Claremont Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, California.
- Location
- 621 W Bonita Ave, Claremont, California 91711
- CMS Provider Number
- 555085
- Inspections on file
- 37
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Claremont Manor Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to perform and/or document the required 20-year testing of quick-response sprinkler heads throughout all smoke compartments, as required by NFPA 25. During review of Life Safety records with the Director of Environmental Services, no documentation of a 20-year sprinkler test was available, despite the sprinklers being original to the building. Spare sprinkler heads in stock showed manufacturing dates from the late 1990s, and the outside testing company could not provide historical records to confirm that the mandated 20-year testing had ever been completed.
Surveyors found that the facility did not activate or transmit the fire alarm signal during multiple fire drills conducted during daytime and evening hours, as required by NFPA 101. Documentation showed that three drills held during non-nocturnal hours were recorded as having no alarm activation. In an interview, the DES stated that staff may have avoided pulling the alarm during a drill held around dinner time and also suggested there might have been documentation errors, but could not clearly explain the discrepancies. This practice was cited as having the potential to negatively affect the health and safety of residents, staff, and visitors.
Surveyors observed that an electrical outlet in Nursing Station 1's med room was installed 18 inches from a sink and was not equipped with a required ground-fault circuit interrupter (GFCI), as mandated by NFPA 70, National Electrical Code. The DES confirmed during the survey that this outlet lacked GFCI protection, resulting in a cited deficiency related to utilities and electrical safety in one of the facility’s smoke compartments.
A resident with intact cognition and independence in daily activities was verbally abused by another resident with cognitive impairment and a history of verbal aggression. The incident, which involved yelling, cursing, and threats, was witnessed by staff including an LVN, the Activities Director, and the DON. The affected resident was left scared and unusually quiet, indicating emotional distress. The facility's policy prohibits all forms of abuse, including resident-to-resident verbal abuse, but the event was not prevented.
A resident with severe cognitive impairment and multiple medical conditions made an allegation of sexual abuse to a CNA, who promptly informed an LVN and the DON. Although the police and Ombudsman were notified within the required two-hour window, the facility failed to report the allegation to the Department of Public Health within the mandated timeframe, as required by facility policy.
A resident with severe cognitive impairment was subjected to repeated loud instructions by an LVN, which staff perceived as verbal abuse. Multiple CNAs witnessed or were informed of the incident, but the allegation was not reported to the administrator or authorities within the required two-hour window. The delay in reporting was confirmed through staff interviews and documentation, in violation of facility policy and state regulations.
The facility failed to maintain an effective pest control program, resulting in cockroaches in the kitchen. Grease and dirt buildup were observed, and the kitchen had not been deep cleaned recently. The Infection Preventionist confirmed a 48-hour kitchen closure due to the issue. The facility lacked a pest control policy, and recommendations to address pest entry points had been pending. The facility's policies did not adequately address pest control, leading to the deficiency.
A resident with dementia and a history of falls was left unsupervised in their room, leading to a fall and injuries. Despite increased agitation and confusion, the resident's physician was not notified, and the resident was not adequately monitored. This failure to follow facility policies on dementia care and fall prevention resulted in the resident sustaining a laceration, bruising, and abrasions.
The facility failed to develop and implement individualized care plans for four residents, leading to potential unmet needs and incorrect care. A resident with a change in skin condition did not have a care plan for monitoring and intervention. Another resident on Eliquis lacked a care plan for anticoagulant use, and a resident on Quetiapine had no care plan for antipsychotic use. Additionally, a resident with dementia did not have a care plan addressing cognitive impairment and specific behaviors.
Two residents at a facility experienced inadequate pressure ulcer care and prevention. One resident's low air loss mattress was improperly set, reducing its effectiveness. Another resident did not receive documented repositioning, weekly skin assessments, or timely treatment for a pressure injury. The facility failed to follow its policy for skin and wound assessment, leading to potential worsening of pressure injuries.
The facility failed to document drug allergies accurately for two residents, leading to the administration of contraindicated medications. One resident received Ambien despite it being an allergy, and another had incorrect allergy documentation in their EMR. The discrepancies were not communicated to the pharmacy, posing a risk of adverse reactions.
The facility failed to follow infection prevention guidelines, including improper PPE use during peri-care for a resident under enhanced precautions, lack of a HEPA filtration system for a COVID-19 positive resident, and incorrect PPE use by a visitor. Additionally, a laundry aide prefilled disinfection logs, contrary to policy.
