Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
2. Review of Resident 104's Minimum Data Set (MDS - an assessment tool used to guide care, dated
8/20/19, indicated Resident 104 was totally dependent on the assistance of one or two staff persons for
Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene).
Review of Resident 104's Physician Orders, dated 5/24/1,9 indicated an order for condom catheter for
related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention.
During an observation in Resident 104's room on 9/24/19, at 8:22 a.m., Resident 104's urinary catheter
drainage bag was hanging on the right side of his bed frame, facing the door, and the contents were visible
without a privacy bag to cover it.
In an interview immediately following the observation, Certified Nursing Assistant (CNA) 1 stated Resident
104's urinary catheter drainage bag should be placed in a privacy bag due to dignity issues.
Review of the facility's policy Quality of Life - Dignity, with revised date August 2009, indicated .Each
resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and
individuality .1. Residents shall be treated with dignity and respect at all times .2. 'Treated with dignity'
means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11.
Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote
dignity and assist residents as needed by .a. Helping the resident to keep urinary catheter bags covered
Based on observation, interview, and record review, the facility failed to ensure two of four sampled
residents (Residents 36 and Resident 104) were treated with dignity and respect when:
1. Certified Nursing Assistant (CNA) 7 entered Resident 36's room without knocking and/or without
permission. This failure resulted in Resident 36 feeling mad that his privacy was not respected.
2. Resident 104's urinary catheter (small flexible tube inserted through the urethra and into the bladder to
drain urine) drainage bag was not covered by a urinary catheter drainage bag cover. For Resident 104, this
failure had the potential to result in the loss of dignity.
Findings:
1. Review of Resident 36's Minimum Data Set (MDS - an assessment tool used to guide care), dated
3/6/19, indicated Resident 36 was totally dependent on the assistance of one or two staff persons for
Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene). The MDS
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 16
Event ID:
056479
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
also indicated Resident 36's Brief Interview for mental status was 15 (indicated he was able to recall words,
repeat words and knew the correct year, date and month).
During an observation and joint interview on 9/23/19, at 10:21 a.m., CNA 7 entered Resident 36's room
without knocking and without asking for permission. CNA 7 stated she thought it was okay to enter
Resident 36's room without knocking and asking permission because Resident 36's curtain was open, and
he could see her standing in the doorway.
During an interview with Resident 36 on 9/23/19, at 10:25 a.m., Resident 36 stated he was mad and felt his
privacy was not respected when CNA 7 entered his room with knocking and asking permission.
During an interview with the Clinical Instructor (CI) on 9/26/19, at 11:34 a.m., CI stated the staff should
treat residents with dignity and respect.
Review of the facility's policy and procedure titled Quality of Life - Dignity, revised 8/2009, indicated .6.
Residents' private space and property shall be respected at all times. a. Staff will knock and request
permission before entering resident's room
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 2 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
Based on interview and record review, for one of 27 (Resident 51) sampled residents, the facility failed to
inquire about Advance Directive (a legal document in which a person specifies what actions should be
taken for their health if they are no longer able to make decisions for themselves because of illness or
incapacity) from Resident 51 and/or their representative.
This failure had the potential to result in Resident 51 not receiving care in accordance with his wishes.
Findings:
Review of the annual Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/21/19,
indicated Resident 51's Brief Interview for mental status was 15 (indicated he was able to recall words,
repeat words and knew the correct year, date and month).
During a review of the medical record for Resident 51, the Physician Orders for Life-Sustaining Treatment
(POLST) form, signed 7/29/19, indicated Section D - Information and Signatures regarding Advance
Directives was left unanswered.
Review of Resident 51's quarterly Minimum Data Set (MDS - an assessment tool used to direct care),
dated 6/21/19, indicated the advance directive section was not completed. Further review of the MDS
indicated resident 51 had the ability to clearly think, reason, and remember.
During an interview with Resident 51 on 9/26/19 at 11:36 a.m., he stated that no one from the facility had
talked to him about an advance directive prior to 9/25/19. He stated he was interested in receiving
information about one.
Review of Resident 51's Resident Care Conference, dated 7/22/19, indicated the advance directive
question had not been answered for Resident 51.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/24/19
at 9:54 a.m., ADON stated that the advance directive was addressed with residents and their
representatives during the initial resident care conferences and when needed. ADON stated Resident 51's
advance directive should have been addressed during his initial resident care conference.
