Brighton Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanford, California.
- Location
- 361 E. Grangeville Blvd, Hanford, California 93230
- CMS Provider Number
- 055410
- Inspections on file
- 21
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Brighton Post Acute during CMS and state inspections, most recent first.
A resident with diabetes had insulin orders that lacked MD-notification parameters for abnormal blood glucose, and another resident had a significant weight gain with delayed and inconsistent 72-hour alert charting after an SBAR. Two residents were observed on O2 at 1.5 L even though both had orders for 2 L, one resident had duplicate PRN O2 orders that could cause confusion, and an LVN placed a resident on BiPap despite scope limits. A resident’s nasal cannula tubing was also not changed per the ordered 7-day schedule.
Food was not palatable or attractive for several residents when surveyors observed regular and puree meal trays with bland, salty, soggy, wet, gelatinous, sticky, and grainy items. A resident stated the coffee, potatoes, and green beans had no taste and that staff kept bringing food she did not like, while another resident said lunch was not enjoyable and he only ate the ham. The ADM, CDM, RDC, and DON all acknowledged that the puree and regular diets should be appetizing and palatable, and the facility policy required nourishing, palatable meals that appear attractive.
Failure to Permit Return After Hospitalization: A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses was sent to the hospital for a change in condition and later had new behaviors and quetiapine added. The ADC, DON, and Administrator decided the facility could not accommodate the resident because of the new medications and behaviors, declined the resident in the referral system, and did not permit the resident to return despite available beds.
MDS assessments for two residents were not accurately completed. One resident with arthritis, muscle weakness, and significant ADL dependence was coded as having no upper or lower extremity impairment despite being dependent for care and reporting constant pain and stiffness. Another resident with anxiety, depression, and hospice/palliative care needs was not coded for anxiety, even though staff confirmed the diagnosis and noted behavioral symptoms such as hitting, kicking, and yelling. The MDS nurse stated the assessments should have been coded differently, and the DON stated she only verified completion, not accuracy.
A resident with anxiety disorder, hemiplegia, hemiparesis, and dementia did not have a completed PASARR Level I screening that accurately reflected her mental health diagnosis. The AC said she reviewed PASARRs for hospital admissions but only completed them for hospice residents admitted from home, while the LVN/ADON said the existing PASARR was invalid and another Level I assessment should have been completed but was not. The DON stated PASARR accuracy and completeness were the AC’s responsibility, and facility policy required a Level I PASRR screen before admission.
A resident prescribed Plavix did not have a care plan to monitor for antiplatelet side effects. The resident had multiple diagnoses, including anemia, type 2 DM, and moderate cognitive deficits, and the MAR showed daily Plavix for clot prophylaxis. During record review, staff confirmed no antiplatelet care plan had been created, even though the LVN and DON stated one was required to guide monitoring for side effects such as bleeding and bruising.
A resident with COPD, chronic respiratory failure with hypoxia, and heart failure had an oxygen order for 2 L/min via NC PRN for SOB, but the care plan still reflected an older revision and was not updated to match the current order. During review, the LVN, ADON, and DON all confirmed the care plan had not been revised, even though the resident was observed using oxygen and the facility’s policy required care plans to be revised as conditions change.
Failure to Provide Scheduled Bathing and Hygiene Assistance: A resident with paraplegia, fecal and urinary incontinence, a PEG tube, and severe cognitive impairment did not receive bathing as scheduled. Staff documented some shower days and marked other days as N/A, which the ADON and DSD confirmed meant the shower did not occur. The resident stated he was not being bathed and felt dirty, while the DON, ADON, DSD, and IP stated staff should have provided a shower or bed bath and documented any refusals.
Nonfunctional Bed Rail Left Unsecured: A resident with hemiplegia, muscle weakness, and vision loss had a left bed rail that would not stay locked and was observed dropping when touched. The resident said the rail had been broken for months and that she had reported it to CNAs, LNs, and maintenance. During repositioning, CNAs did not use the rail, one CNA was unaware it was broken until checked, and the MA confirmed it was not securely locked. The MD stated inspections were quarterly or complaint-based, with no definite schedule for bed rail checks.
Inaccurate Daily Nurse Staffing Posting: The facility posted projected staffing hours instead of actual hours worked, and the daily staffing sheets did not clearly identify RN, LVN, and CNA titles. The ESR, DON, and ADMIN acknowledged the posting combined licensed staff and did not allow residents, visitors, or the public to determine the actual nursing staff providing care.
Two residents had deficiencies related to medication management. One resident with dementia and depression received Namenda for memory loss without written informed consent and without monitoring for side effects or behaviors. Another resident with osteoarthritis and rheumatoid arthritis received PRN oxycodone and acetaminophen daily, but the orders had no pain parameters, and staff described inconsistent methods for deciding which pain medication to give.
