Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 St Francis Healthcare Center during CMS and state inspections, most recent first.
Failure to Report Allegation of Abuse: A resident with hemiplegia/hemiparesis and moderate cognitive impairment reported that a lady hit him on the head, punched his face, and pushed his head on the bed. The DON said the facility investigated internally but did not report the allegation to the state agency because staff concluded the CNA was only rude and did not hit the resident. The SSD and Adm confirmed the allegation was not reported to the Ombudsman, law enforcement, or the state agency.
Failure to Report Alleged Abuse Investigation: A resident with hemiplegia/hemiparesis and moderate cognitive impairment reported that a CNA hit or pushed his face and head, making him feel unsafe and angry. The DON said the facility investigated but did not report the allegation to the State Agency because it was concluded the CNA was only rude, and the SSD stated the incident was also not reported to the Ombudsman or law enforcement. Records showed the CNA received counseling for rude and aggressive behavior and continued working on multiple days after the allegation.
Ordered meds were not available for three residents when needed. A resident with pain had Norco unavailable and reported severe pain despite Tylenol; a resident with dementia had no Namenda in the med cart; and a resident with respiratory disease had no Ipratropium-Albuterol solution available for the scheduled dose. Staff interviews and record review confirmed the missing meds and delayed pharmacy supply.
Medication errors exceeded the 5% threshold, with 4 errors in 31 observed med passes for a 12.9% error rate. An RN found a resident’s ordered Ipratropium-Albuterol solution unavailable, and Minoxidil and Hydralazine were not administered during the pass; the resident had chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, ESRD, and HTN, and was noted to have accessory muscle use when breathing. In a separate observation, an RN found Namenda 10 mg unavailable for a resident with dementia, and the MAR showed the dose as drug refused.
Medication labeling and storage were not maintained for multiple drugs. An East med cart contained opened Budesonide products without open dates and Breo Ellipta that had exceeded the labeled use period, a bottle of Potassium Chloride was stored in a refrigerator despite manufacturer directions for room-temperature storage, and the narcotic safe was not secured to the wall while holding multiple narcotic bubble packs for destruction.
Improper Cooling Log Documentation for Potentially Hazardous Foods: The facility failed to ensure potentially hazardous foods were cooled properly before storage. During kitchen review, the DM stated staff used the cool down method for leftover or preprepared foods, but the Cool Down Log showed the same temperatures for all menu items at 1 hour, 2 hours, and 4 hours. The DM stated staff appeared to be recording expected temperatures instead of actual food temperatures, despite the facility policy requiring rapid cooling from 135 F to 70 F within 2 hours and to 41 F or below within the next 4 hours.
Infection control failures were identified involving a resident with a midline catheter, another resident using oxygen, and residents on droplet/contact or enhanced barrier precautions. An IV bag remained connected after infusion was complete, a midline dressing was peeling, PPE bins were overflowing or poorly placed, an oxygen humidifier lacked required dating and initials, and staff entered isolation rooms without the required PPE or in the wrong sequence. Residents on precautions were also housed with and allowed access to common areas shared with residents not on precautions.
Meal assistance was not provided with dignity for two residents. One resident with Parkinson's disease, dyskinesia, glaucoma, and moderate cognitive impairment was left to feed herself despite right shoulder and arm pain and tremors, while staff set the tray down and left. Another resident with dementia and severe cognitive impairment was assisted by a CNA who stood beside the resident during feeding, which the DSD acknowledged was not appropriate because of dignity concerns.
A resident with hemiplegia/hemiparesis and moderate cognitive impairment reported that a CNA hit and pushed his face and had rushed him when he needed the bathroom. Record review showed the CNA was later documented for rude, unprofessional, and aggressive behavior, yet continued working and was assigned to the resident’s room and roommates after the allegation. The DSD and DON acknowledged the CNA should not have been assigned there, and the facility’s abuse prevention policy required residents to be free from abuse and staff to be trained in abuse prevention and reporting.
