Blue Oak Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 850 Sonoma Ave, Santa Rosa, California 95404
- CMS Provider Number
- 056090
- Inspections on file
- 33
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Blue Oak Post-acute during CMS and state inspections, most recent first.
The facility failed to implement timely and effective care plan interventions to prevent multiple episodes of resident-to-resident physical abuse among residents with severe mental illness. In one case, a resident with a known history of aggression punched another resident in the head during a med pass, causing pain, swelling, and redness. In a separate incident, the same resident struck and kicked another resident on the patio, resulting in an ear abrasion with bleeding. In a third event, a resident with a known history of physical aggression hit another resident on the chin after a dispute over shower order, leading to pain and skin redness. Documentation showed delayed updating of the aggressive resident’s care plan related to the altercation, and leadership acknowledged that care plans and abuse-related documentation must be individualized and completed timely so staff are aware of residents’ current needs and events.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident with difficulty walking and muscle weakness had a fall care plan that required the bed to be kept in the lowest position after an unwitnessed fall. During observation, the resident’s bed was found not in the lowest position while a sitter and an LN were present. The sitter admitted forgetting to lower the bed and acknowledged the importance of this intervention, while the LN confirmed the care plan requirement and that the resident was at high fall risk with multiple prior falls. The DON verified that the fall care plan specified the bed be in the lowest position and stated that such interventions must be followed, consistent with the facility’s falls management policy.
Two residents experienced ineffective call light function when one resident with Parkinson’s disease and malaise waited an extended period after activating a pendant call light that produced only a faint beep audible at the nursing station, and another resident with difficulty walking and muscle weakness activated a call light that did not illuminate the hallway door light. Staff, including an LPN, were aware that one call light was barely audible away from the nurses’ station but did not report it, and the other call light was confirmed to be broken. Leadership and maintenance staff acknowledged that the call light system was not working as intended, despite a facility policy requiring immediate reporting and response to call light problems.
The facility failed to complete and submit required five-day written investigation reports to CDPH for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. Although the initial allegations were reported to CDPH, the new ADM could not locate any investigation files or evidence that follow-up reports were sent, and the DON did not know if the investigations were completed. This occurred despite a facility policy requiring the ADM to initiate investigations and provide a follow-up report within five business days to ensure the events were investigated and safety interventions were identified.
Two residents did not receive care and monitoring consistent with professional standards and facility policy. A cognitively intact resident with multiple comorbidities reported being physically grabbed, and staff documented only general skin discoloration on the right forearm without completing a detailed skin integrity assessment at the time of the allegation; a more specific skin/wound note was not entered until several days later, despite visible bruising on later observation. Another cognitively intact resident with DM and vascular dementia exhibited increased agitation, physical aggression, and wandering, was placed on 72-hour monitoring, and had a care plan reflecting adverse behaviors and the need for such monitoring, but nursing staff failed to document required 72-hour monitoring every shift, with only two of nine expected progress notes completed.
Two residents were physically assaulted by other residents, resulting in one experiencing mild facial pain and fear. Both aggressors and victims had psychiatric diagnoses but no memory impairment. Facility staff confirmed the incidents as physical abuse, and documentation showed the facility did not prevent these occurrences, violating residents' rights to be free from abuse.
A resident with a diagnosis of Paranoid Schizophrenia was forced by a CNA and an unlicensed staff member to unclog her own toilet containing urine and feces with gloved hands, while the room door was left open despite her request for privacy. This incident caused the resident to feel embarrassed, humiliated, and victimized, constituting psychological abuse.
The facility did not follow its abuse investigation policy by failing to interview other residents who may have been affected by an alleged abuse incident. Only a single resident was interviewed, and both the DBH and Administrator confirmed that no additional resident interviews were conducted, which prevented identification of other potentially affected individuals.
A resident with a history of stroke and anxiety became agitated by another resident's noise and threw a pitcher of water at them. The incident was confirmed through interviews and documentation, and the facility's policy requires protection of residents from abuse by anyone, including other residents.