Failure to Serve Menu Item at Lunch: A cook plated lunch trays with ham, beans, and steamed cabbage, but cornbread listed on the menu was not served to three residents. Each resident stated they did not receive the cornbread, and the cook said he missed adding it when plating began. The CDM, RD, and DON all stated residents were expected to receive all menu items unless otherwise ordered or refused, and the facility policy required staff to ensure the correct meal was provided.
A resident with right-sided hemiplegia, MDD, and CKD was served cabbage even though his care plan listed cabbage as a dislike. During observation, he said he did not enjoy lunch and only ate the ham. The CDM confirmed he should not have been served cabbage, and the RD and DON stated residents should receive foods aligned with documented preferences.
Improper Air Gaps at Ice Machine and Food Prep Sink: The facility failed to maintain proper air gaps for the ice machine drain and the food prep sink. The CDM and MD observed plumbing at the sink and ice machine, and the MD stated the ice machine drain did not have an air gap. The MD also stated he installed an inline air gap under the food prep sink after searching online and did not review regulations or food code before doing so.
Kitchen Pest Control Failure: The facility failed to keep the kitchen free of flies while food was being prepared for residents. Staff observed flies in the dishwashing area and later near the food processor and cornbread, with one fly landing on tongs used with food. The CDM stated the kitchen should have no flies, and the maintenance log documented flies in the building.
The facility's fire protection system was nonfunctional for several days, during which a fire watch was implemented and all fire exit doors were closed. Despite documented procedures requiring notification, the facility did not inform CDPH or HCAI of the system outage, as confirmed by the Administrator and Maintenance Supervisor.
A resident with a history of stroke, moderate cognitive impairment, and high fall risk experienced three falls in three days, including one resulting in a hip fracture, due to the facility's failure to provide adequate supervision and implement individualized interventions. Staff and documentation confirmed that the resident was known to be impulsive, non-compliant with safety instructions, and did not use the call light or assistive devices, yet care plans remained generic and ineffective, lacking timely updates and specific supervision measures.
A resident with a history of stroke, hemiplegia, and moderate cognitive impairment experienced multiple falls resulting in a hip fracture after the facility failed to develop and implement an individualized care plan. Despite staff awareness of the resident's poor safety awareness, impulsiveness, and refusal to use assistive devices or call for help, the care plan remained generic and did not specify the necessary level of supervision or assistance, leading to repeated unwitnessed falls and injury.
A resident was served an uncut country-fried steak instead of the prescribed No Added Salt (NAS) diet with Mechanical Soft texture. The resident had difficulty cutting the meat and only ate half. An LVN and the CDM confirmed the error, acknowledging the risk of choking. The DON stated that dietary staff should verify diet orders during meal plating, and licensed nurses should check meal trays before serving, but this was not done.
A resident reported being hurt by an aide during care to a CNA, who failed to report the allegation to the charge nurse or administrator as required by facility policy. The resident, who had intact cognition and required assistance with daily activities, later stated they felt safe. The administrator was unaware of the incident until informed by surveyors.
The facility exceeded the acceptable medication error rate, reaching 7.41%, due to errors in administering multivitamins with minerals instead of the prescribed multivitamins to two residents. The errors were attributed to the failure of LVNs to verify medication labels against physician orders before administration.
The facility did not meet the required room size of 80 sq. ft. per resident in 26 rooms, with sizes ranging from 66.8 to 78.8 sq. ft. per resident. Despite this, no residents expressed concerns, and the facility had a waiver for non-compliant rooms. The DON and Administrator reported no issues with care provision due to room size.
The facility failed to notify the LTC-Ombudsman of a resident's transfer to the hospital, resulting in the Ombudsman being unaware of the discharge circumstances. The resident had multiple diagnoses, including Metabolic Encephalopathy and End Stage Renal Disease. The Social Services Director admitted to not knowing the requirement to notify the Ombudsman for hospital transfers.