Unverified IV Fluid Order: A resident with dysphagia, dementia, and CHF had an order for D5 IV fluids for high sodium, but the MAR reflected administration that did not match the order. The DON stated the resident received the fluids at 75 ml per hour rather than 75 cc every shift, and acknowledged the IV fluid order should have been verified with the physician before administration. RN 1 stated unclear IV fluid orders should be verified before hanging the fluids.
A resident with schizophrenia, encephalopathy, hemiplegia/hemiparesis, and substance abuse left the facility without staff knowledge and was treated as AMA. Staff searched for the resident, contacted law enforcement, and completed an AMA form while the resident was missing, but the chart did not document the resident’s condition on return, the exact return time, assessments, notifications, or other key details. Staff gave conflicting accounts of the timeline, and the SSD acknowledged the return was not documented in the PN.
Incomplete Personal Property Inventory Reconciliation: A resident’s personal belongings were not timely and accurately reconciled, and the resident’s representative reported several missing items when retrieving the belongings. The record showed multiple inconsistent inventory sheets, while several items on handwritten lists were not added to the electronic inventory or included in the released items, and the ADON stated inventory procedures were inconsistently followed.
Insulin Dose Administered Incorrectly: An RN misread a blood sugar result and gave a resident 11 units of insulin instead of the ordered 6 units. The resident had type 2 DM, CKD, bradycardia, anxiety disorder, and CHF. The RN stated she realized the error right after the injection. The record showed the physician was notified, hourly BS checks were ordered, and later that morning the resident had difficulty breathing, received oxygen, an inhaler, nitroglycerin, and additional orders for Lasix and DuoNeb.
Food was not stored and prepared according to standards when a kitchen staff member prepared bread without a beard restraint, multiple food items in the kitchen refrigerator, dry storage, and a resident refrigerator were past their use-by dates, dry storage items were kept about three inches off the floor, and an ice scoop was left uncovered in the resident hallway. The KM and DON stated the expired food, low storage, and uncovered scoop were contamination risks, and facility policy required facial hair to be covered, dry food to be kept at least 6 inches off the floor, and foods to be labeled and dated.
A resident with a stroke history, communication and swallowing difficulty, and GAD was yelling and screaming, and lorazepam was given without documentation of whether it was effective. The DON confirmed the record also lacked documentation of what was done to address the resident’s repeated daily screaming episodes or whether the interventions helped.
A resident with paranoid schizophrenia had worsening paranoia, confusion, and refusals of meds, ADLs, and care. Her Secuado patch became unavailable, she was not wearing it, and staff did not promptly follow up with the MD for a new treatment plan as her delusions and falls increased.
Unsafe medication storage practices were observed in the medication room and medication cart. Two vials of Lasix for a discharged resident were left in a bag with sticky liquid, several opened meds and eye drops were not properly dated, and one eye drop bottle had an unclear date. Staff food was also found in a lunch box under the sink with molded food inside, and the DON stated this created an unsafe and unhygienic environment that could contaminate meds and supplies.
A facility failed to properly identify two residents with the same surname, resulting in one resident being mistakenly transported for dialysis while the other experienced a delay in treatment. The LVN did not verify the identity of the resident being transported, leading to emotional distress for the resident who was unnecessarily taken to the dialysis center.
The facility failed to ensure that a resident was given antipsychotic medication to treat a specific condition and with adequate monitoring of adverse effects. The resident, who had Parkinson's disease, type 2 diabetes mellitus, and dementia, was prescribed quetiapine for agitation without proper monitoring for adverse reactions. Staff interviews revealed a lack of awareness and monitoring, and the facility's policy on antipsychotic medication use was not followed.