A resident experiencing pain was physically assisted from the hallway floor to bed by an LN, despite repeatedly refusing consent and asking not to be touched. The LN did not comply with the resident's requests, and other staff confirmed that this action violated the resident's rights to dignity and self-determination as outlined in facility policy.
A resident reported physical abuse by a licensed nurse, but the facility did not notify law enforcement within the required two-hour window. Staff interviews and record reviews confirmed the delay, which was not in accordance with facility policy or regulatory requirements.
A medication cart was found unlocked and unattended, with no nurse present, until a nurse returned and secured it. The nurse admitted to leaving the cart unlocked while accompanying the DON, and both the DON and another nurse confirmed that medication carts must be locked when unattended, as required by facility policy.
A resident recovering from surgery and with mobility challenges was left on a soiled bedpan for hours after multiple unanswered call light activations, due to a communication breakdown between CNAs during a shift change. Staff interviews and facility policy reviews confirmed that this failure compromised the resident's dignity and did not meet expected standards for prompt toileting assistance.
A resident alleged mistreatment by a staff member, and while the administrator investigated the claim, a required five-day follow-up investigation report was not submitted to the Department due to the administrator's lack of awareness of this reporting requirement. This failure resulted in the Department not receiving timely information about the incident.
A resident with multiple mental health diagnoses and cognitive impairment did not receive a required Level II PASRR evaluation after a positive Level I screen. Facility staff were unclear on PASRR procedures, and the absence of a specific policy led to the resident missing a comprehensive mental health assessment and access to appropriate resources.
Staff did not consistently perform or offer hand hygiene to residents after meals, nor did they perform hand hygiene before preparing medications or before and after glove use, despite facility policy requiring these actions. Staff and management interviews confirmed awareness of the policy and acknowledged the lapses during the observed incidents.
Surveyors found that the facility failed to properly dispose of discontinued and unused medications, including leaving medications for discharged residents in a medication room refrigerator, placing discontinued medications in resealable bags in disposal bins, and storing discontinued medications among active ones in a medication cart. LNs confirmed the medications were for discharged or current residents with discontinued orders, and records supported these findings. The facility's actions did not follow its own policies for medication destruction and storage.
The facility did not notify the LTC Ombudsman or provide evidence of notification for 42 residents who were discharged or transferred to the hospital by facility initiation. Staff interviews revealed that the behavioral unit had never notified the ombudsman, with some staff unaware of the requirement. Facility policy and state regulations require such notifications, but no documentation was found in the health records.
A resident with severe memory impairment and a history of stroke eloped from the facility and sustained injuries due to inadequate supervision. Despite being assessed as a low risk for wandering, the resident exhibited wandering behavior, leading to the initiation of an elopement care plan and the use of a wandering device (WMD). However, the WMD was improperly placed on the resident's wheelchair, and the resident was later found outside with injuries. The facility acknowledged a breakdown in supervision and risk assessment.