A facility failed to update a resident's code status in the EMR, leading to a discrepancy between a full code MD order and a signed DNR form. Staff interviews revealed that the inconsistency was noted but not corrected, risking incorrect emergency services for the resident.
A resident with Alzheimer's and psychosis showed increased agitation and confusion, attempting to stand unassisted from a wheelchair. The RN failed to notify the physician of this change, contrary to facility policy. Interviews confirmed this was a change in condition requiring immediate notification, which was not done.
A facility failed to ensure the SNFABN form was signed for a resident with severe cognitive impairment, potentially leading to uninformed decisions about denied medical coverage. The resident, diagnosed with dementia, hearing loss, and visual loss, lacked the capacity to make decisions. The Social Services Designee confirmed the absence of signatures could result in billing disputes.
The facility failed to update care plans for two residents, one with Alzheimer's and increased confusion, and another with depression and a change in Trazadone dosage. Staff observations and interviews confirmed the need for care plan revisions to ensure appropriate interventions and medication management, as per facility policies.
A resident with chronic respiratory failure and asthma was found with their nasal cannula disconnected from the oxygen concentrator, and the humidifier bottle was not labeled or dated as per facility policy. The resident expressed uncertainty about receiving oxygen, and staff interviews confirmed the oversight, highlighting the risk of infection and inadequate oxygen delivery.
A resident with a fracture requiring scheduled pain medication did not receive a Lidocaine patch as it was not delivered by the pharmacy on time. The facility's policy required medications to be administered within 60 minutes of the scheduled time, but this was not met, leading to a deficiency in pharmaceutical services.
A resident was prescribed Quetiapine without a documented diagnosis to support its use, despite having severe cognitive impairment and dependency on daily activities. Interviews with the PMHNP and DON confirmed the lack of a clear medical indication for the medication, which was contrary to the facility's policy requiring a thorough evaluation and documented diagnosis before administering psychotropic drugs.
The facility's kitchen failed to maintain sanitary conditions, risking foodborne illness for residents. Observations revealed a cook preparing food without a hairnet, expired food items stored improperly, and dented cans in the dry food area. Interviews with staff confirmed these practices violated facility policies on food safety and sanitation.
A resident with limited mobility and medical decision-making capacity was found with an inaccessible call light, contrary to facility policy. Staff interviews confirmed the call light should have been within reach, as per the facility's procedures.
A facility failed to report an alleged abuse incident involving a CNA and a resident within the required two-hour timeframe. The resident, with conditions like encephalopathy and heart failure, was allegedly subjected to inappropriate touching. The incident was reported to authorities three days late, violating the facility's abuse prevention policy.
A facility failed to remove a CNA from duties during an investigation into alleged inappropriate conduct with a resident. Despite a report of the CNA squeezing a resident's brief inappropriately, the CNA continued working their regular schedule. The resident involved had a history of encephalopathy and other conditions, and the facility's investigation could not substantiate the complaint.
A verbal altercation between two residents during a Cinco de Mayo celebration was not reported to the necessary authorities within the required timeframe. Despite being witnessed by the Activities Director, the incident involving threats and profane language was not communicated to the State Survey Agency, Long-Term Ombudsman, or local law enforcement until over 24 hours later, contrary to facility policy.
Failure to Perform and Document Required 20-Year Sprinkler Head Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct the required 20-year testing of quick-response sprinkler heads in accordance with NFPA 25. During an interview and record review with the Director of Environmental Services (DES), the facility’s Life Safety materials binder was found to lack any record of a 20-year sprinkler test for the quick-response sprinkler heads installed throughout all four smoke compartments. The DES reported that the sprinklers were original to the building, which was constructed in 1999, and stated that the required testing may have been done in 2009, but there was no documentation on site to verify that the test had occurred. Further observation and interview showed that spare quick-response sprinkler heads in the facility’s stock had manufacturing dates such as 1996 and 1999 printed on them, confirming the age of the system components. The DES indicated that the outside testing company was unable to locate records from that time period to confirm whether the 20-year sprinkler testing had been performed. As a result, there was no evidence available to demonstrate that the required 20-year sprinkler head testing had been completed for the sprinkler system serving all four smoke compartments, as required by NFPA 25 and related Life Safety Code provisions.