The facility failed to report a fall with major injury involving a resident who was found on the floor and later diagnosed with a vertebral compression fracture. The administrator was unaware of the reporting requirement, and the facility lacked a policy for reporting such incidents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident 27 to the appropriate agencies within the required timeframe. Resident 27 was admitted with diagnoses including hemiplegia and hemiparesis due to a stroke, and the MDS dated 3/20/26 showed a BIMS score of 8, indicating moderate cognitive impairment. On 3/21/26, SBAR notes documented that the resident reported a lady hit him on the head the night before, said a lady punched his face, and stated it was not the first time and that she rushed him when he needed to use the bathroom. The note also stated no injuries or bruising were observed at that time. During interviews, Resident 27 stated that a lady placed her open hand on his face and pushed his head on the bed, and that the incident made him feel unsafe and angry. The DON stated the facility conducted an internal investigation but did not report the allegation to the state agency because the investigation concluded CNA 1 was only "rude" and did not hit the resident. The SSD stated the allegation was not reported to the Ombudsman, local law enforcement, or the state agency, and the Administrator confirmed it was not reported to the state agency. The facility policy required allegations to be investigated and reported within federal timeframes.
Failure to Report Alleged Abuse Investigation
Penalty
Summary
The facility failed to report Resident 27’s alleged abuse investigation results to the State Agency. Resident 27 was admitted with diagnoses including hemiplegia and hemiparesis due to a stroke, and the MDS dated 3/20/26 showed a BIMS score of 8, indicating moderate cognitive impairment. On 3/21/26, SBAR notes documented that the resident reported a lady hit him on the head, punched his face, and rushed him when he wanted to use the bathroom; no injuries or bruising were noted at that time. During an interview on 4/7/26, Resident 27 stated that a lady placed her open hand on his face and pushed his head back toward the bed, and he said the incident made him feel unsafe and angry. The DON stated the facility conducted an internal investigation but did not report the allegation to the State Agency because the facility concluded CNA 1 was only rude and did not hit the resident. The SSD stated the alleged abuse incident was not reported to the Ombudsman, local law enforcement, or the State Agency. Record review showed an ECF dated 3/27/26 issued to CNA 1 for rude and unprofessional behavior and a specific report of aggressive behavior toward Resident 27, and the DSD stated CNA 1 was called for one-on-one abuse retraining after the allegation. The Incident Investigation Report dated 3/23/26 noted CNA removed from run and planned inservice, but the Daily Assignment Sheets showed CNA 1 continued working in the facility on multiple days after the allegation and was assigned to Resident 27’s room and to care for the resident’s two roommates.
Ordered Medications Not Available for Administration
Penalty
Summary
Pharmaceutical services were not provided to meet resident needs when ordered medications were not available for administration for three sampled residents. The report states that for Resident 37, Resident 3, and Resident 6, the facility failed to ensure ordered medications were on hand when needed, and surveyors observed, interviewed staff, and reviewed records related to each event. For Resident 37, who was admitted with diagnoses including pneumonia and kidney cyst, the physician ordered Norco as needed for pain. During interview, Resident 37 stated the morning dose was not given because the facility had run out of supply and the medication had not yet arrived from the pharmacy, and Tylenol did not relieve the pain, which remained at 8 to 9 out of 10. RN 1 stated the order was sent to the pharmacy and that medication would be obtained from the E-kit if available, but could not confirm whether Norco was given from the E-kit. RN 2 stated Resident 37 was given ibuprofen and routine gabapentin, and the controlled drug record showed the last Norco dose before the new supply was not administered until later that day. The facility policy stated refills should be requested a minimum of three days in advance of need. For Resident 3, who had a diagnosis of dementia and a BIMS score of 14, RN 3 observed that Namenda 10 mg was scheduled but there was no supply in the medication cart. RN 3 later stated the medication was ordered from the pharmacy and that it would not be available for refill until a later date. For Resident 6, who had diagnoses including chronic pulmonary edema and acute and chronic respiratory failure with hypoxia, RN 2 found no supply of the ordered Ipratropium-Albuterol solution in the medication cart during preparation for the scheduled dose. The DSD stated she would order the medication from the pharmacy, and RN 1 later observed Resident 6 asleep but using accessory muscles when breathing.