Review of facility's policy and procedure titled Advance Directives, revised 5/2019, indicated .2. Upon
admission, the resident will be provided with written information concerning the right to refuse or accept
medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .2. If the
resident is incapacitated and unable to receive information about his or her right to formulate an advance
directive, the information may be provided to the resident's legal representative .5. Prior to or upon
admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family
members and/or his or her legal representative, about the existence of any written advance directives. 6.
Information about whether or not the resident has executed an advance directive shall be displayed
prominently in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 3 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0636
Level of Harm - Potential for
minimal harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of
Resident 9's Face Sheet indicated resident was admitted to the facility on [DATE].
Residents Affected - Some
Review of the Minimum Data Set (MDS - an assessment tool used to direct care) indicated the last Annual
MDS was done on 7/18/18 and the next Annual MDS was due on 7/18/19. Resident 9's Annual Assessment
was still open, was not completed, and was more than 120 days overdue.
During a concurrent interview and record review on 9/25/19, at 8:38 a.m., MDSC stated Residnet 9's
Annual MDS Assessment was still open and has not been completed.
Review of the facility's policy Resident Assessment Instrument, with revised date September 2010
indicated, .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment
Team conduct timely resident assessment and reviews according to the following schedule .d. Once every
twelve months
Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set
assessments (MDS - an assessment tool used to guide care) for five of 27 sampled residents (Residents
259, 260, 25, 17, and 9) within the regulatory specified timeframes when:
1. the Minimum Data Set Coordinator (MDSC) did not complete the admission MDS assessment for
Resident 259 and 260 within 14 calendar days of their respective admission to the facility.
2. the MDSC did not complete the annual MDS for Resident 25, 17, 21, and 9 within 12 months of their
respective previous annual MDSs.
This deficient practice had the potential to delay care planning for Residents 259, 260, 25, 17, and 9.
Findings:
1. Review of the Resident 259's Face Sheet, printed 9/24/19, indicated Resident 259 was admitted to the
facility on [DATE].
Review of Resident 259's MDS record, indicated Resident 259's admission MDS had a reference date of
7/22/19, and the MDS was not completed within 14 calendar days of Resident 259's admission to the
facility.
2. Review of the Resident 260's Face Sheet, printed 9/24/19, indicated Resident 260 was admitted to the
facility on [DATE].
Review of Resident 260's MDS record, indicated Resident 260's admission MDS had a reference date of
7/30/19, and the MDS was not completed within 14 calendar days of Resident 260's admission to the
facility.
During an interview on 9/24/19, at 9:55 a.m., MDSC stated Resident 259's and Resident 260's admission
MDSs were not completed due to her workload. MDSC stated the work flow process at the facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 4 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0636
Level of Harm - Potential for
minimal harm
Residents Affected - Some
was meant for two MDSCs, and she could not keep up with the work flow. MDSC stated the admission
MDSs should have been completed by day fourteen of Resident 259's and Resident 260's stay.
The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The
Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct
timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days
of the resident's admission to the facility; d. once every twelve (12) months
3. Review of Resident 25's Facesheet, printed 9/26/19, indicated Resident 25 was admitted to the facility in
2016.
During an interview and concurrent record review on 9/25/19, at 1:35 p.m., Minimum Data Set Coordinator
(MDSC) stated she performed the MDS assessments for the facility. MDSC stated Resident 25's MDS
annual comprehensive assessment was due on 8/12/19. MDSC stated she completed Resident 25's MDS
annual assessment on 8/26/19, which was (14 days) late.
4. Review of Resident 17's Facesheet, printed 9/26/19, indicate Resident 17 was admitted to the facility in
2015.
During an interview and concurrent record review on 9/25/19, at 1:35 p.m., MDSC stated Resident 17's
MDS annual comprehensive assessment was due on 7/29/19. MDSC stated she completed Resident 17's
MDS annual assessment on 9/26/19, which was (59 days) late.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 5 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Assess the resident when there is a significant change in condition
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, for one (Residents 27) of 27 sampled residents the facility failed to ensure a
Minimum Data Set (MDS - a resident assessment tool used to guide care) Significant Change in Status
Assessment (SCSA - major decline or improvement in a resident's status) was done within 14 days after it
was determined. Minimum Data Set Coordinator (MDSC) completed Resident 27's SCSA 64 days after it
was due.
Residents Affected - Some
This deficient practice had the potential to result in Resident 27 not receiving care based on their current
health status.