Failure to Implement Effective Care Plan Interventions to Prevent Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations, by not implementing effective, individualized nursing care plan interventions. Several residents with severe mental illness and known histories of aggression were involved. One resident, admitted in 2017 and readmitted with a diagnosis of severe mental illness, had a known history of aggression toward peers prior to his current admission. During a medication pass, this resident suddenly began punching another resident in the head and face with a closed fist. The assaulted resident’s care plan for skin integrity documented swelling and redness to the back right side of his head after being hit, with a goal for the redness and swelling to decrease. The assaulted resident later recalled the incident, indicated pain in the area where he was struck, and stated he wanted to be discharged when asked if he felt safe. In a separate incident, an unlicensed staff member reported hearing commotion on the patio and finding the same aggressive resident kicking another resident who was on the ground. Other staff reported that the aggressive resident attacked without provocation, initially striking the resident on the head and then kicking him in the torso until staff intervened. A progress note documented a head-to-toe assessment of the assaulted resident, noting an abrasion with bleeding on the right ear, which was cleaned, and the injury was reported to the physician and wound care nurse. These events occurred in the context of multiple residents with severe mental illness residing in the facility, and the facility’s abuse reporting and prevention policy stated that staff and physicians would help identify risk factors for abuse, such as significant numbers of residents with unmanaged problematic behaviors. Another incident involved two different residents, both with severe mental illness, where one resident with a known history of physical aggression struck another resident on the chin after becoming upset about not being able to shower first. A change-in-condition assessment documented that the aggressive resident hit the other resident, and a mandated abuse report (SOC-341) indicated that a nurse witnessed the incident. The assaulted resident’s MAR showed administration of acetaminophen for pain, and his care plan documented that he experienced abuse when struck on the chin, resulting in a skin injury with redness and placing him at risk for emotional distress and psychosocial decline. The care plan for the aggressive resident related to this altercation was created 19 days after the incident, and the ADON acknowledged that nursing care plans must be updated timely with appropriate resident-specific interventions during changes in condition, and that delayed or backdated documentation can place residents at risk for harm because staff may be unaware of current needs or events. The DON and Administrator also acknowledged the purpose of individualized care plans and the requirement for timely documentation of alleged abuse incidents, consistent with facility policies on abuse prevention and resident rights to be free from abuse and neglect.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Implement Fall Care Plan Intervention for Bed in Lowest Position
Penalty
Summary
Surveyors identified a deficiency in the implementation of a fall care plan for Resident 3. Resident 3 was admitted on 3/4/26 with diagnoses of difficulty walking and muscle weakness. Following an unwitnessed fall, a Fall Care Plan dated 3/31/26 specified that the resident’s bed was to be kept in the lowest position as an intervention. During an observation on 4/2/26 at 3:38 p.m., surveyors found the resident’s bed was not in the lowest position, despite the presence of sitter D and Licensed Nurse (LN) E in the room. LN E confirmed that the care plan required the bed to be in the lowest position, and sitter D acknowledged that the bed was not in the lowest position at that time. In interviews, sitter D stated it was important for the bed to be in the lowest position to prevent the resident from hurting himself if he fell and admitted she had forgotten to lower the bed earlier. LN E stated that the resident was at high risk for falls, had already experienced multiple falls, and that the care plan intervention to keep the bed in the lowest position was intended to decrease the risk of injury when the resident falls. During a concurrent interview and record review, the DON verified that the Fall Care Plan included the intervention to keep the bed in the lowest position and stated that fall care plan interventions are put in place for a reason and must be followed, adding that she expected the bed to be in the lowest position unless staff were performing care. The facility’s Falls and Fall Risk, Managing policy indicated that staff, in conjunction with the attending physician, will identify and implement relevant interventions to minimize serious consequences of falling.
Failure to Maintain Effective Call Light Function for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective call light system that allowed residents to directly communicate with staff when assistance was needed. One resident with Parkinson’s disease and malaise, who had a BIMS score of 15 indicating no memory issues, used a pendant call light to request help and waited approximately 21 minutes without staff response. Observation in the hallway outside this resident’s room revealed no audible alert, and only a faint beep could be heard at the nearby nursing station. The Director of Staff Development and the Maintenance Director confirmed that the call light’s volume was too low to be heard unless staff were at the nursing station, and a licensed nurse acknowledged that staff had been aware of this issue but she had not reported it to a supervisor or maintenance, despite recognizing that the faint alert meant there was a significant chance no one would respond. A second resident, admitted with difficulty walking and muscle weakness and having a BIMS score of 12 indicating moderate cognitive impairment, also experienced problems with the call light system. When this resident pressed the call light, the light above the door that should illuminate did not turn on, and the resident reported that staff had not answered the call light the previous night or that morning. The Director of Staff Development and the Maintenance Director verified that this resident’s call light was broken and that the door light failed to illuminate when activated. The facility’s undated policy on call lights stated that staff must report call light problems immediately to a supervisor or the maintenance director and provide immediate or alternative solutions, but staff did not follow this policy in relation to the identified call light issues.