Incomplete orders and improper respiratory and monitoring documentation
Penalty
Summary
Physician orders for insulin administration for two residents did not include parameters for when the MD should be notified for low or high blood glucose levels. One resident had an active order for insulin lispro per sliding scale, and the other had an active order for insulin aspart 5 units before meals. Both residents had diabetes, and one was admitted with type 2 diabetes with ketoacidosis while the other was admitted with type 2 diabetes and morbid obesity. The ADON stated there should be parameters for MD notification related to abnormal blood glucose levels, and the DON confirmed residents receiving insulin should have defined parameters for MD notification. The residents’ care plans did not include parameters for MD notification related to abnormal blood glucose levels. Resident 124 experienced a significant weight gain and an SBAR was completed because of a 25-pound gain within one month. The MD ordered additional diuretics, including spironolactone, and the resident was educated on elevating his feet. The ADON stated the expectation after the change in condition was to complete the COC, notify the MD, refer to the RD, and initiate 72-hour alert charting. The ADON stated alert charting should have started on the night shift after the SBAR and been completed every shift for 72 hours, but it was initiated later and documented only twice. The charting was not completed consistently each shift and did not include consistent documentation of edema or fluid overload assessments. The TAR also did not contain documentation of monitoring for edema or fluid overload. Resident 101 had two active O2 orders with the same PRN indication for shortness of breath, one for 2 L and one for 3 L, which the ADON and DON stated could cause confusion and should have been clarified into one clear order or distinct parameters. During observation, Resident 101’s oxygen concentrator was set at 1.5 L, and Resident 87’s oxygen concentrator was also set at 1.5 L even though the physician order for each resident was 2 L via nasal cannula. LVN 1 confirmed both residents were receiving oxygen below the ordered flow rate. Resident 122 was placed on BiPap by LVN 1, although the current LVN scope of practice indicated LVNs are not allowed to manipulate non-invasive ventilation. Resident 122 also had a physician order to change nasal cannula tubing every seven days, but the tubing observed was dated 3/30/26 and had not been replaced when it should have been.
Food Not Palatable or Attractive
Penalty
Summary
The facility failed to provide food that was palatable and attractive for three sampled residents, including Residents 33, 83, and 119, after residents reported that meals lacked flavor, tasted bad, or were refused. Resident 119 was observed in bed with a regular diet tray containing chopped chicken, potatoes, green beans, and hot chocolate, and stated she did not like the food, that the coffee did not taste good, that the potatoes had no taste, and that the green beans did not taste good. She also stated she told staff she did not like the food but continued to receive it, and said she would prefer a peanut butter and jelly sandwich. Surveyors observed and tasted test trays for both regular and puree diets. The regular diet tray included ham, beans, cabbage, and cornbread; the beans and cabbage were served in residual cooking liquid that made the cornbread and ham wet, and the ham tasted salty while the cabbage and beans had no flavor or seasoning. The puree tray contained formed food items with brown liquid on top, but the cabbage was gelatinous, the beans had no flavor or seasoning, and the cornbread was thick, sticky, grainy, and tasted like plain cornbread. The Administrator sampled both trays and stated the puree tray did not taste as good as the regular tray, and that the puree and regular diets should taste the same. Resident 33 stated he did not enjoy lunch, describing the cabbage as soggy and the beans as having no flavor, and said he only ate the ham and was ready to eat again. The CDM stated puree foods should be colorful, taste good, and have a mashed potato consistency, and the RDC stated the puree tray did not look appetizing and that too much water or thickener could affect taste and reduce palatability. The DON stated food should have nice portions, different food types should not run together, and food should appear presentable and be palatable, and that residents could refuse to eat if food was not presentable or palatable. The facility policy stated residents are to receive a nourishing, palatable, well-balanced diet and that food service staff will inspect trays to ensure meals taste and appear palatable and attractive.
Failure to Permit Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return to the facility following hospitalization after the resident was not re-admitted back on [DATE]. The resident had been admitted to the facility with diagnoses including epilepsy, sequelae of nontraumatic intracerebral hemorrhage, paroxysmal atrial fibrillation, nontraumatic intracranial hemorrhage, cognitive communication deficit, and major depressive disorder. The resident’s MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment. The admission coordinator stated the resident was sent to the hospital for a change in condition and that the hospital provided clinical updates while the resident was followed for return to the facility. The admission coordinator stated the hospital sent discharge orders and transfer information, and that the resident would normally be processed for readmission. The admission coordinator also stated the resident had a significant change in condition, was on restraints, and had been started on quetiapine for agitation. A meeting with the DON and Administrator resulted in the decision that the facility could not accommodate the resident because of the new behaviors and medications, and the resident was declined in the electronic referral system. The DON stated the resident had been sent out for a change in condition and later returned from the hospital with multiple medications and agitation. The DON stated the resident was not permitted to return because of the diagnosis and because the facility considered the new medications to be chemical restraints. The DON and Administrator stated the facility had available beds but decided not to re-admit the resident. The facility policy stated that the requirement to permit return following hospitalization applies to all residents regardless of payer source, and that if the facility determines a resident cannot return, it must comply with facility-initiated discharge requirements.