Findings:
Review of Resident 27's Face Sheet, printed 9/20/19, indicated Resident 27 was admitted to the facility on
[DATE].
During an interview on 9/26/19, at 8:30 a.m., MDSC stated Resident 27's SCSA was completed late
because she had to facilitate care conferences and review charts before care conferences occurred. MDSC
stated Resident 27's SCSA could not be completed until after the care conference had occurred. MDSC
stated it was too much work, not enough time and help to complete the assessment on time.
Review of Resident 27's Minimum Data Set (MDS - an assessment tool to direct resident care) records,
indicated Resident 27 had a SCSA comprehensive assessment reference date of 7/22/19 and was
completed on 9/24/19 (64 days late).
The facility's policy and procedure titled Change in a Resident's Condition or Status, revised 5/2017,
indicated .9. If a significant change in the resident's physical or mental condition occurs, a comprehensive
assessment of the resident's condition will be conducted as required by current OBRA regulations
governing resident assessments and as outlined in the MDS RAI Instruction Manual
The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The
Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct
timely resident assessments and reviews according to the following schedule: b. When there has been a
significant change in the resident's condition
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 6 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0638
Assure that each resident’s assessment is updated at least once every 3 months.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of
Residents 1, 12, 15, 18 and 77's record on 9/26/19, at 12 p.m., indicated the following:
Residents Affected - Some
a. Resident 1's quarterly MDS dated [DATE] was completed 9/24/19 (85 days late);
b. Resident 12's quarterly MDS dated [DATE] was completed 9/24/19 (82 days late);
c. Resident 15's quarterly MDS dated [DATE] was completed 9/25/19, (83 days late);
d. Resident 18's quarterly MDS dated [DATE] was completed 8/15/19, (17 days late), and;
e. Resident 77's quarterly MDS dated [DATE] was completed 9/26/19, (67 days late).
Review of the facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010,
indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment
Team conduct timely resident assessments and reviews according to the following schedule: c. At least
quarterly
Based on interview and record review, for 13 of 27 (Resident 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77)
sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment too
used to direct care) Assessments in the regulatory specified manner.
This failure had the potential for Residents 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77 to not receive care
and services needed based on their current health status.
Findings:
1. Review of Resident 2's the Face Sheet, printed 9/26/19, indicated Resident 2 was admitted to the facility
on [DATE].
Review of Resident 2's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on
9/24/19 (84 days late).
2. Review of Resident 4's the Face Sheet, printed 9/26/19, indicated Resident 4 was admitted to the facility
on [DATE].
Review of Resident 4's Quarterly MDS assessment indicated it was due on 7/10/19 and completed on
9/24/19 (76 days late).
3. Review of Resident 7's Face Sheet, printed 9/26/19, indicated Resident 7 was admitted to the facility on
[DATE].
Review of Resident 7's MDS Quarterly MDS Assessment indicated it was due on 7/3/19 and completed on
9/24/19 (84 days late).
4. Review of Resident 10's Face Sheet, printed 9/26/19, indicated Resident 10 was admitted to the facility
on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 7 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0638
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Review of Resident 10's Quarterly MDS assessment indicated it was due on 7/11/19 and completed on
9/24/19 (76 days late).
During an interview and concurrent record review of Residents 2, 4, 7, 10's last MDS Assessments on
9/25/19 at 8:38 a.m., the MDSC was unable to show completed MDS quarterly reviews, based on each of
the residents' assessment reference dates. MDSC stated all MDSs for the (Quarterly) MDS assessments
for Residents 2, 4, 7, 10's were either still open, completed late, and/or transmitted late.
7. Review of Resident 6's Face Sheet, printed 9/20/19, indicated Resident 6 was admitted to the facility on
[DATE].
Review of Resident 6's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on
9/24/19 (85 days late).
8. Review of the Resident 22's Face Sheet, printed 9/20/19, indicated Resident 22 was admitted to the
facility on [DATE].
Review of Resident 22's Quarterly MDS assessment indicated it was due on 7/31/19 and completed on
9/24/19 (56 days late).
During an interview on 9/26/19 at 8:30 a.m., MDSC stated Resident 6's and Resident 22's
Quarterly MDSs were completed late.
5. Review of Resident 8's Facesheet, printed 9/26/19, indicated Resident 8 was admitted to the facility in
2015.
During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS
indicated it was due on 7/9/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS
assessment on 9/26/19, which was (80 days) late.
