Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Windsor Care Center Of Sacramento during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nurse staffing levels, with Actual DHPPD and CNA DHPPD below required standards, leading to 10 resident falls over a week. The staffing shortfall was due to a loss of CNAs and numerous call-outs, as confirmed by the Staffing Coordinator. The Director of Nursing and a CNA acknowledged the impact on resident care, including challenges in implementing fall precautions.
The facility compromised resident privacy when a shred box containing meal tickets was overfilled, exposing sensitive information. Surveyors observed that the shred box in the dining room was full, allowing resident details to be read from the meal tickets. The Dietary Manager and Administrator acknowledged the issue, which violated the facility's confidentiality policy.
Two residents in an LTC facility were not adequately assisted with their ADLs, leading to potential health risks. A resident with dementia had a blackish substance under her fingernails, indicating a lack of personal hygiene assistance. Another resident, also with dementia, was not provided with the required oral care, resulting in white matter caked on their teeth. The facility's policy on ADLs was not followed, as confirmed by the DON.
Two residents in the facility were not provided with adequate activities to meet their interests and preferences. One resident with Alzheimer's was observed without activities despite a care plan indicating preferences for music and group interactions. Another resident with dementia and brain cancer did not receive activities meeting his psychosocial needs for 35 days. The facility's policies were not followed, and both the DON and AD acknowledged the deficiencies.
The facility failed to maintain effective infection control, with staff not sanitizing shared equipment, neglecting PPE protocols for residents on Enhanced Barrier Precautions, and not performing proper hand hygiene. These actions increased the risk of cross-contamination and infection transmission among residents.
The facility failed to maintain a safe and sanitary environment for 29 residents due to improper cleaning of bathroom exhaust fans, leading to dust buildup. Observations revealed that the fans were not cleaned, posing potential fire hazards and health risks. Staff interviews confirmed the issue, and a review of cleaning protocols showed a lack of adherence to daily cleaning requirements.
The facility failed to promote dignity for three residents during meal times. A CNA stood over two residents while feeding them, which was acknowledged as undignified and increased aspiration risk. Another resident received her meal later than others, causing frustration and a sense of exclusion. The facility's policy emphasizes dignity and respect, which was not upheld.
A resident, identified as a fall risk, did not have their call light within reach, contrary to their care plan and facility policy. This oversight was confirmed by a CNA and acknowledged by the DON, highlighting a failure to meet the resident's needs and prevent potential falls.
A facility failed to provide an accurate MDS assessment for a resident with dementia and major depressive disorder. The MDS inaccurately reported no behavioral symptoms, despite the resident exhibiting yelling behavior multiple times in October. Staff interviews confirmed the inaccuracy, and the facility's policy required MDS assessments to reflect resident observations, which was not met in this case.
A resident did not receive prescribed doses of spironolactone and venlafaxine for several days due to untimely reordering of medications. The nursing staff failed to notify the physician about the missed doses, leading to elevated blood pressure readings. Facility policies required medications to be administered as prescribed, but there was no evidence of a policy for handling missed medications.
A facility failed to provide trauma-informed care for a resident with PTSD, dementia, and major depressive disorder. The resident's trauma triggers were not identified, and her PTSD diagnosis was not included in her care plan. Staff members were unaware of the resident's trauma triggers and PTSD diagnosis, which was confirmed by the DON. The facility's policies require identifying trauma triggers and including them in the care plan, which was not followed, placing the resident at risk for re-traumatization.
A resident did not receive spironolactone for hypertension and the full dose of venlafaxine for depression for several days due to untimely medication reordering. The resident's blood pressure was elevated during this period, and the facility's staff did not inform the MD of the missed doses. The pharmacy delivered medications only after the missed doses were reported.
A resident with vascular dementia was prescribed risperidone without adequate indication or target behavior. The resident was calm with no behavioral issues, and the care plan lacked behavioral interventions. The facility's policy requires antipsychotic medications only when symptoms are due to mania or psychosis, or after behavioral interventions. The consultant pharmacist confirmed the medication's inappropriateness, as risperidone is not approved for dementia-related psychosis.