Medication Error Rate Exceeded Threshold
Penalty
Summary
Medication errors exceeded the 5% threshold, with 4 errors identified during 31 medication pass observations for a 12.9% error rate. During a concurrent observation, interview, and record review, RN 2 prepared medications for a resident with chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, end stage renal disease, and hypertension. The resident’s ordered Ipratropium-Albuterol solution was not available on the cart, and the resident’s Minoxidil 2.5 mg and Hydralazine HCl 100 mg were not administered during the observed pass. RN 2 stated the Minoxidil would be held because the systolic blood pressure was 103 and the pulse was 52, and stated she would hold Hydralazine based on the same vital signs and clarify the physician order parameters. The MAR showed Minoxidil scheduled at 9:00 a.m. was not given, Hydralazine scheduled at 12:00 p.m. was marked for vital signs outside parameter, and Ipratropium-Albuterol scheduled at 8:00 a.m. was not given. RN 1 later observed the resident asleep and noted accessory muscle use when breathing. During another concurrent observation and interview, RN 3 prepared medications for a resident with dementia and found that Namenda 10 mg was not available on the medication cart. The resident’s physician order listed Namenda 10 mg twice daily for dementia, and the MAR showed the 9:00 a.m. dose was marked as drug refused. RN 3 stated she ordered the medication from the pharmacy and was informed it was not available for refill until 04/16/2026. The report also states that the facility failed to ensure the medication error rate was below 5%.
Medication Labeling, Storage, and Narcotic Safe Security Deficiencies
Penalty
Summary
Safe storage and labeling of medications were not maintained on the East Medication Cart and in the medication room. During observation with an LVN, the East Medication Cart contained Budesonide inhalation suspension that had been opened but not dated, Budesonide 0.25 mg/2 ml that was opened but not dated, and Breo Ellipta with an open date of 2/1/26. The LVN stated that medications should be labeled with the date opened and acknowledged uncertainty about how long Budesonide inhalation suspension remains usable after opening, while also stating that Breo Ellipta is only good for six weeks from the open date and should have been discarded because it had passed that period. Manufacturer information reviewed by the facility stated that Budesonide inhalation suspension vials can be stored for 2 weeks after opening the protective foil envelope and Breo Ellipta must be thrown away 6 weeks after opening or when the counter reads 0, whichever comes first. During observation in the medication room, a 150 ml bottle of Potassium Chloride 10% solution was found inside the refrigerator without a sticker indicating it needed refrigeration. The refrigerator temperature was 43.8 degrees F, and the LVN stated she did not know whether the medication needed to be kept in the refrigerator. The manufacturer information reviewed by the facility stated that Potassium Chloride solution should be stored at room temperature between 68F and 77F. In a separate observation with the DON, narcotic bubble packs were stored in a safe that was not secured to the wall, and the DON stated she had been rearranging items and forgot to request maintenance to attach the safe to the wall. The safe contained multiple bubble packs of narcotic medications for destruction.
Improper Cooling Log Documentation for Potentially Hazardous Foods
Penalty
Summary
The facility failed to ensure that potentially hazardous foods were cooled properly before being stored. During a concurrent interview and record review in the kitchen, the Dietary Manager stated that when there was leftover food or a dish prepared ahead of time, staff followed the cool down method. Review of the Cool Down Log showed the menu item, date, time, and expected temperature for the product, but the temperatures listed were the same for all menu items on both pages of the log at 1 hour, 2 hours, and 4 hours. The Dietary Manager stated that staff must have been writing the expected temperature rather than the actual menu item temperature. Review of the facility's untitled policy and procedures for Rapid Cooling stated that potentially hazardous foods are to be cooled from 135 F to 70 F within 2 hours and then to 41 F or below within the next 4 hours, with total cooling time not to exceed 6 hours.
