribed dose. The nurse removed the cap, attached the needle, and dialed the dose directly, omitting the priming step required to ensure accurate dosing. Upon interview, the nurse confirmed not priming the insulin pens and was unaware that priming was a necessary step. The Director of Nursing stated that staff were expected to prime insulin pens with 2 units before dialing the dose. Manufacturer instructions for the insulin lispro pen specify that priming is essential before each injection to ensure correct dosing. The facility's policy also requires medications to be administered safely and as prescribed.
Improper Refrigeration of Medications and Biologicals
Penalty
Summary
Surveyors observed that refrigerated medications and biologicals, including various types of insulin and Afluria Quadrivalent (flu vaccine), were stored in a medication storage room refrigerator at a temperature of 28°F. This temperature was confirmed by the DON and was within the freezing range, which is outside the required storage range of 36°F to 46°F as specified by both the facility's policy and the manufacturers' labeling. The DON acknowledged the improper storage temperature during the inspection. A review of facility policy indicated that medications requiring refrigeration must be kept between 36°F and 46°F, with temperature monitoring in place. Additionally, manufacturer instructions for both insulin and the flu vaccine specifically state not to freeze these products and to discard them if frozen. The facility's policy also requires monthly monitoring of medication storage conditions and corrective action if problems are identified. The improper storage of these medications was directly observed and confirmed during the survey.
Dietary Aides Lacked Competency in Dishwashing and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that dietary aides had the necessary skills and knowledge to safely and effectively perform food and nutrition service functions. During interviews and observations, one dietary aide was unable to accurately describe the proper procedure for manual dishwashing using the 2-compartment sink, including the correct water temperatures, immersion time, and sanitizer concentration. The dietary manager had to prompt the aide using posted instructions, and confirmed that staff, especially dishwashers, needed to be knowledgeable about these procedures. Another dietary aide provided incorrect information regarding the manual dishwashing process and sanitizer concentration, and both aides had attended relevant in-service trainings. Further observations revealed that a dietary aide was unable to properly demonstrate and verbalize the correct method for testing and achieving the appropriate sanitizer concentration when using the dishwashing machine. The aide incorrectly used the test strips and was unable to state the correct concentration required for sanitization. The registered dietitian acknowledged that staff should be able to properly wash and sanitize dishes to prevent foodborne illness. Facility policies and procedures specified the correct steps and concentrations for both manual and machine dishwashing, which were not followed or understood by the aides. A review of employee files showed that both dietary aides had been marked as competent in relevant procedures by the dietary manager, and had attended in-service trainings on dishwashing procedures. However, during the survey, they were unable to demonstrate or verbalize the correct procedures as outlined in facility policies. This failure had the potential to place 31 out of 33 highly susceptible residents at risk for foodborne illness due to improper dishwashing and sanitization practices.
Failure to Follow Prescribed Diet Menus and Portion Sizes
Penalty
Summary
During a lunch meal service, five residents on mechanical soft (MS) texture diets received a smaller portion of meatballs than specified in the facility's menu guidelines. The cook used a #16 scoop (two ounces) instead of the required #10 scoop (three ounces) for these residents, as indicated in the facility's Spring Cycle Menus spreadsheet. Additionally, one resident on a fortified diet did not receive the prescribed extra one ounce of gravy on the meatballs and an extra half ounce of melted margarine on the vegetables, as required for fortified meals. These discrepancies were confirmed through interviews with the cook and the registered dietitian, as well as a review of the facility's menu documentation. The registered dietitian acknowledged that the correct portion sizes and fortification procedures were not followed during the meal distribution. Facility policies and job descriptions for dietary staff require adherence to prescribed menus, portion control, and physician's orders for therapeutic and regular diets. The failure to follow these established procedures resulted in six residents not receiving meals that met their prescribed dietary needs during the observed lunch service.
