Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Vale Healthcare Center during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with multiple serious conditions, including intracranial hemorrhage and stage 4 CKD on dialysis, was allegedly slapped on the arm by a CNA. The DON reported interviewing the CNA and the RN who reported the incident but kept no notes and could not recall interview dates or times. The facility’s sole Investigation Summary lacked any written, signed, and dated witness statements, despite facility policy requiring such documentation. The ADM confirmed that no additional investigative records existed and acknowledged that the resident’s representative should have been notified of the allegation. The DON did not notify the representative, who later confirmed they had not been informed and stated they felt alarmed by the lack of notification.
The facility failed to protect a resident from abuse when two residents were involved in a physical altercation after one, known to use alcohol and exhibit aggression, entered another resident’s room, refused to leave despite repeated requests, and punched the resident in the face, causing facial redness and emotional upset. Records showed the aggressive resident had alcoholic cirrhosis, had previously been observed with slurred speech and suspected alcohol use, and was later found with a bottle of alcohol in their room. The SW and ADM acknowledged awareness of this resident’s alcohol use and aggression and stated that monitoring should have occurred, while facility policy required protecting residents from abuse by anyone, including other residents.
A resident with schizophrenia, alcohol dependence, psychoactive substance abuse, and moderately impaired cognition was assessed as not at risk for elopement despite being ambulatory and having a recent history of wanting to leave. The resident was last seen by an LVN going toward the smoking area after a snack and was later discovered missing when a CNA noted the resident had not returned to the room or eaten lunch. Staff searched resident areas and then initiated a missing-resident code when the resident could not be found. A prior progress note documented the resident asking about going home, and a later entry recorded that the resident had eloped and was subsequently located by authorities for public intoxication and taken to a family member’s home.
The facility failed to report an allegation of verbal abuse and a death threat made by one cognitively intact resident against another to the State Agency, local law enforcement, and the LTC Ombudsman, as required by facility policy. One resident reported that his roommate threatened to kill him, called him a derogatory name, and threw items, while staff documentation showed the roommate became upset about morning phone calls and threw a breakfast tray, requesting a room change. A social services assistant documented the threat and acknowledged that such threats constitute abuse that must be reported, but did not document notifying the administrator, and the DON confirmed the incident was not reported externally because an internal investigation deemed it unsubstantiated, contrary to the written abuse reporting policy.
A resident with dementia and altered mental status was discharged from a hospital to Facility 2 with an approved admission, but upon arrival staff decided the resident was not an appropriate fit. Although prior notifications and transport documentation confirmed the expected admission and arrival, Facility 2 did not create a medical record, did not perform a nursing assessment or initiate clinical care, and did not complete required transfer/discharge documentation. The resident was given food and then sent back to the hospital the same day without proper admission, discharge, or communication of the resident’s condition to the sending facility.
A resident's room was found to have a large dent and exposed wall area behind the bed, which the resident described as unsightly and not reflective of a homelike setting. The Environmental Director confirmed the wall should not be in that condition, and the facility's policy supports residents' rights to a dignified and comfortable environment.
Two residents with long, untrimmed toenails did not receive timely podiatry referrals or foot care, despite one resident's clear request and another having a physician order for podiatry due to nail fungus. Facility policy required regular podiatry scheduling and documentation, but these steps were not followed, resulting in unmet care needs.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with severe cognitive impairment, dysphagia, and no lower teeth did not receive an annual dental exam as required by facility policy. The resident was observed with swollen gums and reported pain while eating. Documentation of dental services was missing from the EHR, and staff could not locate recent dental records, with the last exam documented over a year prior.
Surveyors observed multiple opened food items in dry storage and refrigerators without required open or use-by dates, including cheesecake, cereal, milk, and juice. A paper bag with a ham sandwich and fruit cups for a resident was also improperly labeled and stored. The RD confirmed these items should have been labeled according to facility policy, and unsanitary conditions were noted with food waste found among sealed items.
Surveyors identified infection control deficiencies when a specimen refrigerator containing biological samples was stored in the same room as an ice container used for resident consumption, with the ice scooper exposed to air. Additionally, a medication storage drawer was found disorganized, with medications, specimen containers, needles, and sterile dressing kits mixed together, increasing the risk of cross-contamination.
Three rooms with multiple beds were found to provide less than the required 80 sq. ft. per resident, with each resident receiving only 77.2 sq. ft. Interviews with residents and a CNA indicated no complaints or care issues related to space, and no heavy medical equipment was present to interfere with care.
A resident's code status and advance directives were not documented in the medical record, orders, or face sheet, despite the existence of a signed POLST form indicating DNR and comfort-focused care. The POLST was not signed by the medical provider until after the resident's death, and the DON confirmed that code status was not visible in the EHR or orders prior to the event.