Infection Control Failures With IV Care, PPE Disposal, Respiratory Equipment, and Isolation Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when Resident 5’s one-liter IV fluid bag remained hung and connected to the resident’s midline catheter after the infusion was complete. During observation, the bag was still half full and attached to the midline. The DON acknowledged that the IV should have been disconnected from the midline to prevent infection, and the IP stated the midline should have been capped once the order was completed. Resident 5’s record showed severe cognitive impairment, and the midline insertion record directed that the dressing be changed every seven days and as needed if soiled or not intact. Resident 5’s midline dressing was observed lifting and peeling off, with the inner lower and upper portions no longer secure. RN 1 stated the dressing integrity failure created a risk for infection and potential dislodgement. The record review showed the licensed nurses’ documentation did not indicate monitoring of the midline dressing for soilage or integrity, and RN 1 acknowledged the dressing should have been monitored. The facility policy required the dressing to be changed if damp, loosened, visibly soiled, or compromised, and required frequent assessment of the access device for residents with cognitive impairment. In Resident 5’s room, the garbage bin beside the oxygen concentrator was overflowing with used PPE gowns. The DON stated the used PPE should have been disposed of in the appropriate bin located behind the room door and should not have been beside the oxygen concentrator because of cross contamination. The IP stated Resident 5 was on EBP due to a gastrostomy tube and a history of drug-resistant infection to the foot wound, and that improper disposal of PPE created a spread of infection concern. In another room, the PPE disposal bin was overflowing and touching a folding chair and a walker that were stored behind the door, and staff acknowledged the bin should not have been overflowing or touching resident equipment. The facility also failed to manage respiratory equipment and room placement for residents on transmission-based precautions. Resident 15’s oxygen concentrator humidifier was missing its open date and initials, despite the facility policy requiring distilled water used in respiratory therapy to be dated, initialed when opened, and discarded after 24 hours. Resident 25, who did not require TBP, was placed in a room with residents on droplet precautions, and residents under droplet/contact precautions were allowed to remain in common areas shared by residents without TBP. In the droplet/contact precaution room, the garbage bin for PPE disposal was initially not visible and was found folded behind the door. Multiple staff entered the isolation room without the required PPE or without following the proper donning sequence, including staff who wore only gloves and a mask or donned gloves before gown and face shield. The facility policy stated transmission-based precautions remain in effect until discontinued by the attending physician or IP, and CDC guidance for PPE donning was reviewed during the survey.
Meal Assistance Not Provided With Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during meal service for two sampled residents. One resident with Parkinson's disease, dyskinesia, a brain neoplasm, and unspecified glaucoma had a BIMS score of 12 and required partial/moderate assistance with eating, but during lunch in the resident room staff set the meal tray on the over-bed table and left without assisting. The resident stated she had to feed herself despite right shoulder and arm pain and Parkinson's-related tremors, and that using utensils was difficult and messy, with no staff checking in to ensure her needs were met. A second resident with dementia and muscle weakness had a BIMS score of 3 and was being assisted with eating in the dining room by a CNA who was standing beside the resident while providing the meal assistance. During the observation, the DSD acknowledged that the CNA should have been seated beside the resident and should not have been standing while assisting with eating because of dignity issues. The facility's Assistance with Meals policy stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Failure to Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to follow its written abuse prevention policy after an allegation that a CNA acted aggressively toward Resident 27. Resident 27 was admitted with hemiplegia and hemiparesis due to a stroke, and the MDS dated 3/20/26 showed a BIMS score of 8, indicating moderate cognitive impairment. On 3/21/26, the resident reported to the admission coordinator that a lady hit him on the head the night before and said it was not the first time; the resident also stated that she rushed him when he needed to use the bathroom. The SBAR note documented that the resident said a lady punched his face, and no pain, injuries, or bruising were noted at that time. During interview and record review, the DSD confirmed that CNA 1 was issued an Employee Counseling Form for rude and unprofessional behavior toward residents and for a specific incident involving Resident 27. The facility’s Daily Assignment Sheets showed that CNA 1 continued working after the allegation and was assigned on 3/27/26 to Resident 27’s room and to care for the resident’s two roommates. The DSD and DON both acknowledged that CNA 1 should not have been assigned to that room because of the abuse allegation and the need to protect Resident 27 from further abuse. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that residents have the right to be free from abuse and that staff should be trained in abuse prevention, identification, reporting, and appropriate ways to address conflicts.