6. Review of Resident 14's Facesheet, printed 9/26/19, indicated Resident 14 was admitted to the facility in
2018.
During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS
indicated it was due on 7/16/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS
assessment on 9/26/19, which was (73 days) late.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 8 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, for one (Resident 94) of 27 sampled residents, the facility failed
to develop and implement comprehensive care plans to address medical and nursing needs of the
residents when there was no comprehensive care plan to address indwelling catheter.
This failure had the potential to result in delayed or unrecognized catheter related adverse affects.
Findings:
Review of the Resident Face Sheet, not dated, indicated Resident 94 was admitted to the facility on [DATE].
Review of the annual Minimum Data Set (MDS-an assessment tool used to guide care), dated 5/18/19,
indicated Resident 94 had an indwelling urinary catheter (a flexible tube that is inserted into the bladder to
drain urine).
Review of Resident 94's physician's orders, dated 9/26/19, indicated Resident 94 had an order for a
suprapubic catheter.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/25/19
at 12:08 p.m., ADON stated she could not find in Resident 94's medical record a care plan that addressed
his indwelling urinary catheter. ADON stated Resident 94 needed a care plan that addressed the indwelling
urinary catheter.
Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised
12/2016, indicated .12. The comprehensive, person-centered care plan is developed within seven (7) days
of the completion of the required comprehensive assessment (MDS)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 9 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on interview and record review, the facility did not provide competency training to provide services
for dialysis-dependent (dialysis - a process where a machine filters the blood of wastes when the kidneys
are not healthy enough to do it) residents in accordance with the facility assessment.
This failure had the potential to result in dialysis-dependent residents receiving inappropriate care and
services.
Findings:
Review of the Facility Assessment last reviewed 7/12/19 indicated the average number of residents on
special treatments and conditions included 6-10 residents who were on hemodialysis (also known as
dialysis). Staff training/education and competencies needed to provide level of requirements were also
included in the facility assessment. The nursing staff skill sets that were evaluated annually included
specialized care such as dialysis.
During an interview and concurrent review of competency trainings with Clinical Instructor (CI) on 9/26/19
at 10:36 a.m., CI stated she had just started work in June 2019 and has not given competency training on
dialysis care and management to licensed nurses.
During an interview with Director of Nursing (DON) on 9/26/19 at 11:57 a.m., DON stated there was no
competency training provided to licensed nurses recently. DON stated the last training provided was in
2017. DON stated training should be provided every year because of the resident population and
characteristics that the facility had.
(Refer to F760 for additional information regarding Residents 49 and 76)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 10 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review, for one of 24 (Resident 65) sampled residents, the facility failed to
consistently monitor Resident 65's behaviors and side effects related to the use of psychotropic (capable of
affecting the mind, emotions, and behaviors) medications during the months of July 2019, August 2019,
and September 2019.
For Resident 65, this deficient practice had the potential to result in the physician receiving and using
inaccurate information to make decisions regarding the need to continue, increase, or decrease of the use
of psychotropic medications.
Findings:
Review of Resident 65's Face Sheet indicated Resident 65 was admitted to the facility with diagnoses that
included Traumatic Brain Injury Assault (an injury to the brain caused by an impact such as a road traffic
incident, assault, or fall).
Review of Resident 65's Minimum Data Set (MDS - an assessment tool used to direct care), dated 7/16/19,
indicated Resident 65 had diagnoses that included a severe chronic mental disorder and depression.
Review of Resident 65's Physician Orders (PO) indicated Resident 65 was to receive the following:
a. Haldol, order dated 5/30/19, for a severe chronic mental disorder manifested (m/b) by auditory
hallucination and talking to self;
b. Trazadone (Desyrel), order dated 5/27/19, for insomnia associated with depression m/b sleeplessness,
and;
c. Sertraline (Zoloft), order dated 5/30/19, for depression.
Review of Resident 65's Medication Administration Records (MARs), dated July 2019, August 2019, and
September 2019, indicated that there was inconsistent monitoring of Resident 65's behaviors for the use of
Haldol and Sertraline, and inconsistent monitoring of Resident 65's time spent sleeping related to the use
of Trazadone on multiple days and across multiple shifts (days, afternoon, and night shifts). The MARs also
indicated there was inconsistent monitoring of side effects related to Resident 65's use of Sertraline on
multiple days and across multiple shifts (days, afternoon, and night shifts).
