Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Acc Care Center during CMS and state inspections, most recent first.
A resident with orthostatic hypotension, dementia, and prior pelvic fracture had multiple documented falls and was placed on fall precautions that included use of fall mats at the bedside. Progress notes and incident records described several unwitnessed and witnessed falls, including head injuries and a clavicle fracture, while documentation showed that a fall mat had been incorrectly positioned on one side of the bed and later not in place at all. During surveyor observations and interviews, the resident’s family member and an LN confirmed that no fall mats were present at the bedside despite the resident’s fall history, and the facility’s own policy and the Quality and Compliance Coordinator’s statements indicated that properly placed fall mats were required as part of the resident’s comprehensive care plan.
A cognitively intact resident receiving orthopedic aftercare reported being left alone in a shower room twice by a CNA, who left to retrieve a hairbrush from central supply and then from the resident’s room. Another CNA stated she witnessed the resident being left alone at least once, and the involved CNA confirmed in a written statement and interview that she left the resident unattended on both occasions. A nurse and a nurse manager stated that residents are not to be left alone in shower rooms due to safety concerns, and facility policies on bathing and resident supervision require staff to remain with residents throughout showers and emphasize supervision as a core safety component.
A resident with a history of blood clots was prescribed aspirin 81mg twice daily until a specific date, but due to a miscommunication between the physician and a nurse, the medication was stopped a month early. This error was discovered after the resident was hospitalized, and the family informed the DON. The facility's policy on medication orders was not followed, resulting in the resident not receiving the prescribed aspirin.
A facility failed to protect residents from misappropriation of controlled medications, specifically oxycodone, leading to unaccounted doses and potential resident harm. A nurse altered medication orders and removed medications and count sheets, resulting in discrepancies. An audit revealed 1,915 doses were missing, and the facility's policy on employee conduct was reviewed.
A nurse in an LTC facility entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for multiple residents. This led to discrepancies in medication counts and potential misuse of medications. The facility's policy requires medications to be administered only with authorized prescriptions, which was not followed in this case.
A facility failed to maintain accurate accountability of controlled medications, specifically Oxycodone, for its residents. An LPN manipulated medication orders and records, including forging physician signatures and altering narcotic count sheets, leading to unaccounted doses. The facility's policies for controlled medication storage and accountability were not followed, compromising resident safety and therapeutic needs.
The facility failed to maintain food safety standards, with wet and dirty pans stored improperly, an unclean ice machine, and expired food items in a resident refrigerator. The Food Services Supervisor and Registered Dietician confirmed the issues, while the Plant Operations Manager admitted to not performing necessary deep cleaning. These deficiencies risked foodborne illness for residents.
The facility's dishwashing machine failed to reach the required temperatures and sanitizer concentration levels, placing 89 residents at risk for foodborne illness. The Dietary Aide and Food Service Supervisor confirmed the deficiencies, and the machine company technician suggested that insufficient hot water pressure might be the cause.
The facility failed to conduct annual performance evaluations and competency assessments for five CNAs, as required by their policy. Interviews and record reviews with the DON, CCN, and ADM confirmed the absence of these evaluations for 2024, despite the facility's policy mandating participation in a competency-based training program.
A facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate. An LN crushed and administered uncrushable medications, oxybutynin ER and pantoprazole DR, to a resident, contrary to facility guidelines. Additionally, a prescribed dose of calcium-vitamin D was not administered due to a failure to order the medication on time. The DON confirmed these errors, which violated the facility's medication administration policies.
The facility failed to follow its medication storage policy, resulting in several deficiencies. An expired insulin vial was found in a medication cart, a multi-dose inhaler lacked an open date label, and 16 pills were stored without proper labeling. These actions violated the facility's policy, which requires medications to be stored in original containers with legible labels and outdated medications to be removed immediately.
The facility failed to follow prescribed therapeutic diets for several residents, including incorrect portion sizes and textures. Six residents on fortified diets did not receive extra butter, and four on small portion diets received incorrect salmon portions. Additionally, residents on dysphagia mechanical soft diets received incorrect textures, and a resident on a bite-size texture diet was served ground chicken instead of cubed. The preparation of pureed vegetables did not follow the recipe, resulting in a runny consistency.