A resident with intact cognition reported $500 missing and stated he informed the DON, but no documentation or investigation of the grievance was found in his records. The facility's policy requires prompt investigation and documentation of such reports, but this was not followed, resulting in the resident's grievance going unresolved.
A resident with multiple medical conditions was admitted and allowed to keep cigarettes at the bedside and smoke independently, without a completed safe smoking assessment or a baseline care plan addressing smoking. Facility staff did not follow policy requiring assessment and care planning for smoking, resulting in the lack of interventions to promote safe smoking.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to accident prevention.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A resident with multiple chronic conditions was not kept informed about the status of her power wheelchair, which had been broken for an extended period. Despite documentation of some actions taken by staff, there was no record of the outcome of a scheduled DME assessment or evidence that the resident was notified of an insurance denial for the equipment. The resident remained unaware of the denial and believed efforts to obtain the wheelchair were ongoing.
A resident with multiple medical conditions, including COPD and bilateral arm fractures, was found without a functioning call system in their room. The resident reported not having a call bell for a long time and had to wheel themselves to the nurses' station to request assistance, contrary to facility policy requiring a working call system for residents.
Two residents who required assistance with oral hygiene lost their dentures while in the facility, and staff failed to track, locate, or replace the dentures or provide adequate follow-up. As a result, both residents experienced difficulty eating and speaking, emotional distress, and a negative impact on their dignity and psychosocial well-being.
The facility failed to provide adequate care and documentation for residents, including not referring a psychology consult for a resident after an abuse allegation, not updating a care plan after a physical altercation, and lacking interdisciplinary team signatures on Risk Meeting Notes.
A resident in an LTC facility experienced delays in medication administration, with multiple medications given late over several days. The resident had serious health conditions, and staff interviews revealed that nurses were rushed and unfamiliar with residents, leading to documentation delays. The facility's policy required timely administration and immediate documentation, which was not consistently followed.
Expired medications and COVID test kits were found stored with ready-to-use medications in a facility. An E-kit in Nursing Station One's refrigerator contained expired medications, and the RN Supervisor was unaware of when it was opened or if the pharmacy was contacted for exchange. The ADON was aware of expired E-kits but not the one in Nursing Station One. Expired IV antibiotics, fluids, and heparin syringes were also found, along with expired COVID test kits that were still in use.
The facility failed to provide adequate personal hygiene and mobility care for two residents. One resident had long, dirty fingernails despite being dependent on staff for hygiene due to cognitive impairment. Another resident, with multiple health conditions, had neglected foot care and was not assisted out of bed for activities, contrary to their care plan. These deficiencies highlight unmet basic needs and communication issues within the facility.
A facility failed to act on a pharmacist's Medication Regimen Review recommendations for a resident with Alzheimer's and dementia. The resident was on psychoactive medications and Lisinopril, but the facility did not monitor behavior and side effects as recommended, nor did they address the unnecessary pulse monitoring parameter for Lisinopril. The ADON confirmed these oversights, which were against the facility's policies.
The facility exceeded the acceptable medication error rate, with errors involving incorrect administration of medications and failure to follow physician's orders. An LVN did not flush a GT with the prescribed amount of water and administered Famotidine at the wrong time. An RN failed to instruct a resident to rinse their mouth after using a steroid inhaler, as required.
The facility failed to ensure safe and sanitary food storage, as a thawed pork loin was found on a dirty platform, tied with a disposable glove, and lacking proper labeling. It was later found partially refrozen in the freezer with leaking liquid. The facility's policies and FDA guidelines were not followed, posing a risk of foodborne illness to residents.
A resident with severe left foot pain did not receive appropriate pain management in an LTC facility. Despite reporting constant 9/10 pain, staff failed to assess or document pain levels accurately. Observations showed the resident was left in pain without timely intervention, and staff interviews revealed poor communication and documentation practices. The facility's pain management policy was not followed, resulting in inadequate care.
A deficiency was identified in three resident rooms that did not meet the required 80 square feet per resident. Observations and interviews revealed mixed opinions on space adequacy, with no heavy medical equipment interfering with care. Despite the deficiency, no complaints or negative consequences were reported, and a waiver for room size may be recommended.
