Desert Springs Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Desert, California.
- Location
- 74-350 Country Club Drive, Palm Desert, California 92260
- CMS Provider Number
- 555339
- Inspections on file
- 87
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Desert Springs Post Acute during CMS and state inspections, most recent first.
A resident’s 9 a.m. meds were documented as given before they were actually administered, and empagliflozin was ordered for DM even though the resident had no documented DM diagnosis. For another resident, PRN Norco lacked required pain and effectiveness documentation, and Senna-S was charted as administered despite refusal. Meal service errors also occurred when a resident received another resident’s tray, and no LPN checked the trays for 18 residents before CNAs served them.
Two residents with ESRD did not receive appropriate dialysis-related care. One resident’s CVC site was not assessed or maintained and he received more fluids than ordered, with drainage and pain noted at the access site and repeated fluid intake above the prescribed limit. Another resident repeatedly refused dialysis because of the scheduled time, but the facility did not document coordination with the dialysis clinic or provide documented care for the exposed CVC site while treatments were missed.
Insufficient CNA Staffing and Below-Minimum Direct Care Hours: The facility failed to maintain the required minimum CNA DHPPD of 2.4 hours on multiple weekend dates over several months. Interviews with CNAs and the DSD showed staff were caring for 10 to 13 residents each on the morning shift, and staff reported there were not enough CNAs to meet resident needs or respond promptly to call lights. The facility policy stated sufficient nursing staff would be provided and state minimum staffing requirements would be followed.
Medication administration and controlled substance documentation were not completed in accordance with prescriber orders and facility policy. A resident with ESRD did not receive calcium acetate with meals as ordered, an LPN did not administer lisinopril according to its BP holding parameters, and oxycodone records for two residents did not reconcile between the MAR and CDR, with missing documentation of removals, administrations, and pain assessments.
Medication administration errors exceeded the allowed rate when an LPN failed to follow orders for two residents. One resident’s meds that were ordered with food were given without food, one ordered dose was omitted, and another dose was later given without the required food. For another resident, a vitamin was documented as given but was not actually administered, and the nurse did not instruct the resident to rinse and spit after budesonide nebulizer treatment as ordered.
Improper Medication Storage and Labeling: An opened ophthalmic med for a resident was stored without an opened date and with an uncapped dropper tip covered by tissue. Discontinued meds, including CS, remained in med carts for two residents after discharge or discontinuation, and expired house supply famotidine plus opened inhalers for two residents were stored with active meds without opened dates, despite staff confirming the items were expired or should have been removed.
A physician-prescribed fortified diet was not provided to four residents during lunch. Staff reviewed meal tickets and trays and found that the ordered extra gravy and melted margarine were missing from the served meals, even though the dietary spreadsheet directed those additions and the DD confirmed they were required to provide extra calories.
Meal trays were not delivered timely and food was served at inappropriate temperatures for several residents. Residents reported cold, late, poorly flavored, and sometimes unidentifiable meals, while observation showed trays sitting in a hallway cart until CNAs distributed them and a test meal revealed milk and juice temperatures below policy standards and a hot entree below the expected serving temperature.
Unsafe food storage and kitchen sanitation practices were observed when an aide washed meal carts with detergent and sanitized them without rinsing first, a hot waterspout had calcium buildup, two expired sandwiches were stored in the nourishment refrigerator, multiple kitchen surfaces and equipment had dust or debris, and the drain under the 3-compartment sinks had chipped paint. The DON confirmed these conditions and the facility policies required carts, equipment, and food storage areas to be kept clean, in good repair, and free of expired food.
Homelike Environment and Personal Property Failures: A resident was repeatedly exposed to loud screaming from confused residents in the hallway, with staff not responding to call-bell use and the DON acknowledging the noise disrupted a homelike environment. Another resident had clothes and a blanket left on the floor of her room after repeated requests for help, and staff described assisting residents with keeping rooms tidy as part of routine care. A third resident’s wallet and credit card were not kept secure, the wallet was later found missing and then recovered in a bathroom, and unauthorized charges were identified on one of the cards.
A resident with glaucoma had two eye drops at the bedside and stated she used them on herself, while staff were aware of the medications. The resident had an order for Latanoprost, but there was no physician order for the Sodium Chloride Hypertonicity Solution or artificial tears, and no documented assessment for safe self-administration. The DON confirmed an assessment and self-administration order were needed before the resident could use the eye drops herself.
A resident with psychosis, schizoaffective disorder, depression, and anxiety received risperidone, mirtazapine, and buspirone as ordered, but the chart lacked documentation that NPIs were attempted, implemented, monitored, or found contraindicated. The care plan called for non-pharmacological approaches before medication use, and the DON confirmed the NPI order set had not been added to the resident’s chart; the PNP was unaware NPIs had not been implemented.
Failure to Provide Needed ADL Assistance and Supervision: A resident with dementia and severe cognitive impairment was assessed as needing supervision or touching assistance with dressing, hygiene, and bathing, but was repeatedly observed wearing the same outfit over multiple days. CNA and LVN interviews showed the resident was documented as independent with ADLs despite the DON stating she required supervision/assistance and had a history of refusing care that was not care planned. The resident’s closet was nearly empty, and staff did not report that she refused dressing assistance during the shift reviewed.
Two residents had new skin concerns that were not timely assessed, documented, or reported for treatment orders. One resident had a red, raised, scaly area on the wrist that had been present for months without documented nurse follow-up, while another resident had redness and itching on the neck with no documented skin assessment or physician notification. Staff interviews and record review showed the conditions were observed, but the required documentation and escalation were not completed.