The facility failed to provide required in-service training for CNAs in abuse prevention and dementia management. Four employed CNAs and one contracted CNA lacked abuse prevention training, while two employed CNAs and both contracted CNAs had not received dementia management training. The absence of training documentation was confirmed by the DON and ADM, raising concerns about the CNAs' competency in resident care.
A resident with memory impairment and weakness was not treated with dignity during meal assistance when a CNA stood while feeding her, contrary to facility policy. The resident showed discomfort, and interviews with staff confirmed the expectation to sit beside residents during feeding to ensure dignity.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, with anxiety and depression, lacked an activities care plan and was isolated due to a language barrier. Another resident, with Parkinson's disease, had a skin laceration that was not addressed in a care plan. Staff interviews confirmed the absence of necessary assessments and care plans, contrary to facility policy.
A resident with an endocrine disorder and difficulty swallowing did not have their care plan updated after a physician ordered blood sugar checks due to hypoglycemia symptoms. Despite staff awareness of the order, the intervention was not documented in the care plan, contrary to facility policy.
Two residents experienced deficiencies in care at the facility. A resident with Parkinson's disease had no documented assessment for a new finger laceration, confirmed by a nurse and the DON. Another resident with pulmonary fibrosis received incorrect oxygen therapy, as observed and confirmed by a nurse, contrary to physician's orders. The facility's policy mandates adherence to prescriber orders.
The facility failed to provide necessary communication aids for two residents with language barriers, impacting their ability to communicate effectively. One resident, who spoke only Spanish, and another with severe cognitive impairment and a primary language of Taishanese, both lacked communication boards at their bedsides despite care plans indicating their need. Staff were unaware of the absence of these resources, highlighting a failure to adhere to facility policies on communication for residents with limited English proficiency.
A resident with a Stage 4 pressure injury did not receive a required low air loss mattress upon readmission to the facility, despite care plan and physician orders. Facility staff confirmed the absence of the mattress, citing a misunderstanding about hospice responsibilities, although the facility had the necessary equipment available.
A resident did not receive their prescribed calcium-vitamin D during a medication pass because it was not ordered on time, as observed by a licensed nurse. The physician's orders required the medication twice daily, but it was unavailable. The DON confirmed that medications should be timely ordered and available. Facility policies stated that medications must be administered per physician orders.
The facility failed to honor food preferences for four residents, leading to dissatisfaction with meals. A resident received sausage, which she disliked, and reported never being asked about her food preferences. Another resident was served scrambled eggs, which she disliked, and her dietary profile lacked documentation of preferences. A third resident's meal ticket indicated a dislike for carrots, yet her meal tray included them. A fourth resident, who was underweight, did not receive the Healthshake and Udon soup as per her dietary orders. The facility was unable to provide a policy for residents' food preferences.
The facility failed to follow infection control protocols for three residents. A resident's oxygen and nebulizer tubing were not labeled or dated, contrary to facility policy. Another resident with MRSA had a bandage change where the nurse did not change gloves or sanitize items, risking contamination. A third resident's oxygen equipment was also found unlabeled and undated, violating infection control guidelines.
Failure to Implement Care-Plan Fall Mat Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident with a documented history of falls, specifically the absence of fall mats at the bedside as ordered in the resident’s fall precautions. The resident was admitted in January 2026 with orthostatic hypotension, dementia, and a pelvic fracture, and a progress note dated 4/1/26 documented that the resident did not have capacity to make medical decisions. The care plan dated 3/1/26 reflected an unwitnessed fall that led to implementation of fall precautions, and subsequent care plan entries on 3/17/26 and 3/24/26 documented additional falls, including a minor head injury and a witnessed fall with head impact requiring transfer to the ED. Facility incident records dated 4/2/26 confirmed unwitnessed falls on 3/1/26 and 3/17/26 and a witnessed fall on 3/24/26. A progress note from 3/1/26 described the resident found on the floor next to the left side of the bed while the fall mat was placed on the right side. Further documentation showed that on 3/17/26 the resident was found on the floor near the door with a 2 cm laceration to the right side of the head, and a hospital discharge summary dated 4/1/26 listed diagnoses including a possible syncopal episode, orthostatic hypotension, and an acute distal left clavicular fracture. On 4/2/26, during observation and interview in the resident’s room, the resident’s family member confirmed that no fall mats were in place at the bedside and stated that fall mats should have been present for safety. A concurrent observation and interview with a licensed nurse confirmed that fall mats were not in place despite the resident’s history of falls and that fall mats were part of the resident’s fall precautions. The Quality and Compliance Coordinator stated that after a fall, a change in condition should be documented and care plans updated to include fall precautions such as ensuring the call light is within reach, the bed is in the lowest position, and a fall mat is properly placed at the bedside. The facility’s care plan policy required that residents receive the services and items included in the comprehensive, person-centered care plan, which was not followed in this case regarding the fall mat intervention.