Failure to Document Abuse Investigation and Notify Resident Representative After Alleged Staff Slap
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent resident from potential physical abuse and to conduct and document a thorough abuse investigation, including required notifications. A resident with multiple diagnoses, including nontraumatic intracranial hemorrhage, stage 4 chronic kidney disease, and dependence on renal dialysis, was totally dependent on staff for care and had impaired cognition. The resident’s care plan and orders indicated the need for close supervision, including a sitter during dialysis. An allegation was made that a CNA deliberately slapped this resident on the left arm. The DON reported conducting an investigation by interviewing the CNA and the RN who reported the incident but acknowledged not keeping notes of these interviews and being unsure of the dates and times they occurred. Record review of the facility’s Investigation Summary, dated 3/11/26, showed it was the only documentation of the investigation and contained no notes or written statements from the CNA or RN. The ADM confirmed that the Investigation Summary represented the entire record of the investigation and stated there should have been written and dated statements from the involved staff, consistent with the facility’s Abuse Investigation & Reporting policy. That policy requires witness reports to be obtained in writing, signed, and dated, and requires that all alleged violations involving abuse be reported to the resident’s representative. The ADM stated the resident’s responsible party should have been notified of the allegation, and the DON later confirmed that the responsible party was not notified. The responsible party reported not receiving any call or voicemail about the incident and stated they would have wanted to be informed and felt alarmed that they were not notified.
Failure to Prevent Resident-to-Resident Physical Altercation Related to Alcohol Use
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and interventions to prevent a resident-to-resident physical altercation. Resident 1, who had a diagnosis of rectal cancer and depression and a BIMS score of 15 indicating intact cognition, reported that while sitting in a wheelchair in their room, Resident 2 entered the room in a wheelchair, appeared to be under the influence of alcohol, and spoke loudly. Resident 1 stated they repeatedly asked Resident 2 to leave, but Resident 2 did not comply, then stood up, approached, and punched Resident 1 on the right side of the face, resulting in facial redness and causing Resident 1 to feel upset. Resident 1 stated the facility was aware of Resident 2’s alcohol use and associated behaviors but failed to adequately monitor and implement interventions to prevent Resident 2’s physical aggression. Record review showed Resident 2 had a diagnosis of alcoholic cirrhosis of the liver with ascites, and progress notes documented that staff had previously noted Resident 2 with slurred speech and had intervened regarding alcohol use. An SBAR note documented that the altercation occurred at 4:30 p.m., that Resident 1 reported Resident 2 looked drunk, entered the room, talked loudly, and hit Resident 1 in the face, and that Resident 2 was suspected of consuming alcohol earlier that afternoon. The Social Worker stated they were aware of Resident 2’s alcohol use and aggression and that staff should have monitored Resident 2 if alcohol use was suspected due to unpredictable behavior toward others. The Administrator stated they were aware of Resident 2’s alcohol use, observed Resident 2 partially inside Resident 1’s doorway just before hearing yelling, then found Resident 1 with redness on the right side of the face and later found a full bottle of alcohol in Resident 2’s room. The facility’s Abuse Prevention Program policy stated residents have the right to be free from abuse by anyone, including other residents.
Failure to Identify and Care Plan Elopement Risk Leading to Unauthorized Exit
Penalty
Summary
The facility failed to identify and care plan an elopement risk for a resident who subsequently left the facility without authorization. The resident was admitted with diagnoses including cellulitis of the left lower limb, unspecified behavioral and emotional disorder, psychoactive substance abuse, schizophrenia, and alcohol dependence. An MDS dated 01/25/2026 showed a BIMS score of 08, indicating moderately impaired cognition. An Elopement Risk Assessment dated 11/13/2025 documented that the resident was ambulatory and had a history of wanting to leave the facility within the last 30 days, yet the assessment indicated the resident did not have substance abuse or psychiatric history and concluded the resident was not at risk for elopement. The facility’s policy stated it would provide a safe environment and preventative measures for elopement, with monitoring and documentation of patients at risk. On 01/12/2026, after a morning snack, the resident was last seen by LVN 1 heading toward the smoking area between 10:00 a.m. and 10:30 a.m. Lunch trays were passed between 11:30 a.m. and 12:00 p.m., and while LVN 1 was eating lunch between 12:30 p.m. and 1:00 p.m., a CNA reported that the resident was not in her room and had not eaten lunch. LVN 1 then checked the resident’s room, bathrooms, shower rooms, and the smoking area and, when the resident could not be found, notified her supervisor and a Code Yellow for a missing resident was called. A progress note from the morning of 01/12/2026 documented that the resident had asked when she was going home and was told she would not be moving with family that day. A subsequent late-entry progress note recorded that the resident had eloped from the facility and was later located by authorities due to public intoxication and transported to her sister’s home.