Infection Control Failures in Food Handling, Linen Management, and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving both staff and residents. Staff were observed handling residents' ready-to-eat food with bare hands, including a certified nurse assistant (CNA) who assisted a visually impaired resident and another resident with their meals without using gloves or utensils. In one instance, the CNA had a cut on her finger covered with a dressing while handling food, and the resident expressed discomfort with this practice. Facility policy and FDA Food Code require the use of utensils or gloves when handling ready-to-eat foods, and that any bandaged hand must be covered with a single-use glove. In the laundry area, a laundry aide was seen allowing clean linen to touch both her clothing and the floor while folding, contrary to facility policy and supervisor expectations. The supervisor and director of nursing (DON) confirmed that clean linen should not come into contact with potentially contaminated surfaces, and that linen touching the floor should be rewashed. Additionally, during medication administration, a licensed nurse was observed using a shared glucometer between residents, cleaning it with a single disinfecting wipe for multiple surfaces, and not sanitizing the insulin pen's rubber seal before attaching a needle. The nurse was unaware of the need to disinfect the pen seal and had not received specific training on proper sanitizing procedures for blood glucose monitors. Further deficiencies included nursing staff failing to perform hand hygiene or change gloves between different routes of medication administration, such as oral, inhaled, and eye medications, and after handling contaminated devices. A nebulizer face mask for a resident with chronic respiratory conditions was not changed every seven days as required by facility policy, with the equipment in use for over three weeks. These failures were confirmed by staff interviews and policy reviews, and resulted in increased risk for cross-contamination and potential exposure to infectious agents among residents, staff, and visitors.
Failure to Verify PEG Tube Placement Prior to Enteral Feeding
Penalty
Summary
A deficiency occurred when a licensed nurse administered a bolus feeding to a resident with a percutaneous endoscopic gastrostomy (PEG) tube without first verifying the tube's placement, as required by physician orders and facility policy. The nurse checked for bowel sounds and residual amount but omitted the step of confirming PEG tube placement prior to starting the enteral feeding. During the feeding, the resident exhibited intermittent coughing. The nurse later acknowledged not checking the tube placement and recognized the importance of this step to ensure the tube was correctly positioned in the stomach before administering the feeding. The resident involved had a history of diabetes mellitus, gastroesophageal reflux disease, and required ongoing attention to a gastrostomy. The resident was cognitively moderately impaired and dependent on tube feeding and water flushes, as documented in the care plan. Facility policy and physician orders specifically required verification of tube placement before each feeding, but this protocol was not followed during the observed incident. Interviews with facility leadership confirmed that checking tube placement is the expected standard of practice to prevent complications.
Failure to Document COVID-19 Vaccination Status for Staff
Penalty
Summary
The facility failed to document and maintain records of COVID-19 vaccination status for seven out of eighty staff members, including licensed nurses, a laundry aide, certified nursing assistants, and a cook. During a concurrent interview and record review, the Director of Staff Development and the Infection Control Nurse confirmed that they could not locate COVID-19 vaccination records for these staff members in the Employee Records. The Director of Staff Development stated that immunizations, including COVID-19, are offered to new hires during their first day of orientation, but documentation for these seven staff members was missing. Interviews with the Administrator and Nurse Consultant confirmed that the facility encourages staff to receive the COVID-19 vaccine for safety and that vaccination is recommended to prevent respiratory infections. A review of the facility's policy indicated that vaccination status should be assessed and documented prior to or upon an employee's duty assignment. Despite this policy, the records for the identified staff members did not include documentation of their COVID-19 vaccination status.
Failure to Protect Resident from Physical Abuse in Rehabilitation Room
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of behavioral outbursts related to Huntington's Disease, threw a walker and struck the resident on the left knee in the rehabilitation room. Both residents involved were cognitively intact according to their most recent assessments. The incident was witnessed by the Director of Rehab and a Physical Therapy Assistant, who confirmed that the action was unprovoked and that other residents were present during the event. After the initial assault, the aggressor attempted to attack the same resident again and was restrained by staff. Despite the aggressor's known history of throwing objects and a physician's order to monitor and document such behaviors, the facility did not classify the event as resident-to-resident abuse, instead treating it as a behavioral outburst. The Director of Nursing and other staff interviews revealed that the incident was not reported to the Department as abuse, and the facility's policy on abuse prevention, which mandates protection from all forms of abuse, was not followed in this case.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Department as required by policy and regulation. The incident involved a resident with Huntington's Disease, who had a history of behavioral outbursts, throwing a walker at another resident in the rehabilitation room, striking the second resident's left knee. Both residents were assessed as cognitively intact. The event was witnessed by the Director of Rehab (DOR) and a Physical Therapy Assistant (PTA), both of whom confirmed the altercation and acknowledged their status as mandated reporters. The DOR reported the incident to the facility's Administrator and DON, who indicated it would be handled, but the incident was not reported to the Department as required. Interviews with staff, including the DOR, PTA, and a licensed nurse, confirmed that the event was recognized as a resident-to-resident altercation and should have been reported. However, the DON stated the facility did not consider the incident as abuse, but rather as a behavioral outburst, and therefore did not report it to the Department. Review of the facility's policy indicated that all alleged violations involving abuse must be reported immediately or within specified timeframes, but this procedure was not followed in this case.