Plan Of Correction
K353 – Sprinkler System Maintenance and Testing (NFPA 25) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately contacted a licensed fire protection vendor to schedule the required 20-year sprinkler head testing. The sprinkler system remains fully operational and monitored, ensuring continued fire protection coverage while corrective actions are implemented. 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. On 3/13/2026, the Director of Environmental Services (DES) conducted a review of all available Life Safety documentation to confirm the absence of records for the 20-year sprinkler testing across all smoke compartments. The contracted licensed vendor has been engaged and performed testing on representative sprinkler heads throughout the facility in accordance with NFPA 25 standards on 3/19/2026. Response time, response time index and water seal release all passed. The report is dated 3/20/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a Life Safety compliance tracking system that includes all required inspection, testing, and maintenance schedules in accordance with NFPA 25. On 3/13/2026, the DES re-educated staff on regulatory requirements for sprinkler system testing, including 20-year testing requirements for quick-response sprinkler heads. The facility will maintain all Life Safety documentation in a centralized, secure, and readily accessible binder and electronic file. Additionally, the facility will contract with a licensed fire protection vendor to ensure ongoing compliance with all inspection and testing requirements. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that 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. The DES or designee will track all required Life Safety inspections and testing through a compliance calendar and conduct monthly audits to ensure all required documentation is current and on file. Results of these audits will be reported to the Administrator and reviewed quarterly in the Quality Assurance and Performance Improvement (QAPI) committee meeting. Any identified gaps will be addressed immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.
Failure to Activate Fire Alarm System During Day and Evening Fire Drills
Penalty
Summary
Surveyors identified a deficiency in the facility’s conduct of fire drills, specifically the failure to activate and transmit the fire alarm signal during drills that occurred between 6:00 a.m. and 9:00 p.m., as required by NFPA 101, 2012 Edition, Section 19.7.1. Review of the Life Safety materials binder on 3/12/2026 showed that three of twelve documented fire drills—held at 9:30 a.m. on 4/8/2025, 5:30 p.m. on 5/2/2025, and 8:30 p.m. on 8/19/2025—were conducted outside the nocturnal hours of 9:00 p.m. to 6:00 a.m., yet the records indicated that the fire alarms were not activated during these drills. During an interview, the DES reported that for the 5:30 p.m. drill, staff may have chosen not to pull the alarm because it occurred around dinner time, and also suggested that the technician might have mistakenly documented that alarms were not activated, but the DES could not explain why the records were marked that way. This deficient practice was cited as having the potential to negatively affect staff response during an actual fire emergency, potentially affecting the health and safety of residents, staff, and visitors.
Plan Of Correction
K712 – Fire Drills (NFPA 101) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the Director of Environmental Services (DES) immediately re-educated staff responsible for conducting fire drills on requirements to activate and transmit the fire alarm signal during all drills conducted between 6:00 a.m. and 9:00 p.m. Fire drill procedures were reinforced to ensure compliance with NFPA 101 standards. 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. On 3/13/2026, the DES conducted a review of all fire drill documentation for the past 12 months to ensure compliance with required alarm activation and documentation standards. Any identified discrepancies were reviewed, and staff involved were re-educated on proper fire drill procedures. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has revised its fire drill policy to clearly require activation of the fire alarm system during all drills conducted between 6:00 a.m. and 9:00 p.m. On 3/12/2026, the DES contacted the company responsible for fire drills to ensure understanding of regulatory requirements, proper documentation, and expectations. On 3/31/2026 the DES in-serviced staff on compliance with required alarm activation and documentation standards. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that 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. The DES or designee will review all fire drill documentation monthly for 3 months to ensure compliance with alarm activation requirements and proper documentation. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any identified issues will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Non-GFCI Electrical Outlet Near Sink in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure electrical safety in accordance with NFPA 70, National Electrical Code, 2011 Edition, Section 210.8. During an observation in Nursing Station 1's medication room, an electrical outlet was identified 18 inches from a sink that was not equipped with the required ground-fault circuit interrupter (GFCI). The Director of Environmental Services (DES) was present during the observation and confirmed that the outlet, located near the sink, did not have a GFCI. This deficiency affected one of four smoke compartments and was cited as noncompliance with NFPA 101 requirements for utilities, gas, and electric systems. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on the physical environment and the noncompliant electrical installation near the sink in the medication room.