MDS Assessments Did Not Accurately Reflect Residents’ Functional Status and Diagnoses
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the health and functional status of two residents. For one resident, the admission record showed diagnoses including osteoarthritis of the left hip and right knee, rheumatoid arthritis, and muscle weakness. During observation, the resident was lying in bed with legs flexed and crossed and stated she was uncomfortable, needed repositioning, and had leg pain all the time because of arthritis. The MDS nurse reviewed the resident’s MDS and stated the resident was dependent with toileting, showering/bathing, and was not attempted to walk due to medical condition or safety concern, but the nurse coded the resident as not having impairment of the upper and lower extremities and acknowledged that this should have been coded differently. Staff interviews supported that the resident required extensive assistance with daily care. A CNA stated the resident was dependent with ADLs and required assistance because she complained of pain all the time and became stiff. An LVN stated the resident was dependent on staff to do all ADL needs and was always complaining of pain and did not want to do anything for herself. The MDS nurse stated he did not perform a bedside assessment and based the coding on the therapy evaluation, while also stating it was his responsibility to ensure assessments were accurate. For the second resident, the admission record showed diagnoses including anxiety, palliative care, and depression. During observation, the resident was lying in bed with eyes closed and did not respond when spoken to. The MDS nurse reviewed the resident’s MDS and stated the resident had been diagnosed with anxiety and should have been coded as such, but was not. A CNA stated the resident could understand simple questions and answer simple words and had behaviors such as hitting, kicking, and yelling at staff. An LVN confirmed the resident had a diagnosis of anxiety and had been started on lorazepam when admitted under hospice care. The DON stated she only verified completion in the MDS and expected the assessments to be accurate, and the facility policy stated that the information captured on the assessment reflects the resident’s status.
PASARR Screening Not Completed or Corrected for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to complete a PASARR Level I screening for one sampled resident, Resident 100, and the PASARR Level I screening dated 6/3/24 did not indicate the resident’s diagnosis of anxiety disorder. Resident 100’s admission record dated 4/8/26 showed diagnoses that included anxiety disorder, hemiplegia, hemiparesis, and dementia. During an initial tour on 4/7/26, Resident 100 was observed lying in bed and biting her fingernails, and she stated she did not remember how long she had been in the facility. During interviews, the AC stated she reviewed PASARR when residents were admitted from the hospital, but only completed PASARR assessments for hospice residents admitted from home and for residents with new psychotropic medication orders. The LVN/ADON stated she was responsible for PASARR assessments for significant changes and hospice admissions or discharges, and that the AC was responsible for reviewing PASARR for accuracy, diagnoses, and medications. The LVN/ADON reviewed Resident 100’s PASARR and stated it was invalid and should not have been done, and that another PASARR Level I assessment should have been completed to correct the issue but was not. The DON stated the AC was responsible for reviewing PASARR for accuracy and completeness and that another assessment should be completed if there was a discrepancy or error. The facility policy stated a Level I PASRR screen must be completed for all applicants before admission unless state process provides otherwise, and admission staff must review PASRR documents prior to admission.
Missing Care Plan for Antiplatelet Monitoring
Penalty
Summary
A comprehensive, person-centered care plan was not developed and implemented for Resident 44 to address monitoring for side effects of Plavix. During observation, Resident 44 was found in bed sleeping with a tray table across the bed. The resident’s admission record showed diagnoses including monoplegia of the right lower limb, major depressive disorder, anemia, and type 2 DM. The MDS assessment indicated a BIMS score of 9 out of 15, showing moderate cognitive deficits. The MAR showed Resident 44 was prescribed Plavix 75 mg by mouth daily for clot prophylaxis. During record review with LVN 3, the resident’s care plans were reviewed and no care plan for antiplatelets had been created. LVN 3 stated that a care plan was required for all residents taking an antiplatelet and should include side effects to monitor for such as bleeding or bruising. The DON also stated that when residents are taking antiplatelets, a care plan is required to inform staff what side effects to monitor for, and that the care plan is in place for resident safety. The facility policy on comprehensive person-centered care plans stated that care plans include measurable objectives and timetables and are developed and implemented for each resident.