Failure to Report Resident-to-Resident Verbal Abuse and Threats to Required Authorities
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse and threat of harm made by one resident against another to the State Agency, local law enforcement, and the Long-Term Care Ombudsman. Resident 1, who was cognitively intact with a BIMS score of 15/15, reported that his former roommate, Resident 2, threatened to kill him, called him a derogatory name, and threw items across the room, breaking dishes. Resident 1 stated that staff initially moved Resident 2 to another room, then returned Resident 2 to the original room and moved Resident 1 instead. When Resident 1 expressed concern for his safety, he reported that staff responded by asking him what else he wanted them to do. Progress notes dated 11/3/25 documented that the Social Services Assistant (SSA) spoke with Resident 1 about the altercation, including Resident 2 calling him a derogatory name and threatening to kill him, and noted that the roommate had already been moved and staff were aware of the altercation. Resident 2, who also had a BIMS score of 15/15, was documented by an LVN as having become upset about Resident 1 being on the phone in the mornings and throwing his breakfast tray on the floor, stating he wanted to change rooms. The SSA stated that threats between residents are considered abuse and must be reported to the State agency, local law enforcement, and the Ombudsman, and did not recall notifying the Administrator, who was the Abuse Coordinator, and had no documentation of doing so. The DON confirmed that the incident was not reported to any external authorities because an internal investigation found the allegation unsubstantiated, despite facility policy requiring all allegations of resident abuse to be promptly reported to appropriate agencies and thoroughly investigated.
Improper Handling of Interfacility Admission and Same-Day Return Without Assessment or Documentation
Penalty
Summary
Facility 2 failed to ensure that a transfer/discharge met a resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge. A resident with multiple diagnoses, including dementia and altered mental status, was discharged from an acute care facility (Facility 1) to Facility 2 with an approved admission and insurance authorization. Text messages and an email showed Facility 2 staff were notified in advance of the expected admission time, and an interfacility transport document, signed by the Assistant Director of Nursing, confirmed the resident’s arrival at Facility 2. Despite this, the Director of Nursing stated that when the resident arrived, staff determined the resident was not an appropriate fit for Facility 2. Facility 2 did not create a medical record for the resident, did not perform a nursing assessment, and did not initiate clinical care such as taking and recording vital signs as required by its admission policy. The resident was offered food and then sent back to Facility 1 the same day, without being properly admitted or discharged from Facility 2 and without documentation of why the resident was deemed inappropriate for the facility. Facility 2 also failed to provide required transfer/discharge documentation, including the reason for transfer/discharge, the effective date, the receiving location, and the resident’s appeal rights, and failed to appropriately communicate information about the resident’s condition to Facility 1 prior to returning the resident. Records from Facility 1 showed the resident returned there approximately seven hours after the initial discharge.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
A moderate dent and exposed wall area were observed behind the head of a resident's bed during a facility survey. The resident, who had been admitted several months prior, expressed dissatisfaction with the condition of the wall, stating that it looked awful and was not reflective of a homelike environment. The Environmental Director, when interviewed in the room, acknowledged that the wall should not be in that condition. The facility's policy on resident rights affirms the right to a dignified existence and a homelike environment, but the observed damage to the wall had not been repaired at the time of the survey.
Failure to Provide Timely Podiatry Referrals and Foot Care
Penalty
Summary
The facility failed to provide necessary podiatry referrals and foot care for two residents with long, untrimmed toenails. One resident, who was cognitively intact and able to express her needs, reported that her toenails were curling over her skin and had not been clipped, stating she had not seen a podiatrist in approximately one and a half years. Nursing documentation indicated a referral was given to the social services office, but there was no evidence of follow-up or that podiatry services were provided as needed. The facility's policy required regular scheduling and coordination of podiatry visits, but this was not followed for this resident. Another resident, with moderate cognitive impairment and multiple diagnoses including congestive heart failure and onychomycosis, was observed with long, curved, and jagged toenails. Despite a physician order for a podiatry referral due to a history of nail fungus infection, there was no documentation that the referral was completed or that podiatry services were provided. The Social Services Director confirmed responsibility for coordinating podiatry referrals but could not provide evidence that the required services were delivered according to facility policy.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals.
Failure to Provide Annual Dental Services for Resident
Penalty
Summary
The facility failed to provide up-to-date annual dental services for a resident with significant medical conditions, including altered mental status, dementia, muscle weakness, dysphagia, and visual impairment. The resident was admitted in 2018 and had a care plan that included an annual dental consult. During the survey, the resident was observed to have swollen gums and no teeth on the bottom row, and reported pain while eating. The Minimum Data Set (MDS) and electronic health record (EHR) lacked current documentation in the oral/dental status section, and there was no evidence of a recent dental exam. Interviews with the social worker revealed that dental records for the resident could not be located, and the last documented dental exam was from 2022, despite the facility's policy requiring annual dental services. The social worker indicated a misunderstanding regarding the need for dental exams for edentulous residents and was unable to confirm when the last annual dental exam occurred. The facility's policy stated that routine and emergency dental services should be available and that social services would assist with appointments, but these procedures were not followed for this resident.