The facility failed to label and store medications correctly, as observed during inspections. In the medication room, latanoprost eye drops and a tuberculin vial lacked open or use-by dates, risking expired medication use. Similarly, a medication cart inspection revealed unlabeled glucose strips, a Spiriva inhaler, and a Humulin pen. The DON confirmed the expectation for proper labeling to prevent expired medication administration.
During a kitchen tour, improper food storage practices were observed, including wet steam table pans and an open bag of frozen spinach, which could lead to contamination. The Dietary Manager acknowledged these issues, which contravened the FDA Food Code and the facility's own policies.
A resident with dementia and depressive disorder was physically assaulted by another resident with similar conditions, resulting in harm. The incident was preceded by signs of agitation and aggression from the aggressor, which were not adequately monitored. Staff interviews confirmed a history of aggressive behavior in both residents, and the facility's policy on abuse prevention was not effectively implemented.
A resident with Alzheimer's and severe cognitive impairment was physically abused by a CNA, who slapped the resident's face, pulled their arm, and covered their face with a gown. This incident was witnessed by an RN who intervened. The facility's policy mandates protection from abuse, which was not upheld in this case.
A resident with a history of aggressive behavior physically assaulted two other residents, resulting in injuries. Despite the facility's awareness of the resident's potential for aggression, the incidents occurred, leading to a deficiency in protecting residents from abuse.
A facility failed to create a care plan for a resident prescribed Trazodone for depression, despite the resident's severe cognitive impairment and involvement in a physical altercation. The DON confirmed the absence of a care plan, which was required by the facility's policy on psychotropic medication management.
A resident with severe cognitive impairment was physically abused by another resident with dementia in an LTC facility. The incident occurred when the first resident, known for intrusive behaviors, attempted to enter the second resident's room, leading to the second resident kicking him. Staff were aware of both residents' behaviors but failed to prevent the conflict.
A resident with severe cognitive impairment physically harmed another resident, but the incident was not reported immediately as required by the facility's policy. The incident was witnessed by a CNA, who did not report it, assuming another CNA would do so. The responsible nurse was unaware of the incident until informed by the victim's family the next day, leaving the victim at risk of further harm.
A resident with severe memory impairment was physically abused by a CNA during mealtime, as confirmed by video evidence and interviews with facility staff. The resident was forcefully pulled into a chair, pushed down by the chest, and struck on the hand and arm, contrary to the facility's abuse prohibition policy.
Inadequate Staffing Leads to Resident Falls
Penalty
Summary
The facility failed to maintain sufficient nurse staffing levels for a census of 111 residents, as evidenced by the Actual Direct Care Service Hours Per Patient Day (DHPPD) falling below the required minimum standard of 3.5 DHPPD and 2.4 hours per patient day for certified nurse assistants (CNA DHPPD) from November 1 to November 7, 2024. During this period, the facility's DHPPD ranged from 2.64 to 2.98, and CNA DHPPD ranged from 1.69 to 1.93, which were below the mandated requirements. This staffing shortfall was confirmed by the Staffing Coordinator, who acknowledged the absence of a staffing waiver and attributed the deficiency to a loss of CNAs and numerous call-outs. The inadequate staffing levels coincided with 10 recorded resident falls during the same period, including incidents where residents fell from chairs, while walking, or from beds, with one fall resulting in a head injury requiring emergency room treatment. Interviews with staff, including a CNA and the Director of Nursing, highlighted the challenges faced due to low staffing, such as difficulty in providing adequate resident care and implementing fall precautions. The facility's policy on staffing emphasized the need to adhere to state-imposed minimum staffing requirements, which were not met during the reported period.
