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Complaint Investigation

Katherine Healthcare

March 27, 2026 · Salinas, CA · 315 Alameda Avenue
Citations 2
CMS Rating 2/5
Beds 51
Provider ID 055311
Healthcare Facility
Katherine Healthcare
Salinas, CA  ·  View full profile →
Inspection Summary

KATHERINE HEALTHCARE in SALINAS, CA — inspection on March 27, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0602
Freedom from Abuse, Neglect, and Exploitation Deficiencies

rights include the resident's right to be free from.misappropriation of property.

Review of the facility's

property.

055311 03/27/2026

Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901

services of a licensed pharmacist.

three residents (Resident 1) when there was no accurate accountability of the controlled medication

milligram (mg, unit of measurement) tablet.This failure resulted in Resident 1 not receiving two doses of the controlled medication.Findings:

During an interview with Registered Nurse (RN) A, on 12/2/25 at 1:30 p.m., RN A stated he was counting the narcotics (used to treat moderate to severe pain) in the Station 2 medication cart with the night shift nurse (RN B) on 11/30/25. RN A stated he could not find a bubble pack containing the medication named Lorazepam (a controlled medication used to treat severe anxiety) 0.5 milligrams (mg, unit of measurement) for Resident 1. RN A stated three medication carts and 48 resident rooms were checked but were not able to find the medication. RN A called the pharmacy on 11/30/25 for a replacement of the medication.

Per RN A pharmacy stated refill of the medication was too early and will need authorization from the Director of Nursing (DON). RN A stated the replacement medication was received on 12/2/25. RN A confirmed Resident 1 missed two doses of the medication Lorazepam tablet 0.5 mg give 1 tablet on 11/30/25 and 12/1/25 at 9 a.m.Review of Resident 1's physician's order, dated 9/24/25, indicated lorazepam oral tablet 0.5 mg give 1 tablet by mouth (taken orally) one time a day for anxiety (feeling of fear, worry or uneasiness) as evidenced by repetitive questions/verbalizations.Review of Resident 1's Medication Administration Record (MAR, a record of prescribed medications) indicated lorazepam was documented as not administered on 11/30/25 and 12/1/25.During a concurrent interview and record review with the DON, on 12/2/25 at 12:50 p.m., the DON confirmed Resident 1's Lorazepam medication was missing during RN B's night shift on 11/29/25.

The DON confirmed that Resident 1 missed the dose of the medication on 11/30/25 and 12/1/25 at 9 a.m.During a concurrent observation and interview with the DON on 12/2/25 at 3:05 p.m., the DON confirmed there were no lorazepam in the five E-kits (Emergency Kits, a kit/box containing medications and supplies for immediate use during a medical emergency).

Review of the facility's policy and procedure (P&P), titled Controlled Substances, dated 4/19, indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SALINAS, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KATHERINE HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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