Failure to Ensure Safe and Sanitary Food Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in accordance with professional standards and its own policies and procedures. During an observation in the kitchen, multiple opened food items in both dry storage and refrigerators were found without open dates or use-by dates, including an opened box of cheesecake, prepared bowls of dry cereal, an opened gallon of milk, and an orange juice pitcher. Additionally, a storage container was found to contain two eaten banana peels and a soiled paper cup among sealed items. The Registered Dietician (RD) confirmed that these items should have been labeled with preparation and use-by dates, and was unable to identify when some items were opened. Facility policies reviewed indicated that all open food items must be labeled with open and use-by dates per manufacturer guidelines, and that storage areas should be clean and free of contamination. Further observation revealed a paper bag in the refrigerator labeled for a resident, containing a ham sandwich and two fruit cups, with instructions for use the next day. The RD stated the ham sandwich was good for seven days, but the labeling and storage did not align with facility policy, which requires luncheon meats to be stored until their expiration date or for no more than seven days after opening. These findings demonstrate a lack of adherence to established food storage and labeling protocols, as well as lapses in maintaining sanitary storage conditions.
Infection Control Lapses in Specimen and Medication Storage Areas
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two main deficiencies. First, the specimen refrigerator, which contained biological samples such as stool, urine, and blood, was stored in the same room as the ice container used for residents' oral consumption. The ice scooper was observed hanging on the wall, exposed to air, next to the ice container. Both the Registered Nurse Supervisor and the Infection Preventionist acknowledged that this arrangement posed a risk of infection spread and cross-contamination to residents consuming the ice. Second, in the medication storage room at Station 2, a drawer was found to be disorganized, containing a mix of lidocaine patch medications, specimen sample containers, unused needles, test tubes, a pair of unused socks, and a central line dressing kit. The Registered Nurse and Infection Preventionist confirmed that medications, needles, and sterile dressing kits should not be mixed with specimen containers and other items due to the risk of cross-contamination and infection. The Director of Nursing also acknowledged the infection control risk associated with this storage practice. The facility's infection control policy emphasized the importance of proper procedures and organization to prevent infection.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Three resident rooms (Rooms 35, 41, and 43) were found to have multiple beds with less than 80 square feet per resident, which does not meet the required minimum space standard for multiple occupancy rooms. Each of these rooms contained three beds with a total area of 231.6 square feet, resulting in only 77.2 square feet per bed. This was identified during an observation conducted on 7/24/25 at 3:15 p.m. Interviews with residents occupying these rooms indicated that they did not find the space bothersome and felt they had enough room for their personal belongings. Additionally, a CNA who worked in these rooms stated that the room size was adequate for providing care and for residents' belongings, and reported no issues with resident transfers or the use of wheelchairs in the rooms. Observations of the rooms during the survey did not reveal any heavy medical equipment that could interfere with resident care. There were no complaints from residents in the affected rooms regarding insufficient space for their belongings, and no negative consequences or safety concerns were attributed to the decreased space. The deficiency was based solely on the measured square footage per resident being below the regulatory requirement.
Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to update and document the code status for a resident, resulting in the absence of clear information regarding the resident's wishes for resuscitation and life-sustaining measures. The resident's face sheet, orders, and progress notes did not contain any documentation of advance directives or code status at the time of admission or prior to the resident's death. Although a POLST form indicating Do Not Resuscitate (DNR) and comfort-focused care was prepared and signed by the resident, it was not signed by the medical provider until after the resident had expired. The Director of Nursing confirmed that the code status was not visible in the electronic health record and that there was no order for code status in the resident's records prior to death. The lack of timely documentation and communication of the resident's code status led to a situation where staff would have assumed full code status in the absence of clear orders, contrary to the resident's expressed wishes. The facility's policy requires that the POLST form reflect careful decision-making and be completed in consultation with the physician, but this process was not completed before the resident's death. The deficiency was identified through interviews and record reviews, which confirmed that the resident's preferences were not properly documented or accessible to staff at the time of the event.
Failure to Investigate and Document Resident Grievance Regarding Missing Money
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 15, reported that $500 was stolen from him a few months prior and that he had informed the Director of Nursing (DON) about the missing money. The resident stated that nothing had been done regarding his grievance. Upon review, there was no documentation in the resident's records regarding the missing money or any grievance filed about the incident. The DON confirmed being informed of the missing money but could not provide documentation of any grievance or investigation related to the incident. The facility's policy and procedure on misappropriation of resident property requires that reports of misappropriation be promptly and thoroughly investigated and documented either in the progress notes or through the grievance process. The Administrator stated that if a grievance had been filed, there should have been an investigation and documentation, but there was no record of such actions for this incident. As a result, the resident's grievance regarding the missing money went unresolved, and the facility failed to follow its own grievance policy.