Care Plan Not Updated to Match Oxygen Order
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for one resident when the resident’s oxygen care plan was not updated to match the physician’s order. During an initial tour, the resident was observed sitting in a wheelchair with a nasal cannula connected to a working oxygen concentrator set at 1.5 L/min. The resident’s record showed diagnoses including COPD, chronic respiratory failure with hypoxia, and heart failure, and the MDS indicated a BIMS score of 12, reflecting moderate impairment. The resident’s order summary showed an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath with a start date of 3/29/26. However, the care plan still listed an intervention to give 2 L/min via oxygen nasal cannula and showed a revision date of 11/13/2024. During interviews and record review, the LVN, ADON, and DON all confirmed that the care plan had not been updated to reflect the current oxygen order and stated that the care plan should have been revised. The facility’s policy stated that care plans are developed and implemented for each resident and revised as resident conditions change. The ADON stated that LNs revise care plans and that the MDS nurse reviews them to ensure orders match the care plan. The DON stated the care plan should have been updated and revised to match the resident’s needs and to avoid confusion and ensure the correct order was followed.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary bathing and hygiene assistance for Resident 13, who was unable to perform activities of daily living independently. Resident 13 was admitted with diagnoses including gastrostomy tube placement, paraplegia, fecal incontinence, functional urinary incontinence, and major depressive disorder. The MDS dated 3/16/26 showed a BIMS score of 6, indicating severe cognitive impairment, and the resident was described by staff as totally dependent on facility staff for ADLs. During interview, Resident 13 stated, "They don't bathe me," and said he did not recall the last time he had a bath and wanted one because he felt dirty. Review of the EMR and shower task showed showers documented on 3/11/26, 3/18/26, 3/21/26, 3/25/26, 3/28/26, and 4/4/26, with other days marked Not Applicable. The ADON stated Resident 13 was scheduled for showers on Wednesdays and Saturdays, that residents should receive showers twice a week, and that the expectation was for CNAs to document completed showers or refusals. The ADON also stated the shower schedule was not consistent and that there were instances of 7 days between showers. The DSD reviewed the shower sheet and EMR and stated that Not Applicable meant the shower did not happen. The DSD stated there was no refusal documented on the shower sheets and confirmed that if a shower was not done, a bed bath could be provided. The IP and DON both stated staff should have offered a bed bath and documented refusals if the resident declined. Facility policies stated residents would be offered and assisted with showering or bathing based on their needs, preferences, and care plan, and that bathing and hygiene assistance would be provided in a manner that protects skin integrity and infection control.
Nonfunctional Bed Rail Left Unsecured
Penalty
Summary
The facility failed to ensure a resident’s bed rails were maintained in safe working condition. During observation, the resident was lying in bed with the head of bed elevated and bilateral bed rails up, and she stated that the left bed rail had broken and did not stay up when staff turned her. The left bed rail was observed to not hold steady and would drop when hands were placed on it. The resident stated the rail had not been securely locked for about 2 to 3 months and that she had reported the problem to LNs, CNAs, and maintenance staff. The resident involved was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, contracture of the left hand, generalized anxiety disorder, unspecified visual loss, and muscle weakness. Her MDS indicated she was cognitively intact, dependent on staff for multiple activities of daily living, used a wheelchair, and was always incontinent of bowel and bladder. Her care plan and bed safety assessments identified bilateral bed rails as an enabler and support for mobility, positioning, and safety, and the resident stated she was partially blind and had glaucoma. When CNAs entered the room to reposition the resident, they repositioned her without using the bed rail. One CNA stated she was not aware the bed rail was broken until it was checked during the observation and acknowledged it was a safety issue. A maintenance assistant later confirmed the left bed rail was not securely locked and said he had just been notified. The maintenance director stated the bed and rails were inspected quarterly or when issues were reported, that the last inspection had been months earlier, and that there was no definite schedule for inspecting bed rails. The maintenance log showed multiple requests related to the resident’s bed rails, and the facility policies and job descriptions stated that equipment was to be maintained in safe working condition and that staff were to report defective equipment.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure nurse staffing information was accurately posted each day. During observation, interview, and record review, surveyors found that the staffing hour sheets reflected projected staffing hours rather than the actual hours worked by RNs, LVNs, and CNAs. On review of the staffing sheet dated 4/8/26, the Employee Services Representative stated the posted hours were projected hours and not actual hours worked. The representative also explained that the left side of the sheet combined licensed staff hours for RNs and LVNs, while the right side included CNA and RNA hours. The posted staffing information did not distinguish individual staff titles, and the report did not identify whether licensed staff were RNs or LVNs. During interviews, the Employee Services Representative, DON, and ADMIN acknowledged that the posting reflected scheduled or projected staffing rather than actual hours worked, and that residents, visitors, and the public would not be able to determine the actual staffing from the posting. The facility policy titled Posting Direct Care Daily Staffing Numbers required the form to include the type and category of nursing staff, the actual time worked during the shift for each category and type, and the total number of licensed and non-licensed staff working for the posted shift.