Resident Privacy Compromised Due to Overfilled Shred Box
Penalty
Summary
The facility compromised resident personal privacy and confidentiality when a shred box containing meal tickets was overfilled, exposing resident information. During the surveyor's initial setup, the survey team observed that the shred box, located in the large dining room off the kitchen, was full to the brim with meal tickets protruding from the box's opening. This allowed the survey team to read resident information directly from the meal tickets. The Dietary Manager confirmed the shred box was overfilled and unsuccessfully attempted to push the meal tickets back inside. The meal tickets, which were picked up every two weeks, contained sensitive information such as resident names, room locations, therapeutic diet orders, fluid textures, likes/dislikes, food allergies, and special instructions. Further observations revealed that the shred box continued to be overfilled with meal tickets, making resident information accessible to non-staff individuals. The Administrator acknowledged the issue, stating that the shred box should not be that full. The facility's policy and procedure on confidentiality and personal privacy, revised in October 2017, indicated that the facility would protect and safeguard resident confidentiality and personal privacy, including medical treatment and personal care. However, the overfilled shred box with exposed meal tickets demonstrated a failure to adhere to this policy, potentially compromising resident privacy.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to potential health risks. Resident 72, who has dementia and major depressive disorder, was observed with a blackish substance under her fingernails on multiple occasions. Despite requiring assistance with personal hygiene, there was no documentation of refusals for hygiene assistance, and staff confirmed that nail care should be performed regularly to prevent hygiene and infection control issues. Resident 59, diagnosed with dementia and malnutrition, was not provided with the necessary oral care as outlined in their care plan. The care plan specified that oral hygiene should be performed twice daily, yet there were numerous missed opportunities for oral care in November and December. Observations revealed white matter caked on the resident's teeth, and staff misunderstood the requirements for oral care, thinking that wiping the mouth sufficed. The facility's policy on supporting ADLs was not adhered to, as evidenced by the lack of appropriate hygiene support for these residents. The Director of Nursing confirmed that the care plans were current and should have been followed, highlighting a failure in the facility's adherence to its own policies and procedures regarding resident care.
Inadequate Activity Provision for Residents
Penalty
Summary
The facility failed to provide adequate activities to meet the interests and preferences of two residents, Resident 35 and Resident 30. Resident 35, who was admitted with Alzheimer's disease, was observed multiple times over two days remaining in her room without engaging in any activities. Her care plan indicated a preference for activities such as music, animals, and group interactions, yet she was only offered activities once a week. The facility's policy required more frequent engagement, and the Activities Director acknowledged that the current level of activity was insufficient. Resident 30, diagnosed with dementia and brain cancer, was not provided with activities that met his psychosocial needs for a period of 35 days. His care plan suggested participation in group activities and interactions with peers, but observations showed him lying in bed unresponsive during this time. The Activities Director confirmed that Resident 30 did not receive the necessary activities, which was not in line with the facility's expectations for meeting residents' psychosocial needs. The facility's policies indicated that activities should be provided in accordance with residents' interests and care plans, yet both residents were not engaged as required. The Director of Nursing and Activities Director both acknowledged the deficiencies in meeting the residents' psychosocial needs, which could potentially affect their overall well-being.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper sanitation of shared medical equipment. A licensed nurse used a blood pressure cuff on multiple residents without sanitizing it between uses, acknowledging the risk of infection due to this oversight. The facility's policy required decontamination of resident-care items between uses, which was not followed in this instance. Another deficiency involved staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, two certified nursing assistants did not wear the necessary personal protective equipment (PPE) while transferring a resident who was on EBP. The staff admitted to not being sure about the PPE requirements, despite clear signage indicating the need for gloves and gowns. This lack of compliance with EBP guidelines posed a risk of spreading infections. Additionally, hand hygiene practices were not consistently followed by staff. A certified nursing assistant failed to perform hand hygiene between feeding multiple residents and handling meal trays. The facility's policy mandated the use of hand sanitizer before and after resident contact and handling objects, which was not adhered to. Furthermore, other staff members, including a hospice nurse, did not wear gowns while providing care to residents on EBP, such as during wound care and feeding tube management, contrary to the facility's infection control policies.