Failure to Submit Required Five-Day Abuse Investigation Reports
Penalty
Summary
The facility failed to provide the State Survey Agency (CDPH) with written five-day investigation reports for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. One allegation involved an altercation between Resident 1 and Resident 2, and another involved an altercation between Resident 3 and Resident 4. Facility documents showed that both allegations were reported to CDPH on the same dates they were made, but there was no evidence that the required follow-up investigation reports were completed and submitted within five calendar days as required by facility policy and regulatory expectations. During interviews, the Administrator, whose first day in the role was 1/01/2026, stated she could not locate the facility files that would normally contain the five-day investigation reports for either abuse allegation and confirmed she could not provide evidence that the reports were sent to CDPH. The DON stated she did not know if the investigation reports for both abuse allegations were completed and acknowledged that the purpose of these reports was to ensure the facility investigated what happened and what interventions were implemented to provide resident safety, and that it was a regulatory requirement to provide the five-day investigation report to CDPH. The facility’s written policy on abuse, neglect, exploitation, or misappropriation specified that all allegations are thoroughly investigated, that the administrator initiates investigations, and that a follow-up investigation report is to be provided within five business days of the incident, which did not occur in these cases.
Failure to Complete Abuse-Related Skin Assessment and 72-Hour Monitoring per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards for assessment and documentation following an abuse allegation involving Resident 1. Resident 1, who had COPD, left-sided hemiplegia, and major depressive disorder and was cognitively intact per a BIMS score of 13, reported alleged physical abuse on 12/18/25, stating that someone grabbed her right arm. An SBAR change-of-condition note documented skin discoloration on the right forearm with intact skin, no swelling, and no pain. However, no detailed skin integrity assessment was completed at that time to describe the bruising in terms of size, exact location, and characteristics, despite facility policy requiring detailed observations and the DON’s expectation that a skin integrity assessment be completed when the bruising was first reported. A skin/wound note was not entered until 12/21/25, and during a later observation on 1/05/26, two distinct bruises were noted on the lateral aspects of Resident 1’s right upper and lower arm, with specific measurements and color changes that had not been previously documented. The deficiency also involves the facility’s failure to complete ordered 72-hour monitoring every shift following a change in condition for Resident 2. Resident 2, who had DM, vascular dementia with behavioral disturbances, and major depressive disorder and was cognitively intact per a BIMS score of 13, was observed on 12/17/25 to have increased agitation, physical aggression, wandering, and entering other residents’ rooms. An SBAR change-of-condition note documented these behaviors and indicated that 72-hour monitoring was initiated, and the care plan reflected that the resident was exhibiting adverse behaviors affecting physical well-being, safety, and aggression toward staff and other residents, with 72-hour monitoring started. Facility documentation and the DON’s review showed that required 72-hour monitoring notes were not completed every shift as expected. Record review revealed that for Resident 2, there was no evidence that 72-hour monitoring was completed by nursing staff on any shift on 12/18/25, nor on AM, PM, and NOC shifts on 12/19/25, and NOC shift on 12/20/25. The DON stated that her expectation was that licensed nursing staff complete 72-hour monitoring every shift, resulting in nine progress notes over the monitoring period, but confirmed that only two notes were completed on 12/20/25. Facility policies required that all services provided to residents be documented in the medical record and that charge nurses ensure care is provided according to the care plan and that nurses’ notes reflect that the care plan is being followed. These omissions in assessment and monitoring documentation for both residents constituted failures to meet professional standards of quality and facility policy requirements.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents in two separate incidents. In the first incident, a resident with schizophrenia and no memory impairment struck another resident, also with schizophrenia and no memory impairment, several times on the back of the head while the latter was sitting on his bed. The assaulted resident reported the incident, denied pain, and had no visible injuries. The aggressor admitted to hitting the other resident, stating that the victim was making weird noises. Facility staff, including the case manager and program director, confirmed the occurrence of physical abuse. In the second incident, a resident diagnosed with schizoaffective disorder hit another resident, who also had schizophrenia and no memory impairment, several times in the head while she was lying in bed. The victim experienced mild pain to the right temple and expressed fear of the aggressor. The program director documented the incident and acknowledged it as physical abuse. Both incidents were confirmed through interviews and record reviews, and the facility's policy states that residents have the right to be free from abuse, including physical abuse.