A resident with a recent suicidal attempt was ordered for 1:1 sitter monitoring, but staff repeatedly left the resident alone in the room without continuous bedside observation. In a separate issue, another resident who smoked and used O2 had cigarettes and a lighter at bedside even though the smoking assessment and care plan required supervision and storage of smoking items in the nurse’s station.
A resident with dementia, heart failure, and Type II DM experienced significant wt loss while on a CCHO, NAS, minced and moist diet with ONS and fortified foods. Staff and RD notes documented variable intake and weekly wt changes, but ONS intake was not individually recorded in the EMR, and the DON could not determine how much the resident consumed. The DON and RD also stated the intake documentation was too vague to show whether the resident’s diet was meeting nutritional needs.
A resident receiving continuous oxygen via nasal cannula was found with tubing last changed more than a week earlier, despite physician orders and facility policy requiring weekly changes. An LVN and the IP both confirmed the cannula should have been changed on the prior Sunday, and the resident’s record showed diagnoses including shortness of breath and fluctuating decision-making capacity.
A resident with ESRD reported arm and shoulder pain and requested acetaminophen, but the LPN did not give medication because there was no MD order. The MAR showed pain rated 7/10, yet there was no documentation of non-pharmacological interventions, no pain medication ordered at the time, and no evidence the resident received pain relief after the complaint. Staff later documented attempts to notify the MD, and interviews confirmed the nurse did not escalate the issue to the DON when the MD did not respond.
Failure to Obtain Ordered UA with C&S: A resident with an indwelling foley catheter and a history of UTI had hematuria noted in the catheter, and the MD ordered a UA with C&S to rule out UTI. Record review and staff interviews showed the specimen was not collected as ordered and the lab was not notified through the lab software, despite the facility’s process requiring the nurse to obtain the specimen and arrange lab pick-up.
Failure to follow up on dental treatment after extractions. A resident with RA, enterocolitis, swallowing/nutritional concerns, and moderate cognitive impairment was observed without dentures and stated she wanted them. The dentist recommended full extractions with immediate full dentures, but after extractions were completed, the record showed no documented follow-up with the dental provider regarding denture impressions or denture status. The RDH later noted the resident was missing too many teeth to chew and break down food properly, and the SSM stated she did not follow up after the dental visit.
Failure to provide ordered adaptive eating utensils during meals. A resident with Parkinson's disease and trembling hands was observed self-feeding with a shaking hand while food dropped onto clothing and the floor. The meal ticket listed buildup utensils, and the OT confirmed the physician had ordered weighted utensils with meals due to tremor, but the utensils were not on the tray. The RNA and DD both stated the resident should have received the adaptive utensils with meals.
The facility failed to ensure safe and sanitary storage and consumption of food brought in by family and visitors. Staff gave inconsistent answers about how long such food could remain in the nourishment refrigerator, while the facility policy stated that items without a manufacturer expiration date must be dated on arrival and discarded 2 days later.
A resident with severe cognitive impairment and known wandering behavior repeatedly entered other residents’ rooms and used their bathrooms without permission, despite staff awareness of her tendency to wander. One resident with moderate cognitive impairment reported that the wandering resident entered his room and was found by an LVN sitting on his toilet, leaving him upset and angry that his requests for her to stay out were ignored and that staff did not prevent her entry. Another cognitively intact resident with a history of stroke and left-sided weakness reported that the same wandering resident had come into his room to use his bathroom on multiple occasions, prompting him to question why staff did not intervene. The DON acknowledged that residents have the right to refuse others in their rooms or bathrooms and confirmed that these entries violated those residents’ privacy rights, while the existing care plan for the wandering resident lacked specific interventions for her elopement and wandering behavior.
Surveyors found that the facility failed to ensure appropriate clinical monitoring and timely response to changes in condition for two residents. One resident with diabetes had an elevated HgbA1C and frequent blood glucose readings over 200 mg/dL with repeated sliding-scale Humalog administration, but there was no evidence of repeat HgbA1C testing or physician notification for possible adjustment of insulin therapy, despite facility diabetes protocols requiring periodic A1C monitoring and evaluation when short-acting insulin is used frequently. Another resident with serious medical conditions had multiple documented episodes of diarrhea over several days, yet there was no documentation that these loose stools were addressed or reported to a physician until the resident later developed N/V/D and abdominal tenderness, at which point diagnostic testing confirmed C. diff infection; the DON acknowledged this delay was inconsistent with the facility’s change-in-condition policy.
Surveyors found that staff did not follow the facility’s infection control policies and CDC guidance for residents on isolation precautions. Multiple staff entered rooms of residents with C. diff wearing incomplete PPE, failed to perform hand hygiene with soap and water after exiting, and sometimes relied only on ABHR. In several cases, staff donned PPE without cleaning their hands first. Isolation signage on room doors did not match MD orders: a resident with metapneumovirus on droplet precautions was labeled for contact/C. diff, a resident with influenza on droplet precautions had only Enhanced Barrier Precautions posted, and a resident with confirmed C. diff had signage that directed use of ABHR instead of soap-and-water handwashing. These actions and inaccurate signs resulted in inconsistent implementation of required transmission-based precautions.
A resident with Type 2 DM and severe cognitive impairment had persistent hyperglycemia, an elevated HgbA1C of 10.5%, and was receiving Lantus and Humalog per sliding scale, with a care plan noting poor glycemic control. During a monthly MRR, the consultant pharmacist recommended clarifying with the physician the need for HgbA1C and Vit D 25 OH labs, but this recommendation was not referred to the physician and there was no documentation that the labs were obtained. The DON confirmed the pharmacist’s recommendation was not communicated, contrary to facility policy requiring MRR findings and physician responses to be documented in the medical record.