Resident Left Unattended in Shower Room Contrary to Supervision Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a shower area free from accident hazards when a cognitively intact resident receiving orthopedic aftercare was left alone in the shower room on two occasions. The resident, admitted in March 2026 with a diagnosis of encounter for orthopedic aftercare, reported that a CNA left her alone in the shower room twice to obtain a hairbrush. During an observation and interview in the resident’s room, the resident, seated in a wheelchair with her right leg raised, stated that the CNA left her unattended in the shower room on both occasions. A second CNA reported witnessing the first CNA leave the resident alone in the shower room at least once during her shift. In a written statement dated 3/22/26 and in a subsequent telephone interview, the first CNA acknowledged leaving the resident alone in the shower room to retrieve a brush from central supply and then again from the resident’s room. A licensed nurse and the nurse manager both stated that no resident should be left alone in the shower room and that doing so is a safety risk. Review of the facility’s Bath/Shower policy from 2001 indicated staff must stay with the resident throughout the bath and never leave the resident unattended in the shower, and the Safety and Supervision of Residents policy from July 2017 emphasized resident supervision as a core component of the facility’s safety system.
Incorrect Discontinuation of Aspirin for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality for a resident when their prophylactic aspirin was discontinued incorrectly. The resident, who was initially admitted with a broken thigh bone and later readmitted with blood clots in the lungs and legs, was prescribed aspirin 81mg twice daily until December 24, 2024. However, the medication was stopped prematurely on November 24, 2024, due to a miscommunication between the physician and a licensed nurse regarding the stop date. This error was discovered after the resident was hospitalized, and the family notified the Director of Nursing (DON) about the issue. The DON confirmed that the medication administration record indicated the incorrect stop date and acknowledged the mistake. The physician also confirmed that the aspirin was intended to be continued until December 24, 2024, but was stopped earlier than planned. The facility's policy on medication and treatment orders, which emphasizes consistency with safe and effective order writing, was not adhered to in this instance, leading to the resident not receiving the prescribed aspirin as ordered.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their controlled medications, specifically oxycodone, resulting in a lack of accountability for these medications. The issue was identified when a licensed nurse (LN 2) discovered that the narcotic count for a resident was missing during a shift change. The count sheet for another resident's medication was also missing, although the medication itself was present. The night shift nurse (LN 3) confirmed that the narcotic count had been accurate the previous night, and both nurses attempted to locate the missing medication without success. Further investigation revealed that LN 1 had borrowed keys to the medication cart and subsequently altered medication orders without proper documentation. LN 1 was suspected of diverting oxycodone by placing orders, discontinuing them, and removing the medication and count sheets to cover up the discrepancies. The Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that an audit revealed 1,915 doses of oxycodone were unaccounted for, and LN 1's actions were identified as the cause of the discrepancies. The facility's policy on employee conduct was reviewed, highlighting that unauthorized possession or removal of property could lead to disciplinary action. Interviews with other licensed nurses (LN 4 and LN 5) emphasized the importance of accurate medication administration and documentation. The facility's failure to maintain accountability for controlled medications posed a risk of uncontrolled pain and suffering for residents, as the missing medications were not available for their intended use.