Resident Subjected to Psychological Abuse by Staff
Penalty
Summary
A Certified Nursing Assistant (CNA) and an unlicensed staff member required a resident diagnosed with Paranoid Schizophrenia to unclog her own toilet, which contained urine and feces, using her gloved hands. The CNA instructed the resident to perform this task while the door to her room was intentionally left open, despite the resident's request for privacy. The CNA justified her actions by stating she was trying to teach the resident a lesson, and the unlicensed staff member confirmed the incident occurred as described. The resident reported feeling embarrassed, humiliated, and victimized by the incident, which negatively impacted her psychological well-being. At the time, the resident had no memory impairment, depression, hallucinations, or behavioral symptoms according to her Minimum Data Set assessment. The facility's policy prohibits all forms of abuse, including mental abuse, and commits to preventing such incidents. The actions of the CNA and unlicensed staff directly violated the resident's right to be free from psychological abuse.
Failure to Interview Other Residents During Abuse Investigation
Penalty
Summary
The facility failed to properly investigate an abuse allegation by not interviewing other residents who may have been affected. According to a review of the 5-day summary report, only one resident was interviewed in relation to the abuse allegation. During interviews, both the Director of Behavioral Health and the Administrator confirmed that no other residents were interviewed as part of the investigation, despite facility policy requiring interviews with the resident's roommate and other residents who received care from the accused employee. This omission prevented the identification of any additional residents who could have been impacted by the alleged abuse.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident threw a pitcher of water at another resident. Resident 1, who had a history of respiratory failure, hemiplegia, hemiparesis following a stroke, and major depressive disorder, was assessed as having moderately intact cognition. Resident 2, who had a history of stroke, anxiety disorder, and aphasia, was assessed as having intact cognition. According to documentation, Resident 2 became agitated by what he perceived as excessive noise from Resident 1 and responded by throwing water at him. Resident 1 was surprised by the incident and did not realize his behavior was agitating his neighbor. Interviews confirmed that Resident 2 admitted to throwing water on Resident 1 due to ongoing frustration with the noise and a perceived lack of intervention by staff. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including abuse by other residents. The incident demonstrates a failure to protect Resident 1 from abuse as required by facility policy.
Resident's Right to Refuse Physical Contact Not Honored
Penalty
Summary
A deficiency occurred when a licensed nurse (LN B) physically assisted a resident who was lying on a blanket in the hallway by lifting her from the floor and placing her in bed, despite the resident's repeated verbal refusals and explicit statements that she did not consent to being touched. The resident, who was self-responsible and experiencing significant pain at the time, repeatedly told LN B not to touch her and requested that the police be called, but LN B did not comply with these requests. LN B later acknowledged that he should not have touched the resident without her consent. Interviews with other staff, including the Director of Nursing and additional licensed and unlicensed staff, confirmed that facility policy and standard practice require staff to respect residents' rights to refuse physical contact and to be treated with dignity. The facility's policy on resident rights, as well as staff statements, indicated that touching a resident without consent is a violation of those rights. The incident resulted in the resident feeling disrespected and that her rights had been violated.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse made by a resident against a licensed nurse was reported to the appropriate authorities within the required two-hour timeframe. According to documentation, the resident reported the abuse on 7/7/25 at 3:10 p.m., but the allegation was not reported to the local police department until the following day, 7/8/25. Interviews with facility staff, including the Director of Nursing, Licensed Nurse, and Director of Staff Development, confirmed that all abuse allegations should be reported to the police, ombudsman, and state licensing agency within two hours to ensure resident safety. Record reviews further verified that the reporting to law enforcement was delayed beyond the required period. A review of the facility's policy and relevant regulatory guidance indicated that abuse allegations must be reported immediately, defined as within two hours, to state licensing, the ombudsman, and law enforcement. The facility's own documentation and fax confirmation sheet confirmed the delay in reporting. This deficiency was identified for one of three sampled residents and was substantiated through interviews, record reviews, and examination of facility policies and state requirements.