Unverified IV Fluid Order
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident 5. The resident was admitted with diagnoses including dysphagia, dementia, and congestive heart failure. The physician's orders dated 4/8/26 indicated Dextrose Intravenous Solution 5% at 75 cc intravenously every shift for high sodium, and the MAR showed the resident received Dextrose Intravenous Solution 5% 75 cc intravenously every shift for high sodium from 4/5/26 until 4/8/26. During a concurrent interview and record review on 4/9/26, the DON stated the resident received 75 ml per hour and not 75 ml every shift or every eight hours to correct the high sodium in the resident's body, and acknowledged the IV fluids order should have been verified with the physician before it was administered. RN 1 stated that if an IV fluid order was unclear, it should be verified with the physician before hanging the fluids. The facility policy titled, Intravenous administration of fluids and electrolytes, stated a physician order is necessary to give IV fluids and electrolytes and that the licensed nurse responsible for administering them shall be knowledgeable of appropriate rates, doses, and routes of administration.
Incomplete documentation after resident elopement
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one sampled resident when the resident left the facility without staff knowledge or permission and the event was documented as leaving against medical advice. The resident had diagnoses including schizophrenia, disorders of psychological development, encephalopathy, history of falling, hemiplegia, hemiparesis, weakness, and psychoactive substance abuse. The record showed the resident was missing, had not signed out, and staff searched the front smoking area before contacting the Sheriff’s Office. Progress notes documented that the resident was last seen at 7:20 a.m., was reported missing to law enforcement, and that the Sheriff arrived at the facility and searched for the resident without success. The record also showed that an AMA release form was completed while the resident was missing and later uploaded to the chart. However, the medical record did not include comprehensive information describing the resident’s condition upon return, the time the resident returned to the facility, assessments performed, notifications made to the physician or responsible party, or interventions implemented to ensure the resident’s safety. During interviews, staff gave differing accounts of when the resident returned and when the Sheriff arrived, and the Social Services Director acknowledged that the resident’s actual return was not documented in the progress notes. The Social Services Director stated the AMA form had been completed while the resident was still missing and then presented for signature when the resident returned. The facility policy for wandering and elopements required that when a resident returns after leaving without authorization, the resident be examined for injuries, the physician be notified, search teams be informed, an incident report be completed, and details be documented in the medical record.
Incomplete Personal Property Inventory Reconciliation
Penalty
Summary
The facility failed to exercise reasonable care to protect one resident’s personal property from potential theft or loss when staff did not complete a timely and accurate reconciliation of the resident’s personal item inventories. The resident was admitted to the facility and later discharged on 3/20/26. During a telephone interview, the resident representative stated that when she came to the facility to retrieve the resident’s belongings, several items were missing, and she had previously provided lists of personal items to the facility on two occasions, but had not received a response. A concurrent interview and record review with the ADON showed multiple inventory sheets in the medical record with different dates, and the ADON stated the resident’s personal inventory procedures were inconsistently followed. The ADON explained there should have been one inventory list started on admission and updated as items arrived, but instead there were multiple lists, making reconciliation difficult. The record also contained two handwritten lists of personal items, and several items listed on one of those lists, including socks, pants, a duffel bag, leggings, shirts, and slippers, were not listed or added in the electronic inventory sheets and were not included in the items released to the resident representative.
Insulin Dose Administered Incorrectly
Penalty
Summary
The facility failed to ensure that Resident 44 received insulin as prescribed when RN 4 administered 11 units of insulin instead of the ordered 6 units. Resident 44 was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, bradycardia, anxiety disorder, and congestive heart failure. The physician orders in the order listing included Humalog sliding scale insulin and Humalog 4 units subcutaneously before meals, with instructions to hold if blood sugar was less than 100. RN 4 stated that on the early morning of 3/11/26 she checked residents’ blood sugars, wrote them on paper, and then misread another resident’s blood sugar as Resident 44’s when preparing the insulin dose. RN 4 stated she realized the mistake immediately after giving the injection because it was more than Resident 44 usually received. The progress notes documented that RN 4 accidentally administered 11 units instead of 6 units, and the physician was notified. The record also showed ordered hourly blood sugar checks for three hours, with checks documented at 6:20 a.m., 6:50 a.m., and 7:11 a.m., but no records of the 7:50 a.m. and 8:50 a.m. checks. Later that morning, Resident 44 had difficulty breathing, received an inhaler, oxygen at 4 liters per minute via nasal cannula, and nitroglycerin for chest pain; the physician ordered Lasix 40 mg once and DuoNeb every 4 hours. At 11:29 a.m., Resident 44’s blood sugar was 88.