Plan Of Correction
K511 - Utilities - Gas and Electric (NFPA 70) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately removed the outlet from use and implemented interim safety measures. A licensed electrician was contacted to install a GFCI-protected outlet at Nursing Station 1 medication room sink area. The GFCI outlet was installed on 3/12/2026 to ensure compliance with NFPA 70 requirements and reduce risk of electrical shock. 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. On 3/12/2026, the Director of Environmental Services (DES) conducted a facility-wide audit of all electrical outlets located within proximity to water sources, including medication rooms, kitchen areas, and resident care areas. Any outlets identified as not GFCI-protected were immediately removed from service and scheduled for correction by a licensed electrician. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a preventive maintenance program that includes routine inspection of all electrical outlets near water sources for GFCI compliance. On 3/13/2026, the DES re-educated staff on NFPA 70 requirements, specifically related to GFCI installation near sinks and wet locations. The facility will ensure that all future electrical work is reviewed for compliance with applicable codes and completed by licensed professionals. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that 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. The DES or designee will conduct weekly environmental rounds for 3 months to ensure all outlets near water sources are GFCI-protected and functioning properly. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any deficiencies will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse when one resident verbally threatened, cursed, and yelled at another resident in the activities room. The resident who was verbally abused had intact cognitive skills and was generally independent in daily activities, while the resident who initiated the verbal aggression had moderately impaired cognitive skills and a history of verbal aggression. Multiple staff members, including an LVN, the Activities Director, and the Director of Nursing, directly observed or were made aware of the incident, which involved one resident yelling, cursing, and threatening to physically harm another resident. Following the incident, the affected resident was observed to be scared, upset, and unusually quiet for the remainder of the shift. The facility's policy explicitly states a zero-tolerance approach to any form of abuse, including resident-to-resident abuse, and defines verbal abuse as yelling, cursing, and threatening another resident. Despite this policy, the incident occurred and was witnessed by staff, with the affected resident experiencing emotional distress as a result. The report documents that the facility did not prevent the occurrence of verbal abuse between residents, as required by their own policy and regulatory standards.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health within the required two-hour timeframe, as specified in the facility's policy and procedure. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and hypertension, was assessed as severely impaired in cognitive skills and required significant assistance with daily activities. On the morning of the incident, the resident reported an allegation of sexual abuse to a CNA, who then informed an LVN. The LVN subsequently notified the Director of Nursing (DON) and stated that all allegations of abuse must be reported within two hours to the police, Ombudsman, and the Department. Despite the internal notifications, the facility did not report the allegation to the Department within the required two-hour window. The administrator confirmed that the report to the Department was faxed more than three hours after the initial allegation was made, although notifications to the police and Ombudsman were made within the required timeframe. The facility's policy, revised in April 2018, clearly states that any observed, suspected, or known abuse must be reported to the Department, Ombudsman, law enforcement, and the administrator immediately, but not later than two hours.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving a resident with severe cognitive impairment was reported immediately, but no later than two hours after the allegation was made, as required by facility policy and state regulations. The resident, who had diagnoses including Alzheimer's disease and unspecified psychosis, was observed by staff attempting to get up from a wheelchair. During this event, a Licensed Vocational Nurse (LVN) was reported by multiple Certified Nursing Assistants (CNAs) to have repeatedly and loudly instructed the resident to sit down, which was perceived as yelling and considered by staff to be a form of verbal abuse. Despite the incident occurring on the same day as a documented fall, the allegation of abuse was not reported to the facility administrator or other required authorities within the mandated two-hour timeframe. Interviews with staff, including the Director of Staff Development (DSD), revealed that the administrator was not notified until the day after the incident, and the official report to the State Agency was not completed until over a month later. Facility policy and in-service training materials clearly stated that all suspected abuse must be reported immediately to the administrator and appropriate authorities. Documentation reviewed included progress notes, staff statements, and the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), all of which confirmed the delay in reporting. The failure to promptly notify the administrator and external agencies as required resulted in a delay in initiating protective measures and investigation for the resident involved.
Facility Lacks Effective Pest Control Program, Leading to Cockroach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in the kitchen of a 59-bed facility. During an inspection, grease and dirt buildup were observed on the pipes and kitchen exhaust hood, and cockroaches were found near the dishwashing area. The kitchen had not undergone a deep cleaning recently, and the head chef, who was new to the facility, was unaware of the last deep cleaning date. The kitchen staff performed daily cleaning, but it was insufficient to prevent pest infestation. The Infection Preventionist (IP) confirmed that the kitchen had been closed for 48 hours due to the cockroach issue, and no food from the kitchen would be served to residents after lunch on the day of the inspection. The Director of Environmental Services (DES) and Housekeeping Supervisor (HKS) stated that a professional deep cleaning was conducted twice a year, with the last one completed several months prior. However, the housekeeping department did not clean the kitchen area, leaving it to the kitchen staff. The facility lacked a pest control policy, and the Administrator, who was also new, relied on vendor recommendations for pest control services. A review of vendor receipts revealed that recommendations to remove debris and seal entry points for pests had been pending since the previous year. The facility's policies did not include specific cleaning protocols for the kitchen, and the Infection Prevention & Control Program did not adequately address pest control measures. The U.S. Food & Drug Administration Food Code requires effective measures to eliminate pests in food establishments, which the facility failed to implement, leading to the observed deficiency.