Failure to Develop Baseline Care Plan for Smoking Upon Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop a baseline care plan to address the smoking needs of a newly admitted resident within 48 hours of admission. The resident, who had diagnoses including osteomyelitis, severe sepsis, and generalized anxiety disorder, was observed with an open pack of cigarettes at the bedside and reported smoking independently four times a day. Facility staff allowed the resident to keep cigarettes at the bedside, contrary to facility policy, and there was no documentation in the Baseline Care Plan Summary addressing the resident's smoking. Interviews with staff revealed that a safe smoking assessment was initiated but not completed, and the admitting nurse did not develop a baseline care plan for smoking as required. The facility's policy required a safe smoking assessment and the development of care plans based on the assessment and interdisciplinary team findings, as well as the storage of smoking materials at the nurse station. These steps were not followed, resulting in the lack of interventions to promote safe smoking for the resident.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Failure to Inform Resident of Power Wheelchair Status
Penalty
Summary
The facility failed to ensure that a resident was kept informed regarding the status of her power wheelchair, which had been broken for about a year. The resident, who had multiple diagnoses including COPD, diabetes mellitus type 2, chronic pain, anxiety disorder, major depressive disorder, hypertension, osteoarthritis, generalized muscle weakness, and severe morbid obesity, reported difficulty being as mobile as she was with her power wheelchair and expressed that she had not received any updates about its status. Documentation in the resident's chart showed several actions taken by staff, such as weighing the resident, faxing paperwork to the DME provider, and scheduling an assessment appointment. However, there was no documentation of the outcome of the scheduled DME visit, and the social worker could not locate any record of it in the chart. Further review revealed that the resident's insurance had denied authorization for the power wheelchair, but there was no documented follow-up or evidence that the resident was informed of this denial. The resident stated she was unaware of any denial and believed that efforts to obtain the power wheelchair were ongoing. Facility policies required social services to maintain records and meet residents' medically-related social service needs, including communication about adaptive equipment, but these requirements were not met in this case.
Resident Lacked Access to Call System in Room
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including COPD, bilateral humerus fractures, vertigo, anxiety, and depression, was found without access to a functioning call system in their room. During an observation, no call light was present above the bed, attached to the wall, or on the bedside table. The resident reported not having a call bell for an extended period and stated that to request medications such as pain or sleep aids, they had to use their wheelchair to go to the nurses' station. A Licensed Vocational Nurse confirmed the absence of a call light and acknowledged the importance of having one available, especially if the resident was unable to get up. Review of the facility's policy indicated that residents should have access to a communication system to request assistance and that the system should remain functional at all times, with routine maintenance and testing by the maintenance department. The lack of a call system in this case was contrary to facility policy and created a situation where the resident could not easily summon help for their needs.
Failure to Track and Replace Lost Dentures for Two Residents
Penalty
Summary
The facility failed to track, locate, replace, and follow up on lost dentures for two residents, resulting in both individuals being without their dentures for an extended period. One resident, admitted for heart failure and with intact cognition, required assistance with oral hygiene and had upper dentures on admission. Her dentures were lost approximately two months prior to the survey, and despite repeated inquiries, the facility did not provide updates or facilitate replacement, leaving her to eat only soft foods and feel blamed for the loss. The resident reported emotional distress due to the situation, and staff confirmed awareness of the missing dentures but had not resolved the issue. Another resident, admitted with cerebral infarction and end-stage renal disease on hemodialysis, also required assistance with oral hygiene and had both upper and lower dentures on admission. His dentures were lost, and although a dental appointment was scheduled, neither he nor his family received follow-up communication from the facility. The resident was forced to use ill-fitting temporary partials, which impaired his ability to eat and speak, and negatively affected his social interactions and self-esteem. Staff interviews revealed a lack of a tracking log for lost dentures and uncertainty about whether the issue was discussed in interdisciplinary meetings. The facility's policy required investigation and documentation of lost property, but this process was not followed for these cases.