During an interview and concurrent record on 9/26/19, at 8 a.m., Registered Nurse (RN) 4 stated Resident
65's behavior and side effect monitoring was not consistent for multiple days and across multiple shifts from
July to September 2019. RN 4 stated it was important to monitor the (Resident 65's) behaviors and
presence of side effects during psychotropic drug use in order (for the physician) to know the need for
continued use, increase, or decrease of the psychotropic medications.
In an interview with the Director of Nursing (DON) on 9/26/19 at 12:20 p.m., and concurrent record review
of Resident 65's MAR from July to September 2019, DON stated some of the licensed nurses were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 11 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
noncompliant with the behavior and side effects monitoring documentation for resident's psychotropic drug
use from July to September 2019. DON stated the Interdisciplinary Team's (IDT's) recommendations for the
psychotropic drugs' Gradual Dose Reduction (GDR) were based on the identified number of incidents of
behavior manifestations and medication side effects monitored.
Review of the facility's policy and procedure titled, Antipsychotic Medication Use, with revised date
December 2018, indicated .Antipsychotic medications may be considered for residents with dementia but
only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental
cause of behavioral symptoms have been identified and addressed. Antipsychotic medications will be
prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose
reduction and re-review
Event ID:
Facility ID:
056479
If continuation sheet
Page 12 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, for two of 27 sampled residents (Residents 49 and 76
and 94), the facility failed to ensure Residents 49 and 76 were free of significant medication errors when:
Residents Affected - Some
1. Resident 49 did not receive Renvela (a phosphate binder medication that prevents the absorption of
phosphorus in the blood) as ordered by the physician, and;
2. Resident 76 did not receive Renagel (a type of phosphate binder) and Lomotil (medication to treat
diarrhea) as ordered by the physician.
For Residents 49 and 76, this failure had the potential to result in increased phosphorus levels adverse
effects (e.g. body changes that pull calcium out of your bones, making them weak).
For Resident 76, this failure had the potential to result in dehydration.
Findings:
1. Review of Resident 49's nutrition care plan, last reviewed 9/12/19, indicated the goal was for Resident 49
to have blood phosphorus (a mineral) level between 3 - 5.5 milligrams/deciliter (mg/dL). One of the
approaches was for licensed nurses to give medications as ordered.
Review of Resident 49's physician's orders indicated Resident 49 went to dialysis every Monday,
Wednesday, and Friday around lunch time. The physician's orders indicated for Resident 49 to receive one
0.8-gram packet of Renvela by mouth three times daily with meals.
During an interview and concurrent review on 9/25/19, at 10:08 a.m., Director of Nursing (DON) stated
Resident 49's MAR Medication Administration Record (MAR) for September 2019 did not indicate that
Resident 49 receive Renvela as an as needed (PRN) medication. The MAR indicated from 9/3/19 until
9/9/19, there was no information whether Resident 49 received Renvela. The MAR also indicated there
were seven out of 48 possible doses that Resident 49 did not receive in September 2019.
2. Review of Resident 76's facesheet, printed 9/24/19, indicated Resident 76 was admitted to the facility
with diagnoses that included kidney failure.
Review of Resident 76's Minimum Data Set (MDS - an assessment tool used to guide care), dated 5/24/19,
indicated Resident 76 had the ability to clearly think, reason, and remember.
Review of Resident 76's physician's orders indicated Resident 76 was to receive 1600 milligrams (mg) of
Renagel three times daily with meals.
Review of Resident 76's chronic kidney disease care plan last reviewed 7/30/19 indicated for licensed staff
to administer phosphate binder per physician's order.
During an interview and concurrent review on 9/25/19, at 12:06 p.m., Infection Preventionist (IP) stated
there was no documentation in Resident 76's MAR that a breakfast dose of Renagel was administered to
Resident 76. Resident 76's MAR indicated on days that Resident 76 went to dialysis, the breakfast dose for
Renagel indicated not administered, patient off the floor. The MAR indicated Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 13 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
76 did not receive 11 out of 76 possible doses of Renagel.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 9/23/19, at 11:12 a.m., Resident 76 stated she had not been able to eat well
because of diarrhea.
Residents Affected - Some
During an interview on 9/23/19 at 11:12 a.m., Certified Nursing Assistant (CNA) 5 stated Resident 76 had
been having diarrhea, which was known by licensed staff. CNA 5 stated when Resident 76 had two
episodes of loose stools in one shift, the licensed nurses were notified so they could give Resident 76
anti-diarrhea medication.