Failure to Document Food Storage and Sanitization Logs
Penalty
Summary
The facility failed to ensure food safety by not consistently documenting food storage temperature logs and sanitization solution logs. During an observation and interview with a cook, it was found that the Dry Food Storage Temperature Control Log had four missing entries for the month of May 2024. The cook acknowledged that missing entries were unacceptable and could lead to food safety concerns. Similarly, the Kitchen Aid confirmed that the Quaternary Ammonium Log had seven missing entries for the same month, and the Cold Storage Temperature Control Log had 14 missing entries. The Dietary Supervisor also confirmed these discrepancies and stated that the logs were expected to be completed twice daily to prevent potential resident harm. The facility's policies and procedures were reviewed, revealing that the logs were supposed to be maintained to minimize the risk of foodborne illness. The policy on preventing foodborne illness indicated that food temperatures should be monitored and documented at designated intervals throughout the day. The Quaternary Ammonium Log Policy required the concentration of the ammonium in the sanitizer to be tested and recorded at least every shift. The failure to adhere to these policies had the potential to lead to foodborne illnesses for the 38 residents eating facility-prepared meals.
Failure to Monitor Fluid Intake for Residents on Fluid Restriction
Penalty
Summary
The facility failed to assess and evaluate the Intake and Output (I&O) weekly summaries for two residents who were on fluid restriction. Resident 20, diagnosed with hemodialysis, heart disease, and lung problems, had a fluid restriction order of 2000 ml per 24 hours. Resident 23, diagnosed with chronic kidney disease and on anticoagulant therapy, had a fluid restriction order of 1500 ml per 24 hours. Despite these orders, there was no documented evidence that Licensed Nurses (LNs) summed up the residents' 24-hour fluid intake totals or completed the weekly fluid intake summaries for either resident. During interviews, LN 2 confirmed that the weekly I&O summaries were not completed for Resident 20 and Resident 23, acknowledging the importance of these summaries in determining fluid balance and evaluating the effectiveness of fluid restriction orders. The Director of Nursing (DON) also verified the absence of weekly I&O evaluations for the residents, stating that without these evaluations, it was difficult to understand the accurate fluid status of the residents.
Failure to Act on Pharmacist's Recommendations and Manage Medication Storage
Penalty
Summary
The facility failed to provide thorough drug regimen reviews (DRR) for one of 15 sampled residents when it did not act on the facility pharmacist's (FP) report on irregularities and allowed expired medications to be mixed with other medications in the medication storage room refrigerator. This resulted in unresolved irregularities of antipsychotic medication therapy for the resident and increased the potential for medication errors. Resident 23, a long-term resident with unspecified memory problems and behavioral disturbances, was on antipsychotic medication monitoring every shift. The resident had two physician orders for Risperidone that were discontinued, but the facility did not act upon the FP's recommendation to remove the associated side effect and behavior monitoring. The facility's failure to act on the FP's March DRR recommendation led to continued monitoring despite the discontinuation of the medication. Additionally, during a medication storage room observation, expired flu vaccines were found mixed with current vaccines. The FP acknowledged that checking the medication storage room was part of the monthly DRR process and that expired medications should have been identified and removed. The facility's failure to act on the FP's recommendations and properly manage medication storage resulted in unresolved irregularities and potential confusion among healthcare providers.