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice. For one resident, the Interdisciplinary Team's recommendation for a psychology consult related to an abuse allegation was not referred by the Social Services Department. This oversight was confirmed during interviews with the Social Services Assistant and Director, who acknowledged that the department was aware of the physician's order for a psychology referral but could not find documentation that the referral was sent in a timely manner. Another deficiency involved the lack of an appropriate physical abuse care plan for a resident who had a physical altercation with another resident. The Minimum Data Set Coordinator was unable to locate a care plan for the altercation, and the Director of Nursing confirmed that the existing care plan was incorrect and should have been updated promptly. The facility's policy requires that each resident have a comprehensive care plan developed by an interdisciplinary team, which was not adhered to in this case. Additionally, the facility's Risk Meeting Notes for four residents showed only one member's signature, indicating that the interdisciplinary team members did not document their attendance or contributions to the meeting. The Director of Nursing and Assistant Director of Nursing confirmed that the notes should have included signatures from all team members to reflect their participation in reviewing and updating care plans. The facility's policy mandates that all team members sign the Risk Meeting Notes to ensure comprehensive care planning.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications timely for a resident, leading to a deficiency in pharmaceutical services. The resident, who was readmitted to the facility with multiple serious health conditions including HIV, COPD, ESRD, hypertension, hyperlipidemia, and C-diff, experienced delays in receiving prescribed medications. The medications, which included Amlodipine, Biktarvy, Clopidogrel, Metronidazole, and Sevelamer HCI, were administered late on multiple occasions, ranging from 21 to 326 minutes past the scheduled times. Interviews with facility staff revealed that the delays were due to nurses being rushed and unfamiliar with residents, as well as issues with documentation practices. One nurse admitted to being too busy to document medication administration at the time it occurred, which could lead to errors such as double dosing. Another nurse, who was a registry nurse, indicated that she was sometimes unfamiliar with the residents, contributing to the delays. The facility's policy and procedure for medication administration required medications to be given within 60 minutes of the scheduled time, and documentation to be completed immediately after administration. However, this standard was not consistently met, as evidenced by the late administration of medications and delayed documentation. The Assistant Director of Nursing acknowledged that the standard practice was not followed, which contributed to the deficiency.
Expired Medications and COVID Test Kits Found in Storage
Penalty
Summary
The facility failed to ensure that expired medications and COVID test kits were discarded, as they were found stored with ready-to-use medications in medication storage areas. During an observation and interview, an Emergency kit (E-kit) in Nursing Station One's refrigerator was found to contain expired medications, including Levemir, Novolog, Novolin R, and Novolin N, with expiration dates ranging from February 2023 to March 2024. The RN Supervisor acknowledged the presence of expired medications and was unaware of when the E-kit was opened or if the pharmacy had been contacted to exchange it. The Assistant Director of Nursing (ADON) was aware of expired E-kits in the facility and had contacted the pharmacy to replace them, but was not aware of the expired E-kit in Nursing Station One's refrigerator. Further observations revealed an expired E-kit bin in Nursing Station Three's Medication Room containing expired intravenous antibiotics, IV fluids, and heparin syringes. Additionally, nine expired COVID test kits were noted, and the RN Supervisor admitted to using them despite their expiration dates, expressing uncertainty about their effectiveness. The facility's policy and procedure on medication storage, dated 2007, indicated that outdated, contaminated, discontinued, or deteriorated medications should be immediately removed from stock, which was not adhered to in this case.
Deficiencies in Personal Hygiene and Mobility Care
Penalty
Summary
The facility failed to provide adequate care for activities of daily living for two residents, resulting in unmet basic needs necessary for quality of life. Resident 73 was observed with long fingernails and black debris under them, indicating a lack of personal hygiene care. Despite being dependent on staff for maintaining personal hygiene due to severely impaired cognition, the resident's fingernails were not cleaned, posing an infection control issue. The facility's policy on fingernail care was not followed, as the procedure to clean under the fingernails was not executed. Resident 36, who has diagnoses including dementia, hemiplegia, hemiparesis, and diabetes, was found with long, thick toenails and dry, cracked skin around the feet. The resident was dependent on staff for personal hygiene, yet foot care was not provided as per the facility's policy. The Certified Nursing Assistant (CNA) stated she was not allowed to cut the resident's toenails and would inform the nurse, but no further action was documented. The policy required a licensed nurse, therapist, or podiatrist to trim the toenails of diabetic residents, which was not adhered to. Additionally, Resident 36 was not assisted to get out of bed and into a wheelchair for an extended period, despite the cessation of a COVID-19 outbreak that had temporarily halted activities. The resident's care plan indicated they should be out of bed to a chair twice a day, but this was not followed. The activities manager and assistant confirmed that activities had resumed, and CNAs were expected to prepare residents for participation, yet Resident 36 remained in bed. The resident's responsible party expressed concern over the lack of mobility and engagement, highlighting a communication breakdown between staff and family members.