Unnecessary Drug Regimen and PRN Pain Order Deficiencies
Penalty
Summary
Resident 84 was admitted with diagnoses including unspecified dementia, depression, and COPD. During observation, the resident was lying in bed and stated she had been in the facility long enough and had no concerns, though she felt staff could do better with care. Staff described the resident as alert and oriented with confusion, and reported that she had physically and verbally aggressive behaviors during care. The resident was receiving Namenda for memory loss, but the record review and staff interviews found no written informed consent for the medication and no monitoring of side effects or behaviors related to its use. During the review of Resident 84’s record, the LVN stated she did not find an informed consent for Namenda and was not sure if one was needed. The LVN stated informed consent was important to let the family and resident know of medication side effects and to allow a decision about continuing the medication. The LVN/ADON stated the medication classification in PCC was wrong and should have been changed, and stated there was no behavior monitoring or medication side effect monitoring in place. The DON stated there was no informed consent for Namenda because it was used for memory loss, and also stated there was no monitoring for medication side effects and behavior in place. Resident 133 was admitted with diagnoses including osteoarthritis, injury of muscle fascia and tendons, and rheumatoid arthritis. During observation, the resident was lying in bed with legs flexed and crossed and stated she was not comfortable, that repositioning was not helping, and that she needed to be repositioned. She stated she had leg pain all the time because of her arthritis. Record review and staff interviews showed the resident had two PRN pain medication orders, oxycodone HCL and acetaminophen, both given daily, but there were no pain parameters with either order. The LVN/ADON stated the facility did not use pain parameters except for hospice residents and was not sure how nurses decided which medication to administer. RN 1 stated she used pain scale ranges to decide which medication to give, but also stated the resident did not have pain parameters with the medication orders. The DON stated licensed nurses monitored pain every shift and decided which medication to administer based on the resident’s complaint of pain, and confirmed the facility did not add pain parameters to the pain medication orders.
Failure to Serve Menu Item at Lunch
Penalty
Summary
The facility failed to follow the established menu for lunch when cornbread listed on the 4/8/26 menu was not served to Residents 41, 53, and 95. During a kitchen observation, a cook was plating lunch trays with ham, beans, and steamed cabbage, and a pan of squared cornbread was present on the food counter. However, when Residents 53, 41, and 95 were observed in the dining room during lunch, each was served ham, beans, and steamed cabbage without cornbread, and each stated they had not received it. During interview, the cook stated he missed adding cornbread at the beginning of lunch and thought he forgot about it when plating started. The CDM stated cooks were expected to follow the menu and that residents needed the correct amount of carbohydrate, protein, and other nutrients to stay healthy. The RD stated residents should be served all menu items unless a doctor ordered otherwise or the resident did not want the item, and that not receiving all items could lead to weight loss. The DON stated all items on the menu should have been served to the three residents and that the facility menus were based on nutritional values for each day. The facility policy stated each resident should receive a nourishing, palatable, well-balanced diet and that staff should inspect trays to ensure the correct meal is provided.
Food Preferences Not Followed for Resident With Cabbage Dislike
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were followed when the resident was served cabbage even though the care plan listed cabbage as a dislike. During a concurrent observation and interview, the resident stated that he did not enjoy his lunch, describing the cabbage as soggy and the beans as having no flavor, and said he only ate the ham and was ready to eat again but would wait for dinner. The resident’s admission record showed diagnoses of right-sided hemiplegia, major depressive disorder, and chronic kidney disease, and the MDS indicated a BIMS score of 12, reflecting moderate cognitive deficits. A concurrent review of the resident’s care plan with the CDM showed the plan documented “no liver, no spinach, no cabbage.” The CDM stated the resident should not have been served cabbage because it was listed as a dislike. The RD stated residents should be served all menu items unless listed as a dislike on their preferences, and the DON stated the resident’s food preferences should have been followed and that serving disliked foods could cause the resident not to eat the food, resulting in unintended weight loss. The facility policy titled Resident Food Preferences stated nursing staff will document the resident’s food and eating preferences in the care plan.