Expired Flu Vaccines Mixed with Non-Expired Vaccines
Penalty
Summary
The facility failed to discard expired medications, specifically flu vaccines, for a census of 38 residents. During an observation of the medication storage room, it was found that expired flu vaccines from the 2022-2023 season were mixed with non-expired flu vaccines from the 2023-2024 season in the medication refrigerator. There were nine pre-filled syringes of the expired vaccine with an expiration date of 6/30/23. The facility's policy from March 2018 requires outdated medications to be immediately removed from stock and disposed of properly. A Licensed Nurse confirmed the presence of the expired vaccines and acknowledged that night shift nurses were responsible for discarding expired medications. The failure to separate and discard expired medications increased the potential for medication errors and compromised drug safety for the residents.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to maintain accurate, consistent, and complete medical records for several residents, leading to potential miscommunication among healthcare providers. For Resident 23, the medical records were inconsistent regarding the administration of Risperidone, an antipsychotic medication, which was discontinued but still documented as being monitored. Additionally, the resident's fluid intake and output (I&O) were not properly evaluated weekly as required by the facility's policy. The Director of Nursing (DON) acknowledged these inaccuracies and the potential confusion they could cause among healthcare providers. Resident 4's medical record inaccurately reflected the administration of a liquid protein supplement, which the resident had refused. The Licensed Nurse (LN) responsible for administering the medication did not document the refusal or notify the DON or Registered Dietician (RD), contrary to the facility's practice. The DON confirmed that all medication refusals, including supplements and over-the-counter medications, should be documented and reported. Resident 20's medical records showed significant weight fluctuations, which were inaccurately documented, and the resident's fluid restriction therapy was not properly monitored. The RD explained that a recorded weight of 50.7 lbs was likely a typo and should have been in kilograms. Additionally, the weekly I&O evaluations were not conducted as required. For Resident 3, the medical records continued to monitor for side effects of Abilify, an antipsychotic medication, even after it had been discontinued. The DON verified these inaccuracies and acknowledged that the medical records were incomplete and inconsistent with the care provided, potentially misleading healthcare providers about the residents' health status.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a census of 38 residents. Specifically, a Physical Therapy Assistant (PTA) did not wear the required personal protective equipment (PPE) when assisting two residents, both on enhanced standard precautions (ESP) due to their medical conditions. The PTA was observed assisting Resident 233 with mobility exercises and checking their oxygen level without wearing a gown or gloves, despite the resident having a stage 3 pressure ulcer and an occipital abscess. Similarly, the PTA assisted Resident 234 with sit-to-stand mobility exercises without wearing a gown or gloves, even though the resident had a surgical site on the left knee and was under ESP. Both residents had clear signage and care plans indicating the need for PPE during mobility assistance, which the PTA failed to follow. Additionally, the facility failed to properly store a nasal cannula for Resident 14, who had respiratory failure, COPD, heart failure, and was dependent on supplemental oxygen. The nasal cannula was left uncovered and hanging on the resident's bedside rail when not in use, instead of being placed inside a bag as required for infection control. This was confirmed by a Licensed Nurse (LN) who acknowledged that the nasal cannula should have been bagged when not in use. Interviews with the Chief Clinical Officer (CCO) and the Director of Nursing (DON) confirmed that the facility was aware of the new guidelines regarding ESP and that staff should follow these precautions to prevent the spread of infections. The facility's policy and procedure documents also supported the need for enhanced standard precautions and proper storage of medical devices to reduce the risk of cross-contamination and infection among residents, staff, and visitors.
Failure to Provide Proper Nail Care for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 232 and Resident 23, received proper nail care as part of their Activities of Daily Living (ADLs). Resident 232, who had diagnoses including chronic obstructive pulmonary disease and atrial fibrillation, was observed with long fingernails and a blackish substance underneath them. Despite having a moderate cognitive impairment and requiring assistance with personal hygiene, there was no documented refusal of nail care. Both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN) confirmed the lack of nail care, and the Director of Nursing (DON) emphasized the importance of maintaining clean and short nails for infection control. The resident's care plan was updated only after the observation to include the need for nail care to reduce the risk of injury and infection. The facility's policy on ADLs also indicated the need for appropriate hygiene care, which was not followed in this case. Similarly, Resident 23, who had muscle weakness and required assistance with personal care, was found with long, unsanitary fingernails containing a black substance. The resident expressed discomfort and inconvenience due to the long nails, which were getting caught in blankets and clothes. A Licensed Nurse verified the condition of the nails and stated that nail trimming was supposed to occur every Sunday, indicating a lapse in the scheduled care. Both residents' conditions and the lack of proper nail care were confirmed through observations, interviews, and record reviews, highlighting a failure in the facility's adherence to its own policies and care plans.