Failure to Prevent Fall in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, leading to a fall and subsequent injuries. The resident, who had a history of Alzheimer's Disease and psychosis, was admitted to the facility with an unsteady gait and poor balance, making them at risk for falls. Despite these known risks, the facility did not ensure that the resident received adequate supervision or that their physician was notified of changes in their condition, such as increased agitation and confusion. On the day of the incident, the resident attempted to stand up unassisted from their wheelchair multiple times, indicating a change in condition that required immediate attention. However, the registered nurse failed to notify the resident's physician about these changes, as required by the facility's policy. Additionally, a certified nurse assistant took the resident to their room and left them unsupervised in bed, despite the resident's increased confusion and agitation. This lack of supervision resulted in the resident falling out of bed, sustaining a laceration, bruising, and abrasions. Interviews with staff revealed that the resident was known to be at risk for falls and required constant monitoring. However, there was a breakdown in communication and supervision, as the resident was left unsupervised in their room, leading to the fall. The facility's policies on dementia care, change in resident condition, and fall prevention were not followed, contributing to the incident and the resident's injuries.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for four residents, leading to potential unmet needs and incorrect care. Resident 37 experienced a change in skin condition on 1/11/2025, but a care plan was not developed to address this change. The resident's records indicated a new order for Optifoam dressing for protection, but no care plan was created to monitor and implement specific interventions for the unstageable pressure injury or deep tissue injury identified. Resident 27 was receiving Eliquis for atrial fibrillation, but there was no care plan for anticoagulant use. This omission meant there was no identification of the resident as high risk for bleeding or bruising, which could guide staff in implementing necessary interventions. Similarly, Resident 6 was on Quetiapine for poor impulse control, but no care plan was developed for antipsychotic use, leaving staff without guidance on monitoring the drug, its goals, and specific interventions for the resident's behavior. Resident 5, diagnosed with dementia, did not have a care plan addressing cognitive impairment and specific behaviors related to dementia. The absence of a care plan for this resident meant that their needs and continuity of care, especially concerning behavioral issues, were not adequately addressed. The facility's policy and procedure required comprehensive care plans to be developed within 14 days and updated quarterly or upon a change of condition, but these requirements were not met for the residents in question.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, Resident 32 and Resident 37, who were at risk for skin breakdown and pressure injuries. For Resident 32, the low air loss (LAL) mattress was improperly set at 550 pounds, despite the resident weighing only 138 pounds. This incorrect setting reduced the mattress's effectiveness in redistributing pressure and managing moisture, which are critical for preventing skin damage and pressure injuries. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the mattress setting was too high and emphasized the importance of adjusting it according to the resident's weight to ensure effective pressure relief and prevent skin damage. Resident 37 experienced multiple deficiencies in care related to pressure ulcer prevention and treatment. The facility failed to document evidence of repositioning every two hours during the night shift over a month-long period, as required by the resident's care plan. Additionally, weekly skin assessments were not performed as indicated, and treatment for an unstageable pressure injury on the coccyx was missed on one occasion. The facility also delayed the initiation of pressure-relieving devices when the pressure injury was discovered. The Infection Prevention Nurse (IPN) and Registered Nurse (RN) acknowledged these lapses, noting that the lack of documentation and missed treatments could lead to worsening of the pressure injury. The facility's policy and procedure for skin and wound assessment and treatment were not followed, as evidenced by the lack of a change of condition documentation and the failure to implement a low air loss mattress promptly for Resident 37. The Director of Nursing and other staff members recognized the importance of creating a change of condition to inform the care team and ensure proper monitoring and treatment of pressure injuries. The deficiencies in care for both residents had the potential to result in the development of new pressure injuries and the worsening of existing ones.