Review of Resident 76's Medication Administration Record (MAR), printed 9/24/19, indication Resident 76
was to receive 2.5 milligrams (mg) of Lomotil two times per day as needed for diarrhea. The MAR
In an interview and concurrent record review on 9/24/19, at 1:23 p.m., Resident 76's bowel movement
record indicated she had large, thin bowel movements on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19 and
9/22/19. Registered Nurse (RN) 3 stated Resident 76's bowel movement record indicated Resident 76 had
(multiple) episodes of diarrhea. RN 3 stated large, thin bowel movement meant large, watery or loose bowel
movement.
Review of Resident 76's MAR, printed 9/24/19, indicated that Resident 76 did not receive Lomotil when she
had large, thin bowel movements (diarrhea) on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19, and 9/22/19.
(Refer to F726 for additional information regarding dialysis dependent residents)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 14 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, for two of four sampled residents (Residents 104 and
107) the facility failed to implement their infection prevention and control policy and procedures when:
Residents Affected - Some
1. Resident 104's indwelling catheter uncovered drainage bag was touching the floor, and;
2. Registered Nurse (RN) 3 did not perform hand hygiene (general term that applies to hand washing,
antiseptic hand wash, and alcohol-based hand rub)
hands between glove changes and touched clean gauze with bloody gloves.
For Residents 104 and 107, these deficient practices had the potential to result in the spread of infection.
Findings:
1. Review of Resident 104's Physician Orders, dated 5/24/19, indicated Resident 104 had a condom
catheter related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention.
During an observation on 9/24/19, at 8:22 a.m., Resident 104's uncovered urinary catheter drainage bag
was touching the floor.
In an interview on 9/24/19, at 8:22 a.m., Certified Nursing Assistant (CNA) 1 stated urinary catheter
drainage bag should not be touching the floor to prevent cross-contamination.
Review of the facility's policy and procedure titled, Catheter Associated Urinary Tract Infection (CAUTI)
Prevention Policy, revised 8/2015, indicated .Patients with indwelling catheters will receive care compliant
with recommended strategies to prevent Catheter Associated Urinary Tract Infection (CAUTI) under the
professional medical judgement of the provider .Proper techniques for Urinary Catheter Maintenance .Do
not rest the bag on the floor
2. Review of Resident 107's Minimum Data Set (MDS - an assessment tool used to guide care), dated
8/28/19, indicated Resident 107 had multiple diagnoses that included left and right hip pressure ulcers
(opening over the bony area caused by pressured) at Stage 4 (an advance level).
Review of Resident 107's physician's orders, not dated, indicated directions to cleanse the left and right
ischial tuberosity (hip) wounds daily with Theraworx (a cleaning solution), place Theraworx to moisten
Drawtex (gauze), apply on wound bed and cover with Optifoam (foam) dressing until healed.
During an observation of Resident 107's left and right hip pressure ulcers wound treatment with RN 3 on
9/25/19 at 10:44 a.m., RN 3 cleaned Resident 107's bloody wound beds with Theraworx. After RN 3
cleaned the bloody wound beds, without changing gloves, she pat the wounds dry with clean gauze. Then
RN 3, with bloody gloves, applied clean gauze and foam dressing over the wounds. After applying the clean
dressings, RN 3 removed her gloves and sanitized her hands.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056479
If continuation sheet
Page 15 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056479
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/26/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alameda County Medical Center D/P Snf
15400 Foothill Boulevard
San Leandro, CA 94578
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During an interview with RN 3 on 9/25/19, at 11:13 a.m., RN 3 stated she should have changed her soiled
gloves before touching clean gauze during wound care.
During an interview with the Infection Prevention and Control Nurse (IPCN) on 9/25/19, at 11:04 a.m., she
stated during wound care after cleaning a wound and gloves are soiled, the gloves should be changed
before touching clean supplies. IPCN stated hands should be sanitized after removing gloves.
Event ID:
Facility ID:
056479
If continuation sheet
Page 16 of 16
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the September 26, 2019 survey of ALAMEDA COUNTY MEDICAL CENTER D/P SNF?
This was a inspection survey of ALAMEDA COUNTY MEDICAL CENTER D/P SNF on September 26, 2019. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALAMEDA COUNTY MEDICAL CENTER D/P SNF on September 26, 2019?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.