Improper Cleaning of Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for 29 residents due to improper cleaning of bathroom exhaust fans, leading to dust buildup. Observations over several days revealed that the exhaust fans in shared bathrooms were not cleaned, resulting in potential fire hazards and exposure to mold and bacteria. Interviews with staff, including a Certified Nurse Assistant, Infection Preventionist, and Housekeeping Staff, confirmed the presence of dust buildup and acknowledged the potential health risks associated with it. The Housekeeping Manager indicated that rooms were scheduled for deep cleaning monthly, which included cleaning exhaust fans, but spot checks were expected daily. However, the Housekeeping Staff was unaware of any specific schedule for cleaning exhaust fans. A review of the Environmental Services Operations Manual indicated that vents should be cleaned daily, but this was not being followed. The Deep Clean Check Off List also included cleaning vents, but the exhaust fans were not cleaned during recent deep cleans, highlighting a gap in adherence to cleaning protocols.
Failure to Promote Dignity During Meal Times
Penalty
Summary
The facility failed to promote dignity and respect for three residents during meal times. Certified Nursing Assistant 9 (CNA 9) was observed standing over Resident 1 and Resident 33 while assisting them with their meals. Resident 1, who has hemiplegia and hemiparesis following a stroke, expressed discomfort with this approach, stating it made her feel less dignified. Resident 33, who has severe memory impairment due to dementia, was also fed in the same manner. The Director of Staff Development acknowledged that standing over residents while feeding them could increase the risk of aspiration and did not promote dignity. Additionally, Resident 14, who has moderate cognitive impairment and diabetes mellitus, was served her lunch tray later than other residents at her table, causing her frustration and a sense of being left out. The Director of Staff Development noted that serving meals at different times could affect food temperature and negatively impact residents' feelings of inclusion. The facility's policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 89, by not ensuring their call light was within reach. Resident 89, who was admitted in January 2023 with multiple diagnoses including dementia, was identified as a fall risk in their care plan. The care plan specifically included an intervention to prevent falls by placing the call light within reach. However, during an observation on December 18, 2024, it was noted that Resident 89's call light was not visible or accessible, as it was found under the bed. This was confirmed by Certified Nursing Assistant 12, who acknowledged that the call light should have been within the resident's reach. The deficiency was further highlighted during an interview with the Director of Nursing, who stated that the expectation was for call lights to be within residents' reach to meet their needs and reduce the risk of falls. The facility's policy, revised in October 2024, also indicated that call lights should be accessible to residents. Despite these guidelines, the failure to ensure the call light was within reach had the potential to result in further falls for Resident 89, who had previously fallen and injured her head, requiring hospitalization.
Inaccurate MDS Assessment for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident 49. This resident, who was admitted in January 2024, had diagnoses including dementia and major depressive disorder. The MDS assessment dated October 22, 2024, inaccurately indicated that Resident 49 had severely impaired cognition but did not exhibit any physical or verbal behavioral symptoms. However, a review of the Medication Administration Record (MAR) for October 2024 showed that Resident 49 exhibited yelling behavior 17 times between October 14 and October 22, 2024. Interviews with facility staff, including a Certified Nurse Assistant (CNA), the MDS Assistant (MDSA), the Social Services Director (SSD), and the Director of Nursing (DON), confirmed the inaccuracy of the MDS assessment. The CNA described Resident 49 as loud and combative, often refusing care and exhibiting yelling and kicking behaviors. Both the MDSA and SSD acknowledged that the MDS assessment did not accurately reflect Resident 49's behavioral symptoms, and the DON stated that she expected MDS assessments to be accurate for appropriate patient care. The facility's policy indicated that MDS assessments should consistently reflect information in progress notes, care plans, and resident observations, which was not the case for Resident 49.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident diagnosed with hypertension and depression. The resident did not receive spironolactone, a medication for high blood pressure, for four consecutive days because the medication was not reordered in a timely manner. Additionally, the licensed nurse did not notify the physician about the missed doses. During this period, the resident's blood pressure readings were elevated, indicating a potential impact on their health. Furthermore, the resident did not receive the full prescribed dose of venlafaxine, an antidepressant, for four days due to the same issue of untimely medication reordering. Again, the physician was not informed about the missed doses. Interviews with the licensed nurses confirmed the medication was unavailable, and the physician acknowledged that he was