Failure to Document Drug Allergies Accurately
Penalty
Summary
The facility failed to implement its policy on ordering and receiving non-controlled medications for two residents, leading to incorrect documentation of drug allergies in their electronic medical records (EMR). Resident 28, who had 12 documented drug allergies, received Ambien nine times in December 2024, despite it being listed as an allergy. Additionally, Resident 27's EMR did not reflect allergies to clindamycin and Norco, and incorrectly listed allergies to prednisone and prednisolone. Resident 28 was admitted with diagnoses including major depressive disorder, muscle weakness, and atrial fibrillation. Despite having intact cognitive abilities, Resident 28's EMR failed to accurately reflect their drug allergies, leading to the administration of Ambien, which was known to cause anxiety in this resident. Similarly, Resident 27, who had chronic systolic heart failure and hyperlipidemia, reported allergies to penicillin, sulfa, Norco, and some antibiotics, which were not accurately documented in their EMR. Interviews with staff and record reviews revealed that the discrepancies in allergy documentation were not communicated to the pharmacy, which could lead to the administration of contraindicated medications. The Director of Nursing acknowledged that the EMR's failure to trigger alerts for drug allergies posed a risk of adverse reactions, including anaphylaxis, due to incorrect allergy documentation.
Infection Control Lapses in PPE Use and Environmental Measures
Penalty
Summary
The facility failed to adhere to its infection prevention guidelines in several instances, leading to potential risks of infection transmission. In one case, a Certified Nursing Assistant (CNA) entered a resident's room without donning the required gown, despite the room being under enhanced barrier precautions due to the resident's medical condition. The CNA proceeded to perform peri-care without the appropriate personal protective equipment (PPE), which was acknowledged as a necessary measure to prevent the spread of multidrug-resistant organisms (MDROs). The Infection Prevention Nurse confirmed that proper PPE, including gowns and gloves, should have been used during such high-contact activities. In another instance, the facility did not follow its policy regarding the use of a portable HEPA filtration system for a resident who tested positive for COVID-19. The resident's door was left open to monitor for fall risks, but no air purifier was placed in the room, contrary to the facility's infection control policy. This oversight was acknowledged by both the Licensed Vocational Nurse and the Infection Prevention Nurse, who noted that the absence of an air purifier increased the risk of COVID-19 transmission to other residents, staff, and visitors. Additionally, a family member visiting the COVID-19 positive resident was observed not wearing the correct PPE, including gloves, a face shield, and a properly fitted N95 mask. The Infection Prevention Nurse noted that visitors are required to don all necessary PPE to prevent the spread of infection. Furthermore, a laundry aide prefilled disinfection logs, indicating tasks were completed before they were actually done, which was against the facility's policy. This practice was confirmed by the Environmental Services Director, who emphasized that logs should only be signed after tasks are completed to ensure proper infection control measures are followed.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to implement its policy on Advance Directives by not ensuring the correct code status for a resident, referred to as Resident 27. Resident 27 had a Medical Doctor (MD) order for full code status, which indicates that all lifesaving procedures should be performed if the resident's heart stops or they stop breathing. However, there was also an Emergency Medical Services Prehospital Do Not Resuscitate (EMSPDNR) form signed, indicating a DNR status, which means no cardiopulmonary resuscitation should be performed. This inconsistency in documentation could lead to Resident 27 receiving incorrect emergency services. Interviews with staff, including a Licensed Vocational Nurse (LVN 1), the Social Services Designee (SSD), and the Director of Nursing (DON), revealed that the discrepancy was noted but not corrected in the electronic medical record (EMR). The SSD confirmed that the responsible party for Resident 27 had signed the DNR form, but the EMR still reflected a full code status. The DON acknowledged that the nursing staff should have updated the code status in the EMR upon seeing the signed EMSPDNR form. The facility's policy on Advance Directives requires staff to verify and update code statuses, which was not followed in this case.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 1) notified the physician (MD 1) regarding a change in condition for a resident (Resident 92). On 1/20/2025, Resident 92, who was diagnosed with Alzheimer's Disease and psychosis, exhibited increased agitation and confusion, attempting to stand unassisted from a wheelchair multiple times. Despite these changes, RN 1 did not inform MD 1 about the resident's altered condition, which was against the facility's policy and procedure for notifying physicians of changes in resident conditions. Interviews with the Director of Nursing (DON) and the RN Consultant (RNC) confirmed that the increased confusion and attempts to stand unassisted were considered a change in condition, requiring immediate notification to the physician. The hospice registered nurse (HRN 1) also indicated that the hospice agency was not informed of the resident's increased confusion, which would have prompted further assessment and potential intervention. The facility's policy, revised in 2016, mandates timely communication of any sudden or serious change in a resident's condition to the physician, which was not adhered to in this case.