Food Storage and Preparation Deficiencies
Penalty
Summary
Food was not stored and prepared in accordance with professional standards when a kitchen staff member prepared French bread without wearing a beard restraint, leaving the staff member’s mustache and sideburns uncovered. During the same observation, the Kitchen Manager confirmed the staff member should have been wearing a hair net to cover facial hair. The facility’s policy stated that dietary staff must wear hair restraints, including beard restraints, and that beards, sideburns, and mustaches shall be covered. The kitchen refrigerator, dry storage area, and resident refrigerator contained multiple food items past their use-by dates. Observed items included tomatoes, sour cream, whipped butter, cooked rice, chopped onion spice, dill weed spice, cream of tartar spice, and a nutritional shake. Dry storage items, including crates of onions, crates of potatoes, and an unsealed bag of rice, were stored approximately three inches above the floor. The ice scoop was also observed uncovered and open to air in the resident hallway. The Kitchen Manager and DON stated that food past its use-by date, food stored less than 6 inches from the floor, and an uncovered ice scoop were risks for contamination and foodborne illness.
Failure to Document Medication Effectiveness and Behavioral Interventions
Penalty
Summary
Skilled nursing license staff did not accurately assess the healthcare status of one resident who was admitted with diagnoses including difficulty speaking and swallowing following a stroke and was documented as rarely or never understood on the MDS. The resident also had a diagnosis of generalized anxiety disorder and was receiving anti-anxiety medication. On 6/29/2025, the resident was yelling and screaming, attempts to console were unsuccessful, and lorazepam was administered, but there was no documentation in the clinical record showing whether the medication was effective. During interview and concurrent record review, the DON confirmed the clinical record did not show the effectiveness of the lorazepam and stated the licensed nurse should have documented it. The DON also confirmed the resident screamed 1-3 times every day throughout June 2025, and although staff used interventions such as keeping a partial shade over the bed because the resident was sensitive to light, the clinical record did not document what was done to address each episode of screaming or whether those interventions were helpful.
Failure to Address Worsening Behavioral Symptoms and Medication Unavailability
Penalty
Summary
Necessary behavioral health care and services were not fully provided for one resident with paranoid schizophrenia. The resident had a documented history of being resistive to medications, lab work, ADLs, and mobility assistance, and the care plan identified behaviors with a goal for the resident to participate in care and behave safely and respectfully. The resident was described as alert but confused and tearful when asked to do things she did not want to do, and she became tearful during an interview about her care. The resident had been receiving Secuado for schizophrenia with good response, but progress notes showed she refused medications, had increasing paranoia, and experienced falls, including being found on the floor next to her bed and later having an unwitnessed fall. The Secuado patch became unavailable through attempted pharmacies, and the resident was not wearing the patch. Staff documented that social services emailed the MD for a more effective recommendation and noted the resident still had confusion and was waiting for a reply, but the physician evaluation was not scheduled until later. The DON confirmed the resident was getting more behaviors, including increased delusions such as saying she was going to Hawaii, and stated staff should have followed up sooner because of the increase in falls and delusions.
Unsafe Medication and Food Storage in Medication Room
Penalty
Summary
The facility failed to ensure safe medication storage practices in the medication storage room and medication cart. During observation and interview, two vials of Lasix for a resident who had been discharged from the facility on 04/07/25 were found inside a brown plastic bag in the first drawer of a medication cart, with sticky liquid underneath the bag. The LVN stated she did not know why the medication had not been returned or destroyed and said the facility needed to follow its policy to return or destroy medications after discharge. Additional observations showed an opened multi-dose Tuberculin Purified Protein Derivative vial without a date, an opened bottle of Latanoprost eye drops without a date for another resident, and an opened bottle of Brimonidine eye drops dated only "5/20," which the LVN said was unclear and should have included month, day, and year. In the same medication storage room, staff food was found in a lunch box under the sink with white fuzzy growth and molded food inside. The DON stated staff should not keep food in the lunch box under the sink in the medication storage room and that the molded food created an unsafe and unhygienic environment that could contaminate medications and medical supplies.