Unattended Medication Cart Left Unlocked
Penalty
Summary
A medication cart was observed left unlocked and unattended in the facility, with no nurse present in the area at the time. Shortly after, a nurse returned and locked the cart, confirming that she had left it unlocked while accompanying the DON into the medication room. The nurse acknowledged that the cart should remain locked when unattended to prevent unauthorized access to medications. The DON and another nurse both confirmed the expectation that medication carts be locked at all times when not in use, in accordance with the facility's policy and procedure, which requires all compartments containing drugs and biologicals to be locked when not in use.
Resident Left on Soiled Bedpan Due to Staff Communication Breakdown
Penalty
Summary
A resident admitted for surgery aftercare following a right lower leg fracture, with a history of falls and difficulty walking, was left on a soiled bedpan for hours during the night without any response to multiple call light activations. The resident reported feeling helpless and embarrassed by the experience and notified a nurse the following morning. Staff interviews confirmed that the resident was left unattended due to a communication breakdown between two CNAs who changed assignments mid-shift, resulting in the resident's needs being overlooked. Facility staff, including a CNA, a licensed nurse, and the DON, acknowledged that the standard procedure is to respond promptly to call lights and not to leave residents on bedpans for extended periods, as this can cause discomfort and potential skin breakdown. Review of facility policies confirmed that residents should be treated with dignity and respect, with prompt toileting assistance and removal from bedpans as soon as they indicate they are finished. The failure to follow these procedures led to the resident enduring an undignified and uncomfortable situation.
Plan Of Correction
F550 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: DSD/ADSD/Nursing Supervisor In serviced 6/5/25. CNAs on 5/28/25 and 6/5/25 offering and removal of bedpans that emphasize dignity and respect for the residents during this process. One resident was affected by deficient practice. Follow-up interviews with the affected resident confirm that there have been no recurrences of deficient practice and deny any residual emotional effects. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: DON/MDS/Nursing Supervisor identified residents who utilize bedpans. Three (3) residents have the potential to be affected by deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Therapy will track new admissions who utilize bedpans, communicate identified residents to Nursing. Identified residents who utilize bedpans will be updated in their toileting care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system and includes dates when corrective action will be completed. The corrective action dates must be acceptable to the State Agency. Department heads/Interdisciplinary Team will identify resident concerns through daily Angel rounds, via review of monthly Resident Council minutes, and during quarterly care conferences. Findings will be reviewed in QAPI for three months.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to complete and provide a timely investigation report to the Department following an allegation of abuse involving a resident and a staff member. Specifically, after a resident reported not being treated with dignity and respect by a housekeeper, the administrator conducted an internal investigation but did not submit the required five-day follow-up investigation report to the Department. During an interview, the administrator stated that he was unaware of the requirement to send a follow-up report within five days after an abuse allegation, referencing guidance documents that did not indicate this obligation. A review of the facility's policy on abuse, neglect, exploitation, and misappropriation prevention confirmed that the facility is committed to investigating and reporting all allegations within federally required timeframes. However, the lack of a timely report in this instance meant that the Department did not receive necessary information to intervene or ensure protective actions for the resident involved and the other residents in the facility.
Plan Of Correction
Immediate Action Taken The Administrator reviewed the abuse investigation file involved. The alleged abuse was non-physical and was reported under California Welfare & Institutions Code 15630(a)(b)(1)(C). The code section calls for reporting to the local ombudsman or local enforcement agency. The initial report was made to the State Survey Agency, local ombudsman, and local law enforcement agency. Moving forward, results of investigation that fall under this State Law code section will be reported to the State Survey Agency under CFR Section 483.12(c)(4) within 5 working days. Action taken for other potentially affected residents The Administrator reviewed previously reported allegations, and all involved physical abuse in which both federal and state law requires reporting to the State Survey Agency, the local ombudsman, and local law enforcement agency. All initial reports were followed by a 5-day report to the State Survey Agency. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months.