Failure to Obtain Signed SNFABN Form for Resident
Penalty
Summary
The facility failed to ensure that the Advance Beneficiary Notice of Non-coverage (SNFABN) form was signed for a resident, identified as Resident 26. This form is crucial as it informs residents or their responsible parties about potential non-coverage of certain services by Medicare. The deficiency was identified during a review of Resident 26's records, which showed that the SNFABN form was not signed by either the resident or their responsible party. The Social Services Designee (SSD) confirmed that the absence of signatures on the SNFABN form could lead to disputes over billing and costs, as it indicates that the resident or their responsible party was not informed about the services and associated costs after the last covered date. Resident 26 was originally admitted to the facility with diagnoses including dementia, hearing loss, and visual loss, and was readmitted later. The resident's cognitive abilities were severely impaired, as indicated by the Minimum Data Set (MDS) and the History and Physical (H&P) documents, which noted that Resident 26 lacked the capacity to understand and make decisions. The facility's failure to have the SNFABN form signed meant that the resident or their responsible party might not have been able to make informed decisions regarding potential denied medical coverage.
Failure to Update Care Plans for Residents with Cognitive and Depressive Disorders
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident 92, diagnosed with Alzheimer's Disease and psychosis, experienced increased confusion and agitation, as observed by staff on multiple occasions. Despite these changes, the resident's care plan was not updated to reflect the need for increased monitoring and interventions. Interviews with staff confirmed that the care plan should have been revised to address the resident's altered cognitive function and ensure appropriate care. Similarly, Resident 5, who has dementia and a depressive disorder, was prescribed Trazadone 100 mg for depression, but the care plan was not updated to reflect this change in medication dosage. The care plan still indicated a previous dosage of 50 mg, which did not align with the current physician's order. Staff interviews highlighted the importance of updating care plans to ensure that all staff are aware of the current treatment regimen and can provide proper care. The facility's policies on care planning and changes in resident condition emphasize the need for timely updates to care plans, which were not adhered to in these cases.
Failure to Implement Oxygen Therapy Policy
Penalty
Summary
The facility failed to adhere to its policy on Oxygen Therapy, resulting in a deficiency related to the care of a resident requiring supplemental oxygen. During an observation, it was noted that the resident's nasal cannula tubing was disconnected from the oxygen concentrator machine and was found on the floor, while the machine was still running at 3 liters. Additionally, the humidifier bottle attached to the oxygen concentrator was not labeled or dated as required by the facility's policy. The resident, who was admitted with chronic respiratory failure, asthma, and a dependence on supplemental oxygen, expressed uncertainty about receiving oxygen through the nasal cannula. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staff is responsible for dating the humidifier bottle, which should be changed weekly, and ensuring the nasal cannula is properly connected. The LVN acknowledged that the disconnection might have occurred accidentally during repositioning and emphasized the risk of infection from the nasal cannula touching the floor. The DON confirmed that the humidifier bottle should be dated to track its usage duration and reiterated the importance of connecting the nasal cannula to ensure the resident receives the necessary oxygen therapy.
Failure to Provide Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a routine pain medication was available for a resident, leading to a deficiency in pharmaceutical services. The resident, who was admitted with a diagnosis of an unspecified fracture of the lower end of the left humerus, was on a scheduled pain medication regimen that included a Lidocaine external patch for pain relief. The Minimum Data Set indicated that the resident had frequent pain and required both scheduled and as-needed pain medication. However, during a medication administration observation, it was noted that the Lidocaine patch was not applied as scheduled because it was not available at the facility. Interviews with the Licensed Vocational Nurses (LVNs) revealed that the patch was not delivered by the pharmacy in time for the scheduled administration. The facility's Medication Administration Policy and Procedure required medications to be administered within 60 minutes of the scheduled time, but this was not adhered to due to the unavailability of the medication. The resident expressed the need for the Lidocaine patch to manage pain in the right shoulder, which was used more frequently than the left. The delay in medication delivery and administration was documented in the resident's Medication Administration Record and Progress Notes.