Staff failed to follow droplet precaution protocols by not wearing required PPE—including gown, gloves, and face shield—when entering the rooms of two residents with influenza, despite clear signage, care plans, and facility policy requiring full PPE use to prevent the spread of infection.
A facility failed to thoroughly investigate and timely report a resident-to-resident physical altercation, involving residents with complex medical and psychiatric histories. The initial report to the state agency was delayed and lacked required witness interviews, and the correct witness was not identified or interviewed until after the state began its investigation. The facility did not follow its own policy for abuse investigation and reporting.
A resident with dementia and cognitive deficits experienced a critically low hemoglobin level, but staff did not promptly notify the physician or send the resident to the ER as required by protocol. The care plan lacked interventions for low hemoglobin, and there was no documented monitoring after hospital readmission or investigation into the cause of the anemia.
A resident with significant mobility impairments did not receive a timely orthotic consultation and device as recommended by PT. Despite documentation and communication attempts by the rehab department, there was no order or referral for the needed AFO, and key staff were unaware of the recommendation. The lack of timely coordination and communication led to a delay in the resident receiving the necessary support.
The facility did not complete required antibiotic surveillance assessments for multiple residents receiving antibiotics, as documentation was missing for several months. The Infection Preventionist confirmed that monitoring of antibiotic appropriateness and related symptoms was not performed according to policy, affecting residents with infections such as UTIs, sepsis, and pneumonia.
Two residents did not have TB testing completed or documented according to facility policy, as confirmed by interviews with LVNs and the Infection Preventionist. Required TB tests were either not performed within the specified timeframe, not read within 72 hours, or not documented in the eMAR and immunization records, resulting in a deficiency in the infection prevention and control program.
A resident reported that a PTA caused a skin tear during a transfer, and multiple staff members were informed of the allegation. Despite facility policy requiring suspension and investigation of accused staff, the DON did not investigate or report the incident, and the PTA was not suspended. The resident's record did not document the abuse allegation.
A resident reported to staff that a PTA roughly handled her, causing a skin tear. The allegation was communicated among therapy staff and to the DON, but the DON did not report the incident to CDPH as required, citing lack of visible injury. The incident was not documented in the resident's record, and the PTA continued working. Facility policy required such allegations to be reported and investigated.
A resident with impaired skin integrity and on anticoagulants developed a skin tear on the right wrist after blood pressure monitoring. The injury was not documented, monitored, or addressed in the medical record, and no physician's order or care plan update was obtained, contrary to facility policy and the resident's care plan.
Black mold was found in a resident's shower, confirmed by both housekeeping staff and the supervisor, despite facility policy requiring regular cleaning of visibly soiled surfaces. The affected resident had COPD and was cognitively intact at the time of the deficiency.
Nursing staff did not follow required procedures for verifying and documenting narcotic counts, including liquid Ativan, by failing to have the narcotics sheet present during verification and not signing the shift-to-shift count sheet. Interviews revealed that some nurses were unaware of the documentation requirement, and review of records showed multiple unsigned count sheets, despite the facility's policy mandating these steps.
A resident with a history of depression repeatedly requested that bleach not be used in her room due to the strong smell causing her discomfort, but staff continued to use bleach products during cleaning. Although some staff were aware of the preference, there was no formal documentation or signage, leading to a CNA unknowingly using a bleach wipe and causing the resident distress.
A resident with mild cognitive impairment was involved in a financial abuse allegation, where a significant sum of money was given to an acquaintance. The facility failed to notify the police and APS within the required two-hour timeframe, as per their policy. The Social Services Director admitted to not notifying the authorities due to confusion and lack of details, which was confirmed by the administrator.
A facility failed to administer HIV medications to a resident as per physician's orders, leading to a 22-day lapse in medication administration. Staff interviews revealed confusion about the policy requiring residents to supply their own medications, and there was no documentation of physician notification about the medication unavailability. The facility's policies were not followed, resulting in a delay in providing the necessary medications.
A resident did not receive ordered Restorative Nursing Services (RNA) due to refusal and staff unavailability, leading to potential risks of decreased mobility. The RNA responsible did not report the missed treatments, and documentation inaccurately reflected the resident's care. Facility staff were expected to report such issues to supervisors for alternative arrangements.
A resident with a history of falls and moderate cognitive impairment experienced multiple unwitnessed falls despite existing interventions like bed alarms and low bed positioning. The facility failed to evaluate and implement new interventions, such as providing a sitter, which could have prevented further falls. The resident's representative temporarily hired a private sitter, which was effective, but the facility did not assume this responsibility.
A resident reported inappropriate touching by an RNA to a family member, who informed the DON. The DON delayed reporting the incident to the state agency, contrary to the facility's policy requiring immediate reporting within two hours. This delay resulted in a postponed investigation by the CDPH.
The facility failed to properly dispose of garbage, with two dumpsters found overflowing and lids not fully closed, leading to trash on the ground. This was observed with the FSD, who acknowledged the issue, and confirmed by an RD who noted the risk of attracting pests and infection control concerns. The facility's policy requires daily inspection to prevent such issues.
Three residents were found with medications at their bedside without proper assessments for self-administration. One resident had an inhaler in her desk drawer, another had multiple medications on her bedside drawer, and a third had inhalers on her overbed table. The facility failed to conduct necessary assessments, leading to potential misuse and lack of monitoring for adverse effects.