Unauthorized Medication Orders and Prescriptions by Nurse
Penalty
Summary
The facility failed to ensure professional standards of practice were followed when a Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents. This resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. The issue was discovered during a narcotics count when LN 2 and LN 3 noticed discrepancies in the medication count for several residents. Specifically, the medication for one resident was missing, and the count sheet for another resident was missing, although the medication was present. LN 1 had borrowed the keys to the medication cart and later informed the other nurses that the order had been discontinued and changed, without any progress notes or physician authorization. Further investigation revealed that LN 1 had created and discontinued orders, and altered count sheets without proper authorization. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that LN 1 had been entering orders into the electronic chart, writing prescriptions, and signing them without physician authorization. The facility's policy and procedure require medications to be administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The Medical Director also verified that the signatures on the prescriptions were not his, indicating falsification of documents.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications, specifically Oxycodone, for a census of 84 residents. Multiple doses and Controlled Drug Records (CDR) for Oxycodone were missing and unaccounted for. Random controlled medication audits of the Medication Administration Record (MAR) and CDRs for seven of nine sampled residents did not reconcile, indicating discrepancies in medication administration. Licensed Nurse (LN 1) was found to have entered orders, written prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents. The investigation revealed that LN 1 manipulated medication orders and records. LN 1 was reported to have borrowed keys to access medication carts, altered narcotic count sheets, and forged physician signatures on prescriptions. The Assistant Director of Nursing (ADON) and Administrator (ADM) confirmed that LN 1's actions included ordering medications, discontinuing them, and removing both the drugs and count sheets to cover up the discrepancies. This led to a significant number of Oxycodone doses being unaccounted for, raising concerns about potential abuse or misuse of these medications. The facility's policy and procedure for controlled medication storage and accountability were not followed, as evidenced by the discrepancies in the MAR and CDRs. Interviews with staff indicated a lack of adherence to the expected process of medication administration and record-keeping. The facility's failure to maintain accurate records and ensure proper authorization for medication orders compromised the safety and therapeutic needs of the residents.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage and maintenance of kitchen equipment and food items. During an inspection, several metal pans and cooking pans were found stored in the clean and ready-to-use areas while still wet and containing food debris. Some pans had significant scrapes and greasy substances on their surfaces. The Food Services Supervisor confirmed these conditions and acknowledged that the pans should be completely dried and free of debris before storage. The Registered Dietician also stated that the pans needed to be clean and dry, and those with scrapes and black substances were unacceptable. Additionally, the ice machine in the kitchen was found to be unclean, with slimy pink and black substances on various components, including the ice baffle and water curtain. These substances were easily removed with a paper towel, indicating a lack of routine cleaning. The Plant Operations Manager, who was new to the position, confirmed the presence of these substances and admitted that he had not performed any deep cleaning of the ice machine. The last recorded deep clean was several months prior, contrary to the facility's policy requiring monthly maintenance. Furthermore, outdated food items were discovered in the resident's food refrigerator located in the family room. Items such as juice, milk, sliced fruits, and protein supplements were found past their expiration dates. The Director of Nursing confirmed these items were out of date and should have been discarded. The Registered Dietician indicated that monitoring the refrigerator was the responsibility of the nursing staff. These deficiencies had the potential to lead to foodborne illness for the majority of the residents receiving facility-prepared foods.
Dishwashing Machine Fails to Meet Safety Standards
Penalty
Summary
The facility failed to maintain the dishwashing machine in safe operating condition, as it did not reach the required minimum temperatures and sanitizer concentration levels. During an interview, the Dietary Aide (DA) stated that the wash and rinse water temperatures should be at 120 degrees Fahrenheit, and the sanitizer concentration should be 100 PPM. However, observations and tests revealed that the dishwashing machine's temperatures did not reach the required 120 degrees Fahrenheit, and the sanitizer concentration was not detected. The Food Service Supervisor (FSS) confirmed these findings and noted that the machine was new, and some staff, including DA 2, had not received proper training due to being on vacation. Further investigation revealed that the dishwashing machine's temperature gauge showed inadequate temperatures, and the sanitizer test strip did not change color, indicating no sanitizer was present. The dishwashing machine company technician suggested that insufficient hot water pressure might prevent the machine from reaching the required temperature when the facility's hot water demand was high. The facility's policy required immediate reporting and correction of inadequate temperatures and sanitizer concentrations, but these measures were not effectively implemented, placing 89 out of 91 residents at risk for foodborne illness.