Failure to Complete Required Level II PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental illness received a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who had a history of Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression, and bipolar disorder, was admitted with a positive Level I PASRR screening indicating the need for a Level II evaluation. Despite this, documentation showed that the Level II PASRR was not completed, with correspondence from the Department of Health Care Services at one point stating the evaluation could not be conducted due to the resident being isolated for health or safety reasons, and later stating the resident did not require the screening due to not having a severe mental illness. The resident's cognitive status declined over time, as evidenced by a drop in BIMS score from 11 to 3, indicating severe cognitive impairment. Interviews with facility staff revealed a lack of clarity and policy regarding the PASRR process. The Business Manager was unaware of the steps to take if the acute care hospital did not complete the PASRR accurately or if a resident developed a mental illness while in the facility. The Administrator acknowledged that a Level II PASRR should have been conducted and identified a gap in the facility's PASRR process. The facility's policy required referral for Level II evaluation when indicated, but this was not followed, resulting in the resident not receiving a complete mental health evaluation or access to appropriate mental health resources.
Plan Of Correction
On 4/25/25, the Administrator completed a revision of the facility's policy and procedure (P&P) for PASSR to 1) include the definition of a significant change and 2) address what to do when a resident is noted to have a significant change of condition. On 4/28/25, the Administrator revised the P&P with the facility's current PASSR system, authorized users, and the Interdisciplinary Team (IDT), the requirement that a Resident Review (RR) must be initiated by submitting a Level I Screening upon a resident's significant change in condition. On 4/28/25, the Administrator reviewed with the Interdisciplinary Team (IDT) the definition of a "significant change of condition." The facility's current PASSR System authorized users include the Business Office Manager, Business Office Assistant, and Admission's Director. The IDT includes the Director of Nurses, Director of Staff Development, Minimum Data Set Nurse, Social Services Director, Activities Director, Rehabilitation Director, Medical Records Designee, and Administrator. The IDT will review changes of condition as defined in the P&P during morning stand-up meetings and communicate the need to submit Level I Screening to PASSR systems users as needed. The Medical Records Designee will audit changes of conditions and for completion of the process and report findings to the IDT. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
Staff failed to consistently offer or perform hand hygiene (HH) for residents after meals, as observed with multiple residents who were not provided HH following lunch. Interviews with staff confirmed that facility policy requires offering HH before and after meals for infection control, and staff acknowledged not following this policy during the observed incidents. The nurse manager also confirmed that HH should be offered to residents before and after meals to prevent infection. Additionally, staff did not perform HH prior to preparing medications or before and after donning gloves, as observed with a licensed psych technician during medication pass and glove use. Staff interviews confirmed awareness of the facility's policy to perform HH in these situations, and the facility's written policy also requires HH before and after eating, before preparing medications, and after removing gloves. These lapses were directly observed and verified by staff and the nurse manager during interviews.
Plan Of Correction
On 4/7/25-4/10/25, all staff were in-serviced on Hand Washing/Hand Hygiene Policy and Procedure (P&P) by the Director of Nursing (DON), Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), and Infection Preventionist (IP). The training included: 1) Offering Hand Hygiene (HH) to residents after meals 2) Utilizing HH prior to preparation of medications 3) Utilizing HH prior to donning and doffing of gloves The IP, DSD, and ADSD will observe and monitor: (1) Staff offering HH to residents after meals (2) Utilizing HH prior to preparation of medications (3) Utilizing HH prior to donning and doffing of gloves Audits will be conducted three times a week for 3 weeks, twice weekly for 2 weeks, and then once weekly for 1 week. Additionally, random audits will be performed for one month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee for three months.