not contacted regarding the missed doses, which could have led to uncontrolled blood pressure. The facility's policies required medications to be administered as prescribed, but there was no documented evidence of a policy for handling missed medications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident, identified as Resident 102, who was diagnosed with PTSD, dementia, and major depressive disorder. The deficiency was identified when it was found that the resident's trauma triggers were not identified, and her PTSD diagnosis was not included in her care plan. This oversight was confirmed during interviews with a Licensed Nurse and a Certified Nurse Assistant, both of whom were unaware of the resident's trauma triggers and PTSD diagnosis. The Director of Nursing acknowledged the importance of identifying trauma triggers to prevent re-traumatization and stated that the resident's PTSD diagnosis and triggers should have been care planned. The facility's policy on Trauma Informed Care, dated August 2023, requires the identification of triggers that may re-traumatize residents with a history of trauma and mandates that these triggers be included in the resident's care plan. Additionally, the facility's comprehensive care plan policy requires that a resident's care plan be developed within seven days of completing the comprehensive assessment. The failure to adhere to these policies resulted in the deficiency, placing Resident 102 at risk for re-traumatization and not achieving her highest physical, mental, and psychosocial well-being.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 91, who was admitted with diagnoses of hypertension and depression. The resident did not receive spironolactone, a medication for high blood pressure, for four consecutive days due to the medication not being reordered in a timely manner. This resulted in missed doses on specific dates, as documented in the Medication Administration Record (MAR). During this period, the resident's blood pressure readings were elevated, and the progress notes indicated that the facility was awaiting pharmacy delivery. A licensed nurse confirmed that the medication was unavailable during her shift. Additionally, the resident did not receive the full prescribed dose of venlafaxine, an antidepressant, for four days due to similar issues with timely medication ordering. The MAR showed that the medication was not administered as ordered, and the progress notes again cited awaiting pharmacy delivery. A licensed nurse confirmed the failure to administer the correct total dose. The medical doctor was not informed of the missed doses, which could have led to uncontrolled blood pressure, as acknowledged by the doctor. The pharmacy consultant indicated that medications were refilled and delivered only after the missed doses were reported. The facility's policies on medication administration and physician orders were reviewed, but the policy on missed medications was not provided.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically a psychotropic medication, which was prescribed without adequate indication or a target behavior. The resident, who was admitted with a diagnosis of vascular dementia, was prescribed risperidone, an antipsychotic medication, for aggressive behavior manifested by yelling out for needs. However, the resident's psychiatrist consult note indicated that the resident was calm with no behavioral issues, and the care plan did not include any behavioral interventions for aggressive behavior. Furthermore, the Minimum Data Set assessment showed no potential indicators for psychosis. The facility's policy on antipsychotic/psychotropic medication requires that such medications be used only when behavioral symptoms present a danger to the resident or others, and when symptoms are due to mania or psychosis, or after behavioral interventions have been attempted. The consultant pharmacist confirmed that risperidone may not be appropriate for the resident, as yelling out for needs is not a psychotic behavior. Additionally, the manufacturer's prescribing information and a nationally recognized drug information resource both indicated that risperidone is not approved for treating dementia-related psychosis, highlighting the inappropriate use of the medication in this case.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was identified during an inspection. In the medication room, three bottles of latanoprost eye drops and one vial of tuberculin were found without open or use-by dates. This oversight was confirmed by a licensed nurse, who acknowledged that the absence of these dates could lead to the administration of expired medications. Manufacturer guidelines specify that latanoprost should be used within six weeks of opening, and tuberculin vials should be discarded after 30 days of use. Additionally, during an inspection of a medication cart, a bottle of glucose testing strips, a Spiriva Respimat inhaler, and a Humulin 70/30 KwikPen were also found without open or use-by dates. The licensed nurse present confirmed that these items should have been labeled accordingly to prevent the risk of administering expired medications. Manufacturer instructions indicate that glucose strips are valid for three months after opening, the Spiriva inhaler should be discarded three months after cartridge insertion, and the Humulin pen should be disposed of after 10 days of use. The Director of Nursing confirmed the expectation for proper labeling and acknowledged the risk of using expired medications.