Three residents experienced significant delays in call light responses due to understaffing and inadequate adherence to facility policies. A resident with cerebral infarction and moderate cognitive impairment reported that staff often ignored his call light. Another resident with paraplegia was left in soiled conditions due to insufficient night shift staffing. A third resident, cognitively intact, also faced long wait times, with staff confirming reliance on registry workers. Facility policy mandates a five-minute response time, which was not met.
The facility failed to offer and document the formulation of Advance Directives (ADs) for several residents, and did not maintain copies of existing ADs in medical records. Residents who were cognitively intact or had the capacity to make decisions were not provided with necessary education or resources about ADs, nor was there documentation of such offers. Additionally, a resident with an existing AD did not have a copy in their medical record, and no follow-up was conducted to obtain it.
The facility failed to maintain a homelike environment for five residents due to peeling wallpaper in their rooms. Residents expressed discomfort, and staff confirmed the issue, noting a lack of a system to regularly check room conditions. The Administrator acknowledged the need for maintenance to address the damage, aligning with the facility's policy for a comfortable setting.
The facility failed to submit Quarterly MDS assessments to CMS within the required timeframe for several residents, with delays ranging from 40 to 43 days after the ARD. The MDS coordinator and DON acknowledged the backlog in submissions, which had been ongoing since October 2024, and efforts were being made to address it. Despite these efforts, the facility remained out of compliance with federal regulations.
The facility failed to provide resident-centered activities for three residents, leading to inactivity and disengagement. A former beautician, a bartender, and a teacher were not offered activities aligned with their past interests, despite care plans indicating the need for personalized engagement. The Activity Assistant and Director acknowledged the oversight, which contradicted facility policies.
Medication Documentation and Meal Tray Errors
Penalty
Summary
Medication administration was not completed in accordance with the facility’s required timeframe for one resident. The resident’s 9 a.m. medications, including empagliflozin, metoprolol succinate ER, potassium chloride ER, apixaban, zonisamide, and cholecalciferol, were documented as given on the MAR, but were actually administered later in the morning between 11:54 a.m. and 12:11 p.m. The LVN acknowledged that the medications were charted before they were actually administered and stated that medications scheduled for 9 a.m. should be given within the facility’s timeframe. The ADON confirmed the facility expected nursing staff to consult the physician when medications were given outside the required timeframe and to document administration after the medications were given. For the same resident, empagliflozin was ordered with an indication for diabetes mellitus even though the resident stated he had not been diagnosed with diabetes. The MDS Coordinator confirmed diabetes mellitus was listed in the electronic record, but hospital records, referral documentation, and history and physical reports did not show a diabetes diagnosis. The Medical Director confirmed the diabetes diagnosis was inaccurate and stated empagliflozin should have been prescribed for heart failure, not diabetes. The DON also confirmed the diagnosis was incorrectly entered and stated it resulted in additional interventions, including blood glucose monitoring and a diabetic diet. For another resident, documentation for PRN Norco was incomplete. The resident reported pain of 8 and was observed receiving hydrocodone-acetaminophen, but the MAR did not include the pre-medication pain assessment, confirmation of administration, or post-medication effectiveness. The LVN confirmed the pain level had been assessed but not documented and acknowledged that effectiveness was not documented. The same resident refused Senna-S, but the MAR documented the medication as administered. The LVN confirmed the medication was not given because the resident refused it, and the ADON and DON stated medications should be documented after administration and refusals should be accurately recorded. Meal service was also not carried out according to ordered diets. One resident was observed eating from another resident’s lunch tray after the wrong tray had been delivered, and the CNA stated she had only checked the resident’s first name. The tray served to the resident did not match the resident’s ordered diet and texture. In addition, for 18 residents on the 800 hallway, the dietary cart was observed waiting in the hallway while CNAs delivered trays, and no licensed nurse checked the meal trays before service. The DD and DON both stated licensed nurses should check trays before CNAs deliver them, and facility policy required trays to be checked to ensure the correct diet and food consistency before serving.
Dialysis Access Care and Fluid Restriction Failures
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for two residents receiving hemodialysis services. Resident 16 had an IJ/CVC access site on the right upper chest with a physician order to monitor every shift for signs or symptoms of infection or bleeding and to notify the physician of abnormal findings. On April 21, 2026, the access site was observed with a dressing dated April 20, 2026 and greenish brown drainage. On April 22, 2026, the resident stated he had pain at the CVC site since the prior afternoon and said the licensed nurses had not checked it. During interview, an LVN stated she had not assessed the access site that day and was not aware of the complaint of pain or drainage. The DON stated she was not aware of the drainage and confirmed the licensed nurse was expected to assess the site, report abnormalities, and notify the physician. Resident 16 also received more fluid than ordered. The resident had a physician order for a 1500 ml/24 hour fluid restriction, with specific amounts assigned to nursing and dietary. The resident stated that dialysis removed at least 3.5 kilograms each treatment and that the facility usually brought him many fluids to drink. During observation, breakfast included milk, cranberry juice, Nepro, water, and coffee totaling 957 ml, and the CNA later stated the resident should only have 1500 ml for the whole day. The fluid intake record showed multiple days in April 2026 when the resident consumed more than 1500 ml, including 1615 ml, 2120 ml, 1590 ml, and 1690 ml. The dialysis clinic clinical coordinator stated the resident had a 6.6 kg weight gain on arrival for treatment and that the facility had been made aware of problems with excessive weight gain between treatments. The facility also failed to coordinate dialysis care for Resident 137, who had ESRD and a CVC on the right upper chest. The resident stated he had been refusing dialysis because he did not like the scheduled time and said no one had looked at his catheter. On observation, the catheter exit site was exposed with no dressing covering it. Records showed the resident missed dialysis treatments from March 3, 2026 through April 21, 2026, and progress notes documented repeated refusals because he was upset about the dialysis day and time being changed. The record contained no documented evidence that the facility coordinated with the dialysis provider about the refusals, the missed treatments, the resident’s preferred schedule, the dialysis clinic discharge, or care and maintenance of the CVC site while dialysis was not being received. The DON stated there was no documentation that nursing recorded the refusals or coordinated with the dialysis clinic, and there was no documentation that care and treatment for the CVC site was provided by the facility.