Failure to Conduct Annual CNA Evaluations and Competency Assessments
Penalty
Summary
The facility failed to conduct annual performance evaluations and assess staff competency in skills and techniques for five Certified Nursing Assistants (CNAs). This deficiency was identified during interviews and record reviews with the Director of Nursing (DON), Clinical Compliance Nurse (CCN), and the Administrator (ADM). The personnel records for CNAs hired between 1991 and 2022 showed no completed performance evaluations or competency assessments for the year 2024. The DON and ADM confirmed the absence of these evaluations, acknowledging that this oversight could potentially impact the CNAs' ability to provide quality care. The facility's Policy and Procedure (P&P) on the Competency of Nursing Staff, revised in October 2017, mandates that all nursing staff participate in a competency-based staff development and training program as required by state law. Despite this policy, the facility did not adhere to its guidelines, as evidenced by the lack of documentation for performance evaluations and competency assessments. The CCN admitted difficulty in locating these records, further highlighting the facility's failure to ensure that CNAs maintained the necessary skills and competencies to deliver adequate care to residents.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate during a medication administration observation. A Licensed Nurse (LN) crushed and administered uncrushable medications to a resident, specifically oxybutynin ER and pantoprazole DR, which are extended-release and delayed-release medications, respectively. These medications were listed in the facility's document as not to be crushed, as confirmed by the LN and the Director of Nursing (DON). Crushing these medications can alter their intended release and effectiveness, leading to potential side effects. Additionally, the LN failed to administer a prescribed dose of calcium-vitamin D to the same resident, as the medication was not ordered on time and was unavailable during the medication pass. The facility's policy and procedure for medication administration require medications to be administered as prescribed by the attending physician. The DON confirmed that the medication should have been ordered and available for administration as per the physician's orders.
Medication Storage Policy Violations
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several deficiencies. An expired vial of Humulin R insulin was found in a medication cart, which was confirmed by a licensed nurse and the Director of Nursing (DON) as a practice that could lead to negative resident outcomes. The facility's policy clearly states that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, this expired insulin vial was not removed, indicating a lapse in following the established procedures. Additionally, a multi-dose inhaler of fluticasone propionate/salmeterol was found without an open date label, making it impossible to determine its expiration date. The manufacturer's instructions require the product to be discarded 30 days after opening, but without an open date, this could not be verified. Furthermore, 16 pills were stored in a plastic cup without proper labeling, including the name, strength, expiration date, and lot number. The facility's policy mandates that medications be stored in their original containers with legible labels, yet this was not followed, posing a risk of administering incorrect or expired medications.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the prescribed therapeutic diets for several residents during lunch meals on specific dates. Six residents on fortified diets did not receive the required extra melted butter on their vegetables, as observed during meal distribution. Additionally, four residents on small portion diets were served incorrect portions of salmon, receiving three ounces instead of the prescribed two ounces. These discrepancies were confirmed through interviews with the Food Services Director and the Food Services Supervisor, who acknowledged the errors in portion sizes and the failure to follow the menu. Further issues were identified with residents on dysphagia mechanical soft diets. Two residents received pureed chicken instead of the required ground chicken, and another resident received an incorrect portion of broth. Additionally, a resident on a bite-size texture diet was served ground chicken instead of cubed chicken. These inconsistencies were confirmed through interviews and a review of the facility's daily spreadsheet, which outlined the specific dietary requirements for each resident. The preparation of pureed vegetables also did not follow the prescribed recipe, as the cook did not measure ingredients or drain the vegetable juice before blending. This resulted in a runny consistency, as confirmed by a Registered Dietitian who tasted the puree. The dietitian acknowledged the incorrect textures, measurements, and portion sizes provided to the residents. The facility's diet manual and job descriptions emphasize the importance of following recipes and portion control, which were not adhered to in these instances.