Improper Food Storage Practices Observed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Three large steam table pans were found stored with water droplets on both their inner and outer surfaces. This condition was acknowledged by the Dietary Manager (DM), who confirmed that the pans were wet and recognized that such a condition could lead to contamination. According to the 2022 US Food and Drug Administration (FDA) Food Code section 4-901.11, items must be allowed to drain and air-dry before being stacked or stored, as stacking wet items can create an environment conducive to microorganism growth. Additionally, a bag of frozen spinach was observed to be improperly stored, as it was not closed, leaving the spinach exposed to the environment. The DM concurred that the bag should have been tightly closed to prevent contamination. The facility's policy and procedure for food receiving and storage, although undated, indicated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated, with wrappers of frozen foods remaining intact until thawing. These lapses in food storage practices had the potential to result in food-borne illnesses for the 110 residents consuming facility-prepared meals.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 49, who has dementia and major depressive disorder, was physically assaulted by Resident 112, who also has dementia and a depressive episode. The incident occurred when Resident 112 grabbed Resident 49 by the hair, pulled her down, and hit her. This altercation resulted in Resident 49 getting hurt and posed a risk of physical and psychosocial harm to all residents in the facility. Prior to the incident, Resident 112 exhibited signs of agitation and behavioral symptoms, including verbal aggression towards staff, as noted in the progress notes. Despite these behaviors, there was no documentation of monitoring in Resident 112's Medication Administration Record (MAR) for November 2024. Similarly, Resident 49's MAR indicated episodes of yelling out after needs were met, suggesting potential triggers for altercations. The facility's failure to adequately monitor and address these behaviors contributed to the incident. Interviews with staff revealed that both residents had a history of aggressive behavior. Certified Nurse Assistant (CNA) 1 witnessed the altercation and intervened to separate the residents. CNA 2 and Licensed Nurse (LN) 1 confirmed that both residents could be loud and physically aggressive, which could lead to altercations. The Director of Nursing (DON) acknowledged the expectation that residents should be free from abuse, highlighting the facility's policy on abuse prohibition and prevention.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a Certified Nursing Assistant (CNA) engaged in abusive behavior towards a resident. The incident involved CNA 4 slapping the resident's face, aggressively pulling the resident's arm, and using a gown to cover the resident's face. This incident was witnessed by a Registered Nurse (RN) who was preparing medication nearby and heard the resident crying. Upon looking up, the RN observed the abusive actions and intervened to check on the resident. The resident involved in the incident was admitted with diagnoses including Alzheimer's Disease, dementia, and Major Depressive Disorder, and was assessed as severely cognitively impaired. The facility's policy clearly states that residents have the right to be free from abuse and neglect, and this incident represents a failure to uphold that policy. The Director of Nursing (DON) confirmed that all residents should be protected from abuse and neglect, emphasizing the facility's responsibility to ensure a safe environment for its residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse when another resident, who had a history of physical behaviors related to cognitive loss and dementia, physically assaulted them. Resident 1, who was admitted with severe cognitive impairment and a history of aggressive behavior, punched Resident 2 in the face, resulting in a scratch on the lower lip, and bit Resident 3 on the right hand, causing a skin tear. These incidents occurred despite the facility's awareness of Resident 1's potential to exhibit physical aggression. The events unfolded as Resident 1 approached Resident 2 in the hallway and punched him, causing a minor scratch. Shortly after, Resident 1 bit Resident 3 on the hand while Resident 3 was assisting another resident. Staff intervened to separate the residents, but the incidents resulted in physical injuries to both Resident 2 and Resident 3. Observations and interviews with staff and residents confirmed the sequence of events and the injuries sustained. The facility's policies on resident rights and abuse prevention emphasize the right of residents to be free from abuse by anyone, including other residents. However, the facility's failure to adequately protect Residents 2 and 3 from Resident 1's aggressive behavior indicates a deficiency in ensuring resident safety and preventing abuse, as outlined in their policies.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was prescribed Trazodone, a medication used to treat depression. The resident, who was admitted with diagnoses including dementia and depression, had severe cognitive impairment. Despite being prescribed Trazodone initially at 50 mg and later increased to 100 mg following a physical altercation with other residents, there was no care plan developed for the use of this psychotropic medication. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a care plan and stated that the expectation is to have a care plan for any psychotropic medication use. The facility's policy on psychotropic medication management requires that when such medications are prescribed for specific conditions or targeted behaviors, the clinical record should reflect the diagnosis, reasons for use, and have a care plan in place. The lack of a care plan for the resident's use of Trazodone was a deviation from this policy, as the clinical record did not include a care plan with medication use and non-drug interventions that had been attempted to alleviate the condition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident kicked him on the right side of his torso. The incident involved two residents with cognitive impairments. The first resident, who was admitted with encephalopathy and alcohol dependence with withdrawal delirium, had a severe cognitive impairment as indicated by a BIMS score of 3. This resident was known to exhibit intrusive behaviors, such as entering other residents' rooms and going through their belongings. The second resident, diagnosed with dementia and having a BIMS score of 5, became agitated when the first resident attempted to enter his room through a shared restroom. On the night of the incident, staff heard yelling and found the first resident on the floor, being kicked by the second resident. Interviews with staff revealed that the first resident's wandering and intrusive behaviors were known, as was the second resident's tendency to become angry when his space was invaded. The facility's policy on abuse prevention emphasized the need for ongoing assessments and care planning to address behaviors that could lead to conflict, but these measures were not effectively implemented to prevent the incident.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of abuse, neglect, exploitation, or misappropriation. This deficiency was identified when an incident involving two residents occurred, where one resident physically harmed another. The incident was witnessed by a Certified Nursing Assistant (CNA 1) but was not reported to the appropriate authorities or staff members on the day it happened. The Director of Nursing (DON) confirmed that the alleged abuse was not reported immediately, as required by the facility's policy. Resident 3, who was admitted with diagnoses including major depressive disorder and unspecified dementia, was involved in a peer-to-peer altercation as the aggressor. The incident was documented in various records, including the SBAR communication form and progress notes, indicating that Resident 3 physically twisted and hit Resident 2. Despite the documentation, the incident was not reported to the nurse on duty, the DON, the Assistant Director of Nursing (ADON), or the abuse coordinator on the day it occurred. Resident 2, who was bedbound and unable to communicate effectively, was left in the same room with Resident 3 until the following day, increasing the risk of further harm. Interviews with staff members revealed a breakdown in communication and reporting. CNA 1 witnessed the incident but did not report it, assuming CNA 2 would do so. CNA 2, in turn, did not report the incident, believing that the Licensed Nurse (LN 1) had heard the call for help. LN 1, who was responsible for both residents, was unaware of the incident until informed by Resident 2's responsible party the next day. This lack of immediate reporting and action violated the facility's policy, which mandates that any suspicion of abuse must be reported within two hours.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a Certified Nursing Assistant (CNA) forcefully handled the resident during mealtime. The resident, who had severe memory impairment due to Alzheimer's disease and dementia, was aggressively pulled into a chair, pushed down by the chest, and struck on the hand and arm by the CNA. This incident was confirmed through video evidence and interviews with the Health Information Director (HID), the Administrator (ADM), and the Director of Nursing (DON). The incident was documented in the resident's clinical records, including a Minimum Data Set (MDS) and an eInteract Change in Condition Evaluation, which noted increased agitation and confusion in the resident following the abuse. The facility's policy on abuse prohibition, which explicitly forbids any form of abuse, mistreatment, or neglect, was not adhered to in this case. The ADM and DON confirmed the physical abuse during their interviews, acknowledging that the CNA's actions were inappropriate and harmful to the resident.
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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 Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Pointe Care Center | 0 mi | ★★★★★ | 28 | 0 |
| Advanced Health Care Of Sacramento | 3.2 mi | ★★★★★ | 1 | 0 |
| Gramercy Court | 3.8 mi | ★★★★★ | 16 | 0 |
| Sherwood Healthcare Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Woodside Healthcare Center | 4.8 mi | ★★★★★ | 0 | 0 |
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