Insufficient CNA Staffing and Below-Minimum Direct Care Hours
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs when it did not maintain the required minimum actual total CNA direct care hours per patient day of 2.4 hours. Facility staffing records reviewed with the DSD showed CNA staffing levels were below 2.4 hours on multiple weekend dates from November 2025 through April 2026, including several dates in November and December 2025, January through March 2026, and April 2026. The DSD stated the CNA DHPPD hours were below 2.4 hours on the listed weekend dates and acknowledged that CNA DHPPD hours should be maintained at 2.4 hours or above to ensure residents' needs were met and quality care was provided. During interviews, CNA 14 stated there were days when there were not enough staff to care for residents on weekends and that residents might call for assistance for extended periods of time, which could lead to residents' needs not being met. CNA 14 also stated she was responsible for providing care to 13 residents during the morning shift, especially on weekends, which made it difficult to complete resident care. CNA 8 stated she worked full time on the morning shift and was providing care to 10 to 13 residents at a time, and she stated there were not enough staff to meet residents' needs. The facility policy titled, Staffing, Sufficient and Competent Nursing, dated April 2025, stated the facility provides sufficient numbers of nursing staff to provide nursing and related care and services for all residents and that minimum staffing requirements imposed by the state are adhered to when determining staff ratios.
Medication Administration and Controlled Substance Record Discrepancies
Penalty
Summary
Pharmaceutical services were not provided in accordance with prescriber orders for Resident 16, who had end-stage renal disease and an active order for calcium acetate to be given with meals. During an interview while the resident was eating breakfast, the resident stated the phosphorus binder was supposed to be given with meals but was not. The LVN stated the medication had been administered at 9:58 a.m. and not while the resident was eating breakfast, and the MAR showed calcium acetate was not administered with meals on multiple occasions. For Resident 17, who had an order for lisinopril 40 mg daily with instructions to hold for systolic blood pressure less than 110 or heart rate less than 60, the medication was not administered in accordance with the order. During medication administration observation, the LVN checked the resident’s blood pressure and pulse, administered the morning medications, but did not give lisinopril. The MAR documented code 4 for vital sign out of parameter without recording the blood pressure or pulse values, and record review showed lisinopril had also been administered on other dates when the systolic blood pressure was below the ordered holding parameter. Controlled substance records did not reconcile with the MAR for Residents 88 and 146. For Resident 146, oxycodone was documented as removed on the CDR on one date without a corresponding MAR entry, and on another date it was documented as administered on the MAR without a corresponding CDR removal. For Resident 88, oxycodone removals were documented on the CDR without corresponding MAR documentation of administration or pain assessment, and several MAR-documented administrations had no corresponding CDR removal. The DON confirmed the discrepancies, and the facility policy required controlled substances to be documented on both the MAR and CDR and reconciled by nursing staff.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and its medication administration policy, resulting in a medication error rate of 16.13% (five errors out of 31 opportunities) during medication pass observations for two residents. The report identified errors involving medications that were ordered to be taken with food, a medication that was not administered despite being documented as given, and an inhaled corticosteroid for which the resident was not instructed to rinse and spit after use. For one resident with diabetes, hypertension, and hypokalemia, the 9 a.m. medications empagliflozin, metoprolol succinate ER, and potassium chloride ER were prepared and documented as administered without food, even though the physician orders required them to be taken with food or with food/snack and liquid. Later, metoprolol succinate ER and potassium chloride ER were administered again without food, and empagliflozin was not administered during the medication pass and was not subsequently given. The nurse acknowledged that a snack should have been offered when meal trays were not available. For another resident with COPD/asthma, budesonide inhalation suspension was administered by nebulizer, but the nurse did not instruct the resident to rinse the mouth and spit afterward as ordered. The resident’s MAR also documented cholecalciferol as administered even though the medication bottle was not present among the prepared medications, and the nurse confirmed it was not actually given. The DON stated staff were expected to administer medications as ordered, document after administration, and follow all administration instructions, including rinsing the mouth after budesonide use.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with its policies and procedures and the manufacturer’s specifications. During inspection of the Oasis Medication Room, an opened bottle of latanoprost ophthalmic solution for Resident 103 was found in the medication refrigerator without an opened date, and the dropper tip was uncapped and covered with tissue inside the pharmacy-supplied amber bottle. The resident’s April 2026 MAR showed the medication was ordered daily at bedtime, and the DON confirmed the storage condition was not appropriate. The IP stated the eye drop should have been discarded if the cap was missing because exposure of the dropper tip could result in contamination and potential eye infection. Medication carts also contained discontinued medications that had not been removed. In Medication Cart #8 at the Dunes Nursing Station, multiple blister cards labeled for Resident 153 were observed with active medications even though the resident had been transferred to the hospital on April 12, 2026, and discharged from the facility on April 19, 2026. The medications included tramadol, oxycodone-acetaminophen, allopurinol, sevelamer, sucralfate, icosapent ethyl, hydralazine, clopidogrel, amlodipine, escitalopram, furosemide, montelukast, gabapentin, atorvastatin, clonidine, and carvedilol. LVN 5 stated discontinued medications should have been removed from the medication cart for proper disposal, and the DON confirmed they should have been removed after discharge. In Medication Cart #9 at the Oasis Nursing Station, discontinued hydrocodone-acetaminophen controlled substances labeled for Resident 63 were also stored with active medications, and LVN 6 stated they had been discontinued on March 25, 2026. Expired house supply medication and inhalers were also found stored with active medications. In Medication Cart #9 at the Oasis Nursing Station, an opened box of famotidine house supply was observed with an expiration date of January 2026, and tablets inside the box had expiration dates of November 2025 and January 2026. In Medication Cart #4 at the MedBridge Nursing Station, opened fluticasone propionate and salmeterol inhalers labeled for Residents 145 and 140 were stored without opened dates. The pharmacy fill dates were March 2, 2026, and March 20, 2026, respectively, and the dose counters showed remaining doses. The manufacturer’s labeling stated the inhaler should be discarded 1 month after opening the foil pouch or when the counter reads 0, whichever comes first. LVN 5 confirmed the inhalers had exceeded 30 days from first use and should have been removed from the medication cart, and the DON stated staff were expected to document opened dates and use the BUD cheat sheet to determine expiration.