Resident Identification Error Leads to Dialysis Transport Mix-up
Penalty
Summary
The facility failed to ensure adequate supervision and proper identification of two residents who shared the same surname, leading to a mix-up in their transportation for dialysis treatment. Resident 1, who required dialysis due to end-stage renal disease, was not properly identified by the staff, resulting in Resident 2 being mistakenly transported to the dialysis center. This error occurred because the Licensed Vocational Nurse (LVN) showed the transport crew the room location but did not verify the identity of the resident being transported. As a result of this oversight, Resident 1 experienced a one-hour delay in receiving dialysis treatment, which could have potentially affected the availability or duration of the treatment. Meanwhile, Resident 2, who did not require dialysis, was unnecessarily taken to the dialysis center, causing emotional distress. The incident highlights the importance of proper resident identification and supervision to prevent such errors and ensure the safety and well-being of residents.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that Resident 38 was given antipsychotic medication to treat a specific condition and with adequate monitoring of adverse effects. Resident 38, who was admitted with diagnoses including Parkinson's disease, type 2 diabetes mellitus, and dementia, was prescribed quetiapine for agitation and behavioral issues related to Parkinson's disease. However, the Order Summary Report did not indicate any monitoring for adverse reactions from quetiapine, and the Medication Administration Record (MAR) showed that Resident 38 received the medication without any documented monitoring for adverse effects from 3/4/24 to 3/19/24. Interviews with staff revealed a lack of awareness and monitoring of Resident 38's behaviors and potential adverse effects from the medication. Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1 both indicated that they were not aware of any negative behaviors or adverse effects in Resident 38. The Minimum Data Set Coordinator (MDSC) mentioned that pain management was revised to address agitation and behaviors, but when it did not help, quetiapine was started. Despite this, there was no care plan to address the use of quetiapine, and the MAR indicated no monitoring for adverse effects. The facility's policy and procedure on antipsychotic medication use, last revised in July 2022, stated that residents should only receive antipsychotic medications when necessary to treat a specific condition and that such medications should be monitored for adverse effects. The policy also listed specific conditions for which antipsychotic medications could be used and symptoms that should not be treated with these medications. The facility's failure to adhere to these guidelines resulted in the potential for unnecessary use of antipsychotic medication and delayed management of adverse effects for Resident 38.
Failure to Report Fall with Major Injury
Penalty
Summary
The facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a fall with major injury was not reported to the State Agency. Resident 7 was found sitting on the floor at the bedside on 3/8/24 and subsequently experienced vomiting and verbalized not feeling well. Radiology results on 3/9/24 indicated a vertebral compression fracture at L1, and the resident was transferred to the hospital for further management. The resident returned to the facility the next day with a diagnosis of a closed fracture lumbar vertebra. During an interview, a Certified Nursing Assistant (CNA) stated that since the fall incident, Resident 7 could not have the head of the bed elevated long enough to drink or eat adequately, and the pain had caused significant confusion. The facility administrator admitted to not being aware of the requirement to report falls with major injuries and confirmed that the facility did not have a policy and procedure to address such reporting. According to the California Code of Regulations Title 22, major accidents threatening the welfare, safety, or health of patients must be reported within 24 hours to the local health officer and the Department.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Driftwood Healthcare Center - Hayward | 0.1 mi | ★★★★★ | 6 | 0 |
| Golden Harbor Healthcare Center | 1.1 mi | ★★★★★ | 60 | 0 |
| Morton Bakar Center | 1.3 mi | ★★★★★ | 0 | 0 |
| St Anthony Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Bethesda Home | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.