Failure to Act on Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to respond to a pharmacist's Medication Regimen Review (MRR) recommendations for a resident with Alzheimer's Disease and dementia. The resident was receiving psychoactive medications, including Seroquel, Escitalopram, and Lamotrigine, as well as Lisinopril for hypertension. The pharmacist recommended monitoring the resident's behavior and side effects for the psychoactive medications and questioned the necessity of a pulse monitoring parameter for Lisinopril. However, the facility did not act on these recommendations. A review of the resident's electronic Medication Administration Record (eMAR) showed no documentation of behavior and side effects monitoring for the psychoactive medications, and the pulse monitoring parameter for Lisinopril remained in place. The Assistant Director of Nursing (ADON) confirmed the lack of monitoring and documentation during an interview. The facility's policies and procedures required monitoring for drug side effects and acting upon MRR recommendations, but these were not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 8.57% during a medication pass. This was due to three medication errors out of thirty-five opportunities involving two residents. One error involved a Licensed Vocational Nurse (LVN) who did not follow the physician's orders for flushing a gastrointestinal tube (GT) with the correct amount of water before and after medication administration. The LVN used 30 milliliters of water instead of the prescribed 50 milliliters, stating they were unaware of the specific order and were following their standard procedure. Another error occurred when the same LVN administered Famotidine to a resident in the morning instead of at bedtime as prescribed. Additionally, a Registered Nurse (RN) failed to instruct a resident to rinse their mouth after using a steroid inhaler, as required by the physician's orders and the manufacturer's instructions. The RN was unaware of the reason for this instruction and incorrectly informed the resident that rinsing was necessary because the medicine tasted bad.
Improper Food Storage and Handling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food, specifically concerning a thawed pork loin. During an inspection of the kitchen walk-in refrigerator, a pork loin was found resting on a dirty plastic platform, tied closed with a disposable glove, and lacking a label indicating the thaw or use-by date. The Certified Dietary Manager (CDM) confirmed that the pork loin was previously frozen and thawing in the refrigerator but was unable to provide information on when it was pulled out to thaw. The facility's policy requires all meat and perishable food placed in the refrigerator for thawing to be labeled with the date it was transferred, along with a pull-by and use-by date. The FDA Food Code also mandates that food packages be in good condition to prevent contamination and that temperature-controlled foods be clearly marked with a consumption or discard date. Further inspection revealed that the same pork loin was later found in the walk-in freezer, partially refrozen, with red liquid leaking from the package. The kitchen manager acknowledged that refreezing the pork loin was inappropriate and disposed of it. The facility's policy states that frozen food thawed in the refrigerator should be used within 72 hours and not refrozen. The FDA Food Code highlights that improper thawing and refreezing can lead to cross-contamination and the preservation of harmful bacteria or toxins. These failures in food handling and storage practices had the potential to place all residents receiving meals from the kitchen at risk for foodborne illness.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide accurate pain assessment and management for a resident, identified as Resident 18, who was experiencing severe pain in the left foot. Despite having a history of Crohn's disease, peripheral vascular disease, and unspecified atrial fibrillation, Resident 18's pain was not regularly assessed using an appropriate pain scale. The resident reported constant 9/10 throbbing pain, which frequently increased to 10/10, yet the staff did not assess or reassess the pain severity after administering pain medications. Observations revealed that Resident 18 was often left in pain without timely intervention. On one occasion, the resident was heard moaning in bed and requested pain medication, but the staff did not assess the pain level or offer non-pharmacological relief. The medication administration records showed that pain assessments were not documented accurately, and the severity of the pain was often omitted. The resident expressed that the pain management regimen was ineffective and that requests for better pain relief were not addressed. Interviews with the nursing staff indicated a lack of communication and documentation regarding the resident's pain levels. Certified Nursing Assistants and Licensed Vocational Nurses failed to document pain assessments or communicate the severity of the pain to the attending provider. The Assistant Director of Nursing confirmed that pain evaluations were not consistently documented, and the facility's policy on pain management was not followed, leading to inadequate pain management for Resident 18.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility was found to have a deficiency related to room size requirements, as three resident rooms (Rooms 35, 41, and 43) with multiple beds provided less than the required 80 square feet per resident. This deficiency was identified through observations and interviews conducted on May 22 and 23, 2024. During these observations, it was noted that the rooms did not contain heavy medical equipment that might interfere with resident care. Interviews with residents and staff revealed mixed opinions about the adequacy of space, with one resident feeling cramped but manageable, while a Certified Nursing Assistant (CNA) from a registry company stated that the room size was adequate for care and storage of belongings. The Environmental Manager acknowledged the limited space and mentioned efforts to create more storage space for residents' belongings. Despite the deficiency, there were no complaints from residents regarding insufficient space, and no negative consequences or safety concerns were reported. The report suggests that a waiver for room size requirements may be recommended, as the deficiency did not result in any adverse outcomes for the residents involved.
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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 San Pablo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Healthcare Center | 0.1 mi | ★★★★★ | 3 | 0 |
| San Pablo Healthcare & Wellness Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Richmond Post Acute Care | 0.8 mi | ★★★★★ | 0 | 0 |
| Shields Richmond Nursing Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Greenridge Post Acute | 2.2 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.