Fortified Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that a physician-prescribed fortified diet was provided to four sampled residents during lunch service. On April 20, 2026, the undated Fortified Diet Spreadsheet in the kitchen directed staff to add extra gravy to hamburgers and extra melted margarine to wheat rolls for Monday lunch. During concurrent observations in the dining room, staff reviewed the meal tickets for Residents 64, 114, 84, and 26 and identified each resident as being on a fortified diet, but the served meals did not include the ordered extra melted margarine and/or extra gravy as listed on the spreadsheet. CNA 16 and LVN 8 each checked the residents’ trays and stated that the fortified items were not present on the meals served. The Dietary Director later stated that cooks were supposed to follow the Fortified Diet Spreadsheet and that residents on a fortified diet were prescribed extra calories to help gain weight and/or promote wound healing. Review of the residents’ physician diet orders confirmed that Residents 26, 84, 64, and 114 were ordered a fortified diet, and the facility policy stated that calories and/or protein would be added to selected foods according to the Fortified Menu Plan.
Meal trays not served timely and food served at inappropriate temperatures
Penalty
Summary
The facility failed to follow its Meal Service policy to provide appetizing food at appropriate temperatures and to serve meal trays timely for five sampled residents. Resident council minutes from January 13, 2026 noted a concern that nursing was not serving meals timely. During interviews, Resident 52 stated lunch was scheduled for 11:00 a.m. but the meal tray did not arrive until 11:30 a.m. or later. Resident 21 stated that all served meals were cold, Resident 5 stated served foods were cold, meal trays were missing items, and the food was unidentifiable, Resident 54 stated the food had no taste and arrived late so it was cold, and Resident 17 stated meat was overcooked, sometimes cold, had poor flavor, and was always late. Observation and record review showed meal cart 800 arrived on the floor at 8:30 a.m. and was later observed parked in the hallway outside the room while nursing staff removed and delivered trays. On April 22, 2026, the cart remained in the hallway until CNAs began removing trays at 8:58 a.m., and all trays were not delivered until 9:09 a.m. A test meal at 9:10 a.m. with the Dietary Director showed temperatures of 116.1 degrees for sausage, 52.2 degrees for whole milk, 55.9 degrees for cranberry juice, 50.4 degrees for whole milk on the puree diet, 63 degrees for cranberry juice on the puree diet, 51.6 degrees for whole milk on the fortified mince and moist diet, and 56.3 degrees for orange juice. The Dietary Director stated the trays sat in the hallway waiting for nursing staff to pass them out, which resulted in residents receiving food at inappropriate temperatures and meals not being served timely.
Unsafe Food Storage and Kitchen Sanitation Practices
Penalty
Summary
Safe and sanitary food preparation and storage practices were not maintained in the kitchen for 163 out of 163 sampled residents who received foods from the kitchen. During observation, a Dietary Aide was seen washing dirty meal carts with detergent and then sanitizing them without first rinsing off the detergent, and the Dietary Director confirmed this did not follow the facility’s food cart cleaning procedure. The Dietary Director stated the detergent could interact with the sanitizer and make it ineffective, and the facility policy required the cart to be washed, rinsed with clean warm water, and then sanitized. Additional kitchen observations showed a hot waterspout at the coffee station with white grime buildup identified by the Dietary Director as calcium buildup, two house-made sandwiches in the nourishment refrigerator labeled with a used-by date of April 19, 2026, and multiple areas and pieces of equipment with dust or debris, including door frames, storage shelves, the fire suppression system, and the walk-in refrigerator fan cover. The water drain under the 3-compartment sinks was also observed with chipped paint, and the Dietary Director stated the chipped paint could create pores that trap dirt and bacteria. Facility policies required equipment and surfaces to be kept clean, in good repair, and free from chipped areas, and food was not to be kept beyond the expiration date.