Failure to Properly Dispose of Discontinued and Unused Medications
Penalty
Summary
Surveyors identified multiple failures in the facility's handling of discontinued and unused medications. During observations, medications belonging to two discharged residents were found left inside a medication room refrigerator, despite both residents having been discharged weeks prior. Additionally, discontinued medications for two other residents were found disposed of in their original containers inside resealable plastic bags within a disposal bin, rather than being properly destroyed according to facility policy. Further, various discontinued medications, including birth control pills, were left intact and undisposed in a disposal bin, and a discontinued medication for another resident was found stored among active medications in a medication cart. Interviews with licensed nurses confirmed that the medications found belonged to residents who were no longer in the facility or whose medication orders had been discontinued. Record reviews corroborated the discharge dates and medication discontinuation orders for the affected residents. The facility's policy requires that discontinued and unused medications be destroyed in compliance with federal and state regulations, and that such medications be removed from storage areas and secured until destruction. Despite these requirements, the facility failed to properly identify, segregate, and dispose of discontinued and unused medications. The observed practices included leaving medications accessible in medication rooms and carts, and placing them in disposal bins without proper destruction. These actions were not in accordance with the facility's own policies or regulatory requirements for pharmaceutical service, labeling, and storage.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 Inservices with licensed staff regarding the facility policy and procedure titled Discarding and Destroying Medications. Licensed staff will follow the facility protocol for proper disposal and destruction of unused and discontinued medications. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medications 3 times a week for 3 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused medications 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication randomly for 1 month. System Effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three months.
Failure to Notify LTC Ombudsman of Facility-Initiated Discharges and Transfers
Penalty
Summary
The facility failed to notify and provide evidence that the LTC Ombudsman was given a copy of the transfer notice for 42 out of 42 residents who were subjected to a facility-initiated discharge or transfer to the hospital between December 2024 and March 2025. Multiple staff interviews, including those with the program director, nurse manager, licensed nurses, and the social services director, confirmed that the behavioral unit had never notified the ombudsman of any discharges or transfers to the hospital. Staff members indicated that they were either unaware of the requirement or believed it was not necessary to notify the ombudsman. A review of facility policy and the All Facilities Letter (AFL 17-27) indicated that the facility is required to send notice to the local LTC Ombudsman for any transfer or discharge initiated by the facility. The administrator acknowledged that the behavioral unit is licensed under the skilled nursing facility and is therefore required to follow state regulations, including ombudsman notification for all discharges and transfers. No evidence was found in the health records that the ombudsman had been notified for any of the affected residents.
Plan Of Correction
On 4/26/25, the Administrator reviewed the content of AFL 17-27 with the Social Services Director (SSD) and Behavioral Unit's Program Director (PD) and Nurse Manager (NM) for compliance. The Administrator stressed AB 940's requirement that the facility 1) must notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representative when a facility-initiated transfer or discharge occurs, and 2) is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if the resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis. The SSD will maintain a binder organized by year containing 1) a list of all discharged residents to date, 2) copies of the facility-initiated transfer notices, and 3) proof of transmission of the notices to the LTC Ombudsman's office. The PD and NM will maintain the same for the Behavioral Health Unit. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who eloped and sustained injuries. The resident, who had been admitted with a diagnosis of cerebral infarction and had severe memory impairment, was assessed as being at moderate risk for falls and low risk for wandering. Despite this, an elopement care plan and a wandering device (WMD) were initiated after the resident exhibited wandering behavior and attempted to leave the facility. However, the WMD was improperly placed on the resident's wheelchair instead of on the resident, and the elopement care plan did not document the reason for this placement. On the night of the incident, the resident was found missing from the facility, and staff discovered the resident outside on the sidewalk with injuries, including a fracture to the left thumb and abrasions to the face and knees. Interviews with facility staff revealed that the resident was not adequately supervised, and there was a breakdown in the system that allowed the resident to elope without staff knowledge. The Director of Nursing acknowledged the inaccuracies in the resident's wandering risk assessment and the improper use of the WMD, confirming the facility's responsibility for ensuring resident safety.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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