Improper Air Gaps at Ice Machine and Food Prep Sink
Penalty
Summary
The facility failed to store and prepare food in accordance with professional food service standards for 49 residents who were served food from the ice machine and kitchen. During an initial kitchen tour with the CDM, the food preparation sink was observed with black pipes going into the wall and a drain sink under and to the left of the food preparation sink that was not being used. The CDM stated the white plastic piece on top of the black pipe was an air gap installed by maintenance. During a later observation with the MD, the facility's ice machine had two pipes going from the ice machine to the drain on the floor, and one pipe was inserted into the drain beyond the level of the floor. The MD stated the hopper pipe from the ice machine was going past the lip of the sink drain and that the ice machine drain did not have an air gap. During another observation with the MD in the kitchen, the food preparation sink was seen with the white plastic piece connected to the black pipe coming from the sink. The MD stated the white plastic piece was an air gap for garbage disposal and that he had installed it. In interview, the MD stated he had installed an inline air gap on the pipe under the food preparation sink after using Google to search for one, chose it because it went along with the existing plumbing, and did not look up regulations or food code before installing it. The Administrator stated there should have been an air gap for the ice machine drain and that the facility should follow the regulations for an air gap at the food preparation sink. The facility policy stated sinks, drains, and equipment that discharge into the plumbing system shall maintain a proper air gap when required, and drain pipes must not be placed directly into a sewer or floor drain without the proper gap.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to have an effective pest control program to keep the kitchen free of flies for 51 residents who ate food prepared there. During an initial tour of the kitchen, two flying insects were observed around the dishwashing area. The Dietary Aid stated there had not been a problem with flies in the kitchen until that day and explained that the kitchen had negative airflow over the exit door to help control flies. The Dietary Aid also stated that if flies were found in the kitchen, staff would notify the Certified Dietary Manager. On a later observation, one flying insect was seen on a wood countertop near the food processor, then flying around food being prepared and landing on metal tongs sitting on top of a pan of cornbread. The Certified Dietary Manager stated she had observed two flies in the kitchen on one day and one fly in the kitchen the next day, and stated her expectation was that the kitchen had no flies. A maintenance request log documented a problem of flies in the building, and the facility's pest control policy stated the facility would maintain a clean, safe environment and take prompt action to keep the building free of insects, rodents, and other pests, with sightings, reports, treatments, and follow-up actions documented.
Failure to Notify Authorities and Maintain Fire Protection System
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors when the fire protection system became nonfunctional for a period of several days. During this time, all fire exit doors were closed as a precaution, and a fire watch was initiated by the Maintenance Supervisor and other staff, with hourly inspections documented. However, the facility did not notify the California Department of Public Health (CDPH) or the California Department of Healthcare Access and Information (HCAI) about the fire protection system malfunction, as required by regulations. The Administrator confirmed that the facility remained under a fire watch and acknowledged unawareness of the notification requirement. Review of facility documents and policies indicated that the fire alarm system is expected to be operable at all times and that maintenance personnel are responsible for keeping the fire alarm system in good working order. The facility's fire watch log and maintenance policies further outlined the procedures to be followed in the event of a system outage, including the implementation of a fire watch. Despite these documented procedures, the required notifications to regulatory agencies were not made during the period when the fire protection system was out of service.
Failure to Provide Adequate Supervision and Individualized Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement effective, individualized interventions to prevent falls for a resident assessed as high risk. The resident, who had a history of left-sided hemiplegia and hemiparesis following a stroke, moderate cognitive impairment, and other significant medical conditions, was known by staff to be impulsive, non-compliant with safety instructions, and did not use the call light to request assistance. Despite these known risk factors, the care plans in place were generic, not tailored to the resident's specific needs, and did not address the root causes of his falls, such as his poor safety awareness and refusal to use assistive devices. The resident experienced three falls within three days. The first fall occurred when the resident attempted to enter a shared bathroom and was struck by the door, resulting in a fall and injuries to his head and hip. The second fall was unwitnessed; the resident was found on the floor after attempting to retrieve pants from his closet, reporting that he blacked out and fell. The third fall was witnessed by staff, occurring when the resident, despite being on non-weight bearing status, stood up in his doorway and fell after turning around. Staff interviews confirmed that the resident routinely ambulated independently, did not use his walker, and did not call for assistance, even after repeated education and reminders. Documentation and interviews with the MDS Coordinator, ADON, and DON revealed that the care plans were not updated promptly after the initial falls and did not specify the level of supervision or assistance required for the resident's activities of daily living. The interventions listed, such as encouraging use of the call light and providing education, were ineffective given the resident's non-compliance and cognitive status. The facility's policy required individualized, resident-centered fall prevention plans, but this was not achieved for this resident, resulting in repeated falls and a hip fracture that required emergency department evaluation.
Failure to Individualize Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was identified as a high fall risk with poor safety awareness and a known behavior of not calling staff for assistance. Despite multiple assessments and staff awareness of the resident's impulsiveness, noncompliance with using the call light, and refusal to use assistive devices, the care plan interventions remained generic and did not address the resident's specific needs. The care plans primarily included standard interventions such as encouraging call light use, education, and routine monitoring, which staff acknowledged were ineffective for this resident. The resident experienced three falls within three days, resulting in a comminuted fracture of the left greater trochanter, pain, and decreased mobility, necessitating transport to the emergency department for assessment and treatment. Interviews with CNAs, LVN, the MDS Coordinator, ADON, and DON confirmed that the resident continued to ambulate independently to the bathroom without supervision, did not use the call light, and refused to use a walker, despite repeated education and reminders. Staff also noted that the care plan was not updated promptly after the initial falls and did not specify the level of supervision or assistance required for the resident's activities of daily living, particularly toileting and ambulation. The facility's own policies required individualized, measurable objectives and interventions that address the underlying causes of problems, as well as ongoing assessment and revision of care plans when residents' conditions change. However, the care plans for this resident did not reflect these requirements, as they failed to address the root causes of the resident's falls—impulsiveness, poor safety awareness, and noncompliance. The lack of individualized interventions and timely updates to the care plan contributed to the recurrence of falls and subsequent injury.