Homelike Environment and Personal Property Failures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when Resident 52 was repeatedly exposed to loud yelling and screaming from confused residents in the hallway near his room. On April 20 and April 21, 2026, surveyors observed Resident 177 screaming for help and ringing his call bell by banging it against the overhead table, while staff in the hallway, including an LPN, did not respond. Resident 52 stated he was unable to sleep at night because of residents screaming in the hallway across from his room, that he had notified staff several times over the prior month about the noise, and that he was awakened at 3 a.m. on April 21 because of the screaming. CNA 1 stated there were approximately five residents in that hallway with screaming and yelling behaviors throughout the shift, and the DON stated Resident 52 did not experience a homelike environment because of the unreasonable noise levels. The facility also failed to assist Resident 53 in keeping her room tidy and free of belongings on the floor. During an observation and interview in her room, Resident 53’s clothes and blanket were observed on the floor, and she stated she had asked staff multiple times to help put away her clothes but no one had assisted her. CNA 2 stated CNAs were responsible for helping residents maintain a clean room, putting away clothes, and keeping rooms tidy and home-like, while CNA 3 stated Resident 53 had asked her to put away the clothes and blankets on the floor and that she had noticed the items on the floor on prior days. The DSD stated CNAs should assist residents in maintaining clean and safe surroundings and should offer to put away personal items as part of routine care. The facility further failed to keep Resident 20’s personal credit card safe and accounted for. Resident 20 stated his wallet, which contained his credit card, was missing in late January to February 2026 and was later found in a bathroom by an unknown staff member, and his credit card company contacted him about unusual transactions. The inventory of personal effects showed three credit cards, and the SSM stated residents’ credit cards were to be secured in the facility safe or, if kept at bedside, placed in a lock box with a key provided to the resident. Resident 20 stated he had not been informed about safekeeping options, and the SSM stated he should have been informed of those choices to secure his belongings and prevent psychosocial distress. The ADON stated the wallet went missing during transfer to another unit and unauthorized charges were identified on one of the credit cards.
Failure to Assess Safe Self-Administration of Bedside Eye Drops
Penalty
Summary
The facility failed to ensure an assessment and/or evaluation for self-administration of medication was completed for one resident when eye drop medications were found at the bedside and readily available for use. On April 21 and April 22, 2026, the resident was observed in bed, alert, and interviewable, with a box of Sodium Chloride Hypertonicity Solution 5% eye drops and an opened bottle of artificial tears on the bedside table. The resident stated the eye drops were hers, that staff knew about them, and that she used both eye drops on herself when her eyes were itchy and sometimes because she had glaucoma. She also stated licensed nurses administered another glaucoma eye medication for her. The resident’s record showed diagnoses including glaucoma and a history and physical indicating she had the capacity to understand and make decisions. Her order summary included an order for Latanoprost Ophthalmic Solution 0.005% to both eyes at bedtime, but there was no physician’s order for the Sodium Chloride Hypertonicity Solution 5% or the artificial tears. The LVN observed the eye drops on the bedside table and stated the resident did not have a physician’s order for the two eye drops and did not have an assessment for safe self-administration. The DON stated the resident should have had an assessment for safe self-administration and that both eye drops and a self-administration order were needed before the resident could self-administer them. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and that this determination is documented in the medical record and care plan.
Failure to Document Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 18 was free from unnecessary psychotropic medication use because there was no documented evidence that non-pharmacological interventions (NPIs) were attempted, implemented, monitored, or documented as clinically contraindicated. Resident 18 was admitted with diagnoses including unspecified psychosis, schizoaffective disorder, major depressive disorder, and anxiety disorder. The resident had physician orders for risperidone 2 mg three times daily for psychosis manifested by verbalization of hallucination, mirtazapine 15 mg at bedtime for depression manifested by poor appetite, and buspirone 10 mg three times daily for anxiety manifested by being overly worried about health. The care plan for antipsychotic, antidepressant, and anti-anxiety medications indicated that non-pharmacological approaches should be attempted prior to medication administration. The April 2026 MAR showed the resident received risperidone, mirtazapine, and buspirone as ordered, but there was no documented evidence that NPIs were attempted, implemented, monitored, or evaluated for effectiveness. During interview and record review, the DON confirmed that no such documentation existed and stated the NPI order set in the PCC system had not been added to the resident's chart. The PNP stated he was not aware NPIs had not been implemented and noted that NPI information would assist in evaluating behavioral symptoms and medication response.
Failure to Provide Needed ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide necessary care and services to support activities of daily living for Resident 36, who had dementia and a February 19, 2026 MDS indicating severe cognitive impairment with a BIM score of 03. The MDS also showed the resident needed supervision or touching assistance with oral hygiene, showering/bathing, upper body dressing, lower body dressing, and personal hygiene. The resident’s care plan, dated May 14, 2025, identified ADL needs related to altered mental status and dementia and stated staff should anticipate and meet needs, but there was no documented evidence that the resident’s refusal of ADL assistance was identified and addressed. During observations from April 20 through April 22, 2026, Resident 36 was repeatedly seen wearing the same matching blue printed flannel top and bottom. On April 20 and April 21, the resident was observed ambulating in the hallway with a FWW and stated she had not yet received her lunch tray. On April 22, the resident was observed in the morning wearing the same outfit, searching for a snack, and later asleep in her room still dressed in the same clothing. When asked about having another set of clothes, the resident stated, "I do not know," and walked away. Interviews and record review showed CNA 10 stated she did not help the resident get dressed that morning and could not recall whether the resident had been wearing the same outfit when she arrived. CNA 10 also found the resident’s closet empty except for two knitted sweaters. LVN 2 stated the resident had a history of refusing ADL assistance, including showers, but no report was received that she refused services that day. CNA 11 stated the CNAs documented the resident as independent with ADLs during the period reviewed, while the DON stated the resident was confused and forgetful, staff should report missing clothing, and the resident should have been supervised and/or assisted with ADLs. The DON also stated the resident’s refusal behaviors should have been care planned, but there was no care plan developed or initiated to address them.