Deficiency in CNA Training for Abuse Prevention and Dementia Management
Penalty
Summary
The facility failed to ensure that both employed and contracted Certified Nursing Assistants (CNAs) received the required in-service training and demonstrated competency in skills and techniques necessary for abuse prevention and dementia management. Specifically, four out of seven employed CNAs and one out of two contracted CNAs lacked abuse prevention training, while two employed CNAs and both contracted CNAs had not received dementia management training. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have the necessary documentation to confirm that these trainings had been completed. During interviews, the Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of training documentation for the CNAs and CCNAs. The Clinical Compliance Nurse (CCN) noted that the facility relied on a staffing agency to provide training documentation for contracted staff, which was not available. The facility's policy required all nursing staff to participate in a competency-based training program, including abuse prevention and dementia management, upon hire and annually. The lack of documentation and training raised concerns about the CNAs' ability to provide competent care to residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure the dignity of a resident during meal assistance, as observed in the case of a resident with memory impairment and weakness. During a lunch meal, a CNA stood up while assisting the resident, contrary to the facility's policy and procedure, which emphasizes sitting beside residents to promote a dignified dining experience. The resident showed discomfort by turning her face away and attempting to push the CNA's hands away. Interviews with the CNA, a Restorative Nursing Aide, and the Director of Nursing confirmed that the expected practice is to sit beside residents during feeding to maintain their dignity and comfort. The facility's policies on dignity and resident rights, reviewed during the investigation, also support this practice, highlighting the importance of treating residents with respect and ensuring a dignified existence.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 148, who was admitted with diagnoses including anxiety, depression, and difficulty walking, did not have an activities care plan developed or implemented. Despite being alert and oriented, Resident 148, who primarily speaks Spanish, was observed to be isolated in his room without engagement in activities. Interviews with staff, including a Licensed Nurse, Certified Nursing Assistants, and the Activities Director, revealed that Resident 148 was not assessed for activities, and his language barrier was not addressed, resulting in a lack of participation in activities. Resident 4, admitted with conditions such as Parkinson's disease and osteoarthritis, had a skin laceration with staples that was not addressed in a care plan. Upon returning from the hospital, there was no documented assessment or care plan for the laceration, as confirmed by a Licensed Nurse and the Director of Nursing. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented for each resident, including assessments and interventions for new injuries, which was not followed in this case.
Failure to Update Care Plan for Resident with Hypoglycemia
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident 71, after a physician ordered an additional intervention. Resident 71 was admitted with diagnoses including an unspecified endocrine disorder, hyperlipidemia, and difficulty swallowing. The Minimum Data Set (MDS) indicated that the resident had no memory impairment and required partial assistance with activities of daily living. Despite a verbal order to check the resident's blood sugar levels as needed due to symptoms of hypoglycemia, this intervention was not documented in the resident's nutrition care plan. Observations and interviews revealed that Resident 71 expressed dissatisfaction with the food quality and variety, and reported experiencing chills, a symptom of low blood sugar, without having her blood sugar checked. Interviews with staff, including a CNA and a licensed nurse, confirmed awareness of the resident's symptoms and the physician's order for blood sugar checks. However, the licensed nurse admitted that the care plan was not updated to include this intervention. The Director of Nursing acknowledged the expectation for nurses to update care plans with new interventions, as outlined in the facility's policy on comprehensive care plans.
Failure to Adhere to Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for two residents. For Resident 4, who was admitted with conditions including Parkinson's disease and osteoarthritis, there was no documented assessment for a new laceration on the index finger. This was confirmed during a record review with a licensed nurse, who acknowledged the absence of necessary assessments and care plans for monitoring the injury. The Director of Nursing also confirmed that assessments and care plans should have been completed to monitor for infection or worsening of the injury. For Resident 65, who was admitted with pulmonary fibrosis and other conditions, the facility did not adhere to the physician's orders for oxygen therapy. The resident was observed receiving oxygen at 2.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by a licensed nurse who acknowledged the importance of following physician orders. The Director of Nursing reiterated that licensed nurses are expected to follow physician's orders as indicated. The facility's policy on administering medications also emphasized adherence to prescriber orders.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that communication needs were met for two residents, Resident 148 and Resident 40, who had language barriers. Resident 148, admitted in 2024, had diagnoses including anxiety, depression, right hip pain, and difficulty walking. The resident's care plans indicated a need for communication aids due to a language barrier, as the resident spoke only Spanish. However, during multiple observations and interviews, it was confirmed that there were no communication resources, such as a communication board, available at the bedside. Staff members, including CNAs and a licensed nurse, acknowledged the absence of these resources, which hindered effective communication with the resident. Resident 40, admitted in 2019, had severe cognitive impairment and a primary language of Taishanese. The care plan noted a communication problem related to a cerebral intracranial hemorrhage and language barrier, with a communication board specified as a tool for interaction. Despite this, observations and interviews revealed that the communication board was missing from the resident's bedside. Staff, including a CNA, licensed nurse, and the Activities Director, were unaware of the board's absence, indicating a lapse in following the care plan. The facility's policies on translation and resident rights emphasized the importance of providing communication tools for residents with limited English proficiency. However, the lack of communication resources for Residents 148 and 40 demonstrated a failure to adhere to these policies, potentially impacting the residents' ability to communicate effectively and receive appropriate care.