Failure to Provide Physician-Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-prescribed therapeutic diet for a resident during lunch on November 1, 2024. The resident, who was on a No Added Salt (NAS) diet with Mechanical Soft texture, was served a piece of uncut country-fried steak. This was contrary to the prescribed diet order, which required the food to be of a mechanical soft texture. The resident expressed difficulty in cutting the meat and only consumed half of it, indicating a preference for soft and small pieces of meat. During an interview, a Licensed Vocational Nurse (LVN) confirmed that the resident was served the wrong diet texture and acknowledged the risk of a choking episode from eating large pieces of meat. The LVN stated that both dietary and nursing staff were responsible for ensuring the resident received the appropriate meal texture and consistency, which was not done in this instance. The Certified Dietary Manager (CDM) also confirmed the failure to follow the physician-ordered diet and highlighted the potential choking risk. The CDM noted that dietary staff should prepare the correct diet, and licensed nurses should verify the meal tray upon arrival to the unit. The Director of Nursing (DON) stated that the standard practice was for dietary staff to verify the diet order during meal plating and for licensed nurses to verify the meal tray contents before serving. The facility's policy and procedure on Tray-Cards/Diet Orders indicated that tray cards should list the resident's diet order and that Nutrition Services staff should check these against physician-prescribed diet orders before each meal service. However, this procedure was not followed, leading to the deficiency.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that staff reported an allegation of abuse involving a resident. According to the facility's policy, any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and other officials as per state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations. In this case, a resident with a history of palliative care, hemiplegia, hemiparesis, and incontinence reported to a Certified Nurse Aide (CNA) that an aide had been rough and hurt them during care. The resident had intact cognition and required extensive assistance with daily living activities. Despite the resident's report, the CNA did not inform the charge nurse or the administrator, instead only telling another CNA. This failure to report was confirmed during interviews with the involved CNAs and the administrator, who was unaware of the incident until the surveyor's inquiry. The Social Service Director began an investigation after being informed by the surveyor, and the resident stated they felt safe and had no physical signs of abuse. The administrator expressed that staff are expected to report any allegations of rough treatment or harm to residents immediately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during a survey. This deficiency was identified through observations, record reviews, and interviews. Two residents were affected by medication errors during the administration process. Resident #78, who was admitted with a diagnosis of generalized muscle weakness, received a multivitamin with minerals instead of the prescribed multivitamin without minerals. The error occurred because the Licensed Vocational Nurse (LVN) did not verify the medication label against the physician's order before administration. Similarly, Resident #43, with a medical history of unspecified dementia and diabetes mellitus type 2, was also given a multivitamin with minerals instead of the ordered multivitamin. LVN #2 failed to check the medication label against the order or seek clarification before administering the medication. Interviews with the Director of Nursing and the Administrator revealed that the facility's expectation was for nurses to match the physician's order with the medication label to prevent such errors, which was not adhered to in these instances.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Observations and measurements revealed that 26 out of 40 resident rooms did not comply with this requirement, with room sizes ranging from 66.8 to 78.8 square feet per resident. Despite the deficiency, interviews with 24 residents indicated no expressed concerns about room size, and the Maintenance Director confirmed the accuracy of the room measurements. The Director of Nursing stated that the facility had a waiver for rooms not meeting the size requirement and expected care to be provided safely and with privacy. The Administrator confirmed there was no policy for room size but expected no difference in care quality for residents in smaller rooms. Both the DON and Administrator reported no complaints or issues related to care provision due to room size, and the Administrator emphasized that the current room sizes allowed for adequate care and privacy.
Failure to Notify LTC-Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman office of a resident's transfer to the hospital. Specifically, the facility did not send a copy of the transfer and discharge notification for a resident who was transferred to an acute hospital. This failure resulted in the LTC-Ombudsman being unaware of the resident's discharge circumstances, which could impact the ability to act promptly should appeals be filed by the resident or their representative. The resident involved had multiple diagnoses, including Metabolic Encephalopathy, Pneumonia, Type 2 Diabetes Mellitus, Hypertension, Congestive Heart Failure, and End Stage Renal Disease. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14 out of 15, the facility's Social Services Director admitted to not being aware of the requirement to notify the LTC-Ombudsman for hospital transfers. This oversight was confirmed by the LTC-Ombudsman, who stated that no transfer and discharge notifications were received from the facility for any residents transferred to the hospital.
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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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