Inappropriate Use of Psychotropic Medication Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for one of the sampled residents, identified as Resident 32. The resident was prescribed Quetiapine, a medication used to treat bipolar disorder and schizophrenia, without a clear, documented diagnosis in the medical record to support its use. The resident's Admission Record indicated diagnoses of hemiplegia/hemiparesis, muscle weakness, and a need for assistance with personal care. The Minimum Data Set showed severe cognitive impairment and dependency on activities of daily living and mobility. Despite these conditions, there was no documented diagnosis justifying the use of Quetiapine for the resident's impulse control disorder, which was manifested by constantly calling for help. Interviews with the Psychiatric-Mental Health Nurse Practitioner and the Director of Nursing revealed that the prescription of Quetiapine was inappropriate due to the lack of a documented diagnosis. The facility's policy on psychotherapeutic medication use emphasized the need for a thorough clinical evaluation and a clear diagnosis before administering such medications. The policy also required gradual dose reductions and behavioral interventions unless clinically contraindicated. The failure to adhere to these guidelines resulted in the potential for unnecessary use of psychotropic drugs, which could lead to side effects and adverse consequences for Resident 32.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that the dietary staff stored and prepared food under sanitary conditions in the kitchen, which placed residents at risk for foodborne illness. During an observation, a cook was seen preparing rice while wearing a ball cap without a hairnet underneath, which is against the facility's policy for proper hair containment during food preparation. Additionally, expired food items, including cottage cheese containers and a cake mix, were found stored in the refrigerator and dry food area, respectively. Dented cans of marinara sauce were also stored in the dry food area, which could compromise the safety and integrity of the food. Interviews with the Sous-Chef and the Director of Dining Services confirmed that these practices were not in line with the facility's policies and procedures. Both staff members acknowledged that expired food should not be stored and that dented cans should be discarded due to the risk of contamination and potential for foodborne illness. They also emphasized the importance of wearing hairnets to prevent food contamination. The facility's policy on Food-Nutrition Services requires adherence to professional standards for food service safety, including proper sanitation and food handling practices to prevent foodborne illness.
Call Light Inaccessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 4, who was observed lying in bed with the mechanical pad call button tucked and hanging on the backside of the bed between the wall and the headboard, making it inaccessible. Resident 4 had been admitted with diagnoses including contracture of muscle, hemiplegia/hemiparesis, and age-related osteoporosis, and was dependent on assistance for activities of daily living and mobility. The resident could make needs known but could not make medical decisions, highlighting the importance of having the call light within reach. Interviews with staff, including a CNA and the DON, confirmed that the call light should have been clipped to the resident's gown or side rail for easy accessibility. The facility's policy and procedure on the call system, revised in 2009, stated that call cords should be placed within the resident's reach at all times. The failure to adhere to this policy had the potential to delay or prevent Resident 4 from obtaining necessary care and services.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the California Department of Public Health (CDPH) and law enforcement within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA) who allegedly squeezed the resident's brief around the genitalia area to check if it was wet. The facility's investigation commenced on September 13, 2024, after receiving a complaint through the corporate compliance department. However, the incident was not reported to the CDPH, local police, and Ombudsman until September 16, 2024, which was beyond the mandated reporting period. The resident involved had been admitted to the facility with diagnoses including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but unable to make medical decisions. The facility's abuse prevention policy and procedure required immediate reporting of suspected abuse resulting in serious bodily injury within two hours. The delay in reporting this incident resulted in a deficiency, as it had the potential to subject residents to further abuse.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to immediately remove a potential threat to a resident after receiving a report of alleged inappropriate conduct by a Certified Nursing Assistant (CNA). The incident involved CNA 1, who was reported to have squeezed a resident's brief around the genitalia area to check if it was wet. Despite the report, the facility did not suspend CNA 1 from resident care duties during the investigation, which is contrary to the facility's abuse prevention policy that mandates making every attempt to prevent further potential abuse while an investigation is in progress. Resident 2, who was involved in the incident, had a medical history including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but could not make medical decisions. The facility's investigation report, which commenced on the same day the complaint was received, was unable to substantiate the complaint of inappropriate touching. However, CNA 1 continued to work their regular schedule throughout the investigation period, indicating a failure to adhere to the facility's policy of non-tolerance towards any form of behavior that might be construed as abuse.
Delayed Reporting of Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged verbal abuse incident involving two residents within the required timeframe to the State Survey Agency, Long-Term Ombudsman, and local law enforcement. The incident occurred in the dining room during a Cinco de Mayo celebration, where one resident verbally threatened another. Despite the altercation being witnessed by the Activities Director, it was not reported immediately to the appropriate authorities or facility staff, leading to a delay in addressing the situation. Resident 2, who was admitted with multiple diagnoses including hypertensive heart disease and moderate cognitive impairment, was involved in a verbal altercation with Resident 3. Resident 3, also with multiple diagnoses and moderate cognitive impairment, was reported to have used profane language and threatened Resident 2. The altercation was documented by a Licensed Vocational Nurse and later communicated to the Director of Nursing, who notified the Primary Care Provider. However, the incident was not reported to the necessary external agencies until more than 24 hours later. The facility's policy requires immediate reporting of any suspected abuse to the relevant authorities within two hours. Interviews with staff revealed a lack of immediate action and communication regarding the incident, contributing to the delay in reporting. The Administrator confirmed the late reporting, which was contrary to the facility's established procedures for handling abuse allegations.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