Failure to Provide Specialty Mattress for Resident with Stage 4 Pressure Injury
Penalty
Summary
The facility failed to provide a specialty mattress for a resident with a Stage 4 pressure injury, as required by the resident's care plan and physician orders. The resident, who was readmitted to the facility with multiple diagnoses including a Stage 4 pressure injury, was observed without a low air loss mattress, which was necessary for treating his condition. Despite the care plan and orders indicating the need for such a mattress, the resident did not receive it upon his return from the hospital. Interviews with facility staff, including a licensed nurse, the Assistant Director of Nursing, and the Director of Nursing, confirmed the absence of the required mattress. The licensed nurse indicated that the hospice was expected to provide the mattress, although the facility had one available. The Assistant Director of Nursing and the Director of Nursing acknowledged that the resident should have been provided with a low air loss mattress, as per the facility's policy and procedure for pressure ulcer care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to implement pharmaceutical policies and procedures for a resident when calcium-vitamin D was not available during a medication pass. During an observation, a licensed nurse prepared and administered the resident's medications, which did not include the prescribed calcium with vitamin D. The physician's orders indicated that the resident should receive one tablet of calcium-vitamin D twice a day. However, the medication administration record showed that the morning dose was not administered on the observed date. In an interview, the licensed nurse stated that the calcium with vitamin D was not ordered on time, resulting in its unavailability during the medication pass. The Director of Nursing confirmed that medications should be ordered on time and available as prescribed. The facility's policy and procedure documents indicated that the facility must provide routine and emergency drugs and that medications are to be administered according to the physician's written orders.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for four residents, leading to dissatisfaction with meals. Resident 19 received sausage, which she disliked, and reported never being asked about her food preferences. Her dietary profile lacked documentation of likes and dislikes, confirmed by the Food Services Director. Similarly, Resident 77 was served scrambled eggs, which she disliked, and her dietary profile also lacked documentation of preferences. The Director of Nursing expected dietary profiles to be completed with good documentation upon admission. Resident 47's meal ticket indicated a dislike for carrots, yet her meal tray included them, resulting in her not eating the meal. The Medical Record Assistant confirmed this discrepancy. Resident 3, who was underweight with poor food intake, did not receive the Healthshake and Udon soup as per her dietary orders, instead receiving tomato soup. The Food Services Supervisor and Registered Dietician confirmed the oversight. The facility was unable to provide a policy and procedure for residents' food preferences.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention practices for three residents. Resident 47's oxygen and nebulizer tubing were not labeled or dated, which was confirmed by a Licensed Nurse (LN) and the Director of Nursing (DON). The facility's policy required that all tubing be labeled and dated, and changed every seven days or as needed. This oversight was identified during an observation and interview with LN 9, who acknowledged the tubing should have been dated. Resident 63, who had a sacral wound infected with Methicillin-resistant Staphylococcus aureus (MRSA), was subject to improper infection control practices during a bandage change. LN 7 did not change gloves after cleaning the wound and touched multiple items, including a pen and bedside table, with soiled gloves. LN 6 did not sanitize the pen after it was used by LN 7. Both nurses acknowledged the lapse in protocol, and the DON confirmed that hand hygiene was expected, especially given the presence of MRSA. Resident 35's oxygen tubing and face mask were found unlabeled and undated, which was confirmed by LN 3. The Infection Preventionist (IP) and the DON both stated that equipment should be labeled and dated immediately upon change. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 508 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenhaven Healthcare Center | 1.6 mi | — | 26 | 0 |
| Double Tree Post Acute Care Center | 2.7 mi | — | 22 | 0 |
| Capital Post Acute | 3 mi | — | 28 | 0 |
| Cedarwood Post Acute | 3.4 mi | — | 0 | 0 |
| Bridgewood Post Acute | 5.4 mi | — | 2 | 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 August 2026) and official state health department websites.