Failure to Follow Wound Care Procedures
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice and the facility's policy and procedure. Resident 233 had a physician's order for the treatment of a stage 3 pressure ulcer on the coccyx, which required cleansing with normal saline, patting dry, applying calcium alginate, and covering with a dry dressing daily and as needed if soiled or dislodged. However, during an observation, it was found that Resident 233's stage 3 pressure ulcer was not covered with a dry dressing as per the physician's order. The Director of Nursing confirmed that the dressing should have been in place according to the physician's order and the facility's wound care policy, which mandates verifying physician's orders and using appropriate dressing materials. Additionally, the dry dressings on Resident 233's head and inner right thigh were not labeled with the nurse's initials, date, and time of application, which was also confirmed by the Licensed Nurse and the Director of Nursing as a requirement for proper wound care management. Resident 234, who was admitted with diagnoses including the need for orthopedic aftercare and assistance with personal care, had a physician's order for the treatment of a surgical site on the left knee. The order specified cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing daily and as needed if soiled or dislodged. During an observation, it was found that the dry dressings on Resident 234's left knee were not labeled with the nurse's initials, date, and time of application. Resident 234 confirmed the observation, and the Director of Nursing stated that the dressings should be labeled properly to keep track of dressing changes and ensure compliance with the physician's order. The facility's policy and procedure for wound care, revised in October 2010, indicated that dressings should be labeled with the nurse's initials, time, and date of application. The failure to follow these procedures for both Resident 233 and Resident 234 had the potential to impact their wound healing and overall well-being. The Director of Nursing acknowledged that the dressings should have been labeled and in place as per the physician's orders and the facility's policy.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper handling and delivery of respiratory care for Resident 14, who had diagnoses including respiratory failure, COPD, heart failure, and dependence on supplemental oxygen. The deficiencies included the absence of an 'oxygen in use' sign on the outside of Resident 14's room entrance door, which was confirmed by Licensed Nurse 4 during an observation. The Director of Nursing (DON) acknowledged that the sign is a precautionary measure to prevent potential harm to patients and staff. The facility's policy and procedures for oxygen administration, revised in October 2010, required the placement of such a sign, but this was not followed in Resident 14's case. Additionally, Resident 14's physician's orders for oxygen therapy were not adhered to. The physician's order specified that oxygen should be administered at 2 liters per minute (lpm) via nasal cannula continuously. However, during an observation, it was found that the oxygen concentrator was set at 3 lpm. Both Resident 14 and Certified Nurse Assistant 3 confirmed this discrepancy. Licensed Nurse 4 and the DON both stated that the staff should follow the physician's orders, and the DON highlighted that administering 3 lpm instead of 2 lpm could cause hyperoxygenation. The facility's policy and procedures also required staff to adjust the oxygen delivery device to ensure the proper flow of oxygen, which was not done in this instance.
Failure to Document Dialysis Care Consistently
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care services received care consistent with professional standards of practice, facility policies, and physician's orders. Specifically, the resident's post-dialysis weight was not consistently documented in the resident's chart on multiple occasions, including specific dates in May. The Director of Nursing (DON) and a Licensed Nurse (LN) confirmed the absence of these documented weights, which are crucial for monitoring significant weight changes as per the physician's order. Additionally, the facility did not consistently complete the dialysis communication sheet for the resident. The sheet, which should be filled out before and after dialysis sessions, was found incomplete or missing on several occasions. The DON and LN confirmed these lapses, with the LN noting that the dialysis communication sheet binder sometimes gets lost. The facility's policy and procedure, as well as the resident's care plan, require the completion of these sheets to document vital signs, changes in condition, and other relevant information pre- and post-dialysis.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to ensure residents' rights to personal privacy and confidentiality of their personal medical information when meal tray tickets containing residents' names, diets, and room numbers were found discarded in the general trash. During observations, kitchen aides were seen throwing away these meal tickets into the kitchen garbage can, which was later emptied into an outside garbage bin. The Dietary Supervisor confirmed that this practice was against the facility's policy, which requires meal tickets to be collected for shredding to protect residents' confidential information. The facility's policy on confidentiality and personal privacy, revised in October 2017, mandates that access to resident personal and medical records be limited to authorized staff.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 707 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Mckinley Park Care Center | 0.4 mi | ★★★★★ | 31 | 0 |
| University Post-acute Rehab | 0.6 mi | ★★★★★ | 0 | 0 |
| Mid-town Oaks Post-acute | 0.7 mi | ★★★★★ | 27 | 0 |
| Sherwood Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Sacramento | 2.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.