Delayed assessment and reporting of new skin conditions
Penalty
Summary
The facility failed to ensure timely assessment, physician notification, and treatment orders for two residents with new skin concerns. For Resident 95, who had diabetes mellitus, chronic osteomyelitis of the left foot, and muscle weakness, a defined circular area of erythema on the top of the right wrist was observed as red, elevated, dry, and scaly. The resident stated the area had been present for about two to three months, had been treated with cream, and had not improved. Facility staff, including licensed nurses and CNAs, stated they were not aware of documentation showing the wrist condition had been identified, assessed, reported to the physician, or followed with treatment orders when first noted. Resident 95’s record showed a shower/bath sheet on April 20, 2026, documenting no apparent skin issues and no new skin issue or change, while a skin evaluation on April 22, 2026, documented a change in condition with dry reddened skin on the right wrist and noted a new alteration with no drainage or odor. During interviews, an LVN stated any alteration in skin condition should be assessed, documented, reported to the physician, and followed with treatment orders the day it is identified. The DON stated licensed nurses were expected to immediately assess a new skin concern, create a Change of Condition Report, notify the physician, document the skin condition, and initiate a care plan and treatment orders the same day it was identified, and stated there was no documentation showing the right wrist problem had been identified by licensed nurses. For Resident 66, who had hemiplegia affecting the left side and had capacity to understand and make decisions, redness and irritation were observed on the right side of the neck, and the resident was constantly scratching the area. The resident stated the neck had been itching and believed it was related to shaving cream or a cheap razor. The shower sheet contained no documentation of a new rash, redness, or itching to the neck, and no documentation that the neck was assessed or monitored for skin changes. An LVN stated skin checks were performed every shift and new skin conditions should be reported, assessed, documented, monitored, and communicated to the physician and resident representative, but there was no documented assessment or care plan revision for the neck condition.
Failure to Maintain 1:1 Supervision and Smoking Safety Controls
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who had a physician order for 1:1 sitter monitoring after a suicidal attempt. The resident’s record showed a history of left-sided hemiplegia and capacity to understand and make decisions, and progress notes documented that the resident had wrapped a call light cord around his neck and then grabbed a butter knife and motioned to cut his throat. The care plan identified a psychosocial well-being problem related to suicidal attempt, anxiety, family discord, and ineffective coping, with an intervention for 1:1 sitter monitoring to ensure safety. During observations, the resident was repeatedly found alone in his room without staff present. The call light was observed out of reach on the dresser, and a call bell was on the bedside table. At one point, the resident was ringing the call bell and yelling for help in Spanish while a nurse was seen down the hallway and did not respond. A CNA entered the room, left to speak with a nurse, and no staff remained with the resident. Another CNA later stated she had been assigned as the sitter but did not know who covered the resident before her shift. An LVN stated the resident should have had a sitter 24 hours per day due to safety concerns, and a CNA stated the resident should not be left unattended. The DON stated the sitter was expected to remain at bedside at all times and that if the sitter needed to leave, another staff member had to provide continuous observation. The facility also failed to follow its smoking-related care plan for a resident who smoked and used oxygen. The resident’s smoking assessment stated that supervision was required, that the resident may smoke with supervision, that oxygen therapy was needed as needed, and that the resident refused to use a smoking apron. The care plan stated that cigarettes and a lighter would be stored in the nurse’s station. However, during observation the resident was lying in bed with oxygen via nasal cannula, and a purse at bedside contained cigarettes and a lighter. The resident stated she was supervised when smoking and could light her own cigarettes. Staff interviews confirmed that the resident had cigarettes and a lighter at bedside, and the ADON stated this was not consistent with the resident’s care plan and smoking assessment.
Failure to Monitor Nutrition Interventions and Document Oral Supplement Intake
Penalty
Summary
The facility failed to ensure nutritional care and services were provided for one resident with significant weight loss. The resident was admitted with diagnoses including heart failure, dementia, and Type II diabetes, and had severely impaired cognition on MDS assessment. The resident’s weight declined from 165.4 lbs. to 151 lbs. over a 4-month period, which was identified as an 8.5% loss and significant weight loss. The resident’s physician orders included a controlled carbohydrate diet, no added salt diet, minced and moist texture, oral nutrition supplements three times daily with meals, and a fortified diet for weight loss. The resident’s nutrition records showed repeated weekly weight monitoring and multiple dietitian notes documenting variable intake and weight fluctuations. The dietitians recorded interventions such as Glucerna with meals, fortified diet, weekly weights, and appetite stimulant changes. However, the resident’s oral nutrition supplement intake was not individually documented. During observation, the resident was served an 8-ounce oral nutrition supplement with breakfast and finished the entree, supplement, and milk, but left the cream of wheat and apple juice untouched because she stated she was full. CNA 12 stated she documented supplement intake as part of meal consumption and did not separately document the amount taken. The DON and LVN were unable to locate the amount of oral nutrition supplement intake in the EMR. The DON stated that nursing assistants should document oral nutrition supplement intake individually, not as part of fluid or meal intake, and acknowledged that without monitoring and documenting the supplement, the effectiveness of the nutrition interventions could not be determined. RD 3 stated nutrition interventions should be documented and monitored for effectiveness and that consultant RDs should communicate with the IDT if nursing did not document and monitor interventions. The facility’s WEIGHT CHANGE PROTOCOL stated the facility RD would assess, diagnose, suggest interventions, monitor, and evaluate the success of interventions, including determining whether intake would be sufficient to meet needs. The report also noted that the dietitian documentation used broad descriptions such as 0-100% intake, variable intake, and variable to good intake, which the DON and RD 3 stated were too vague to determine whether the resident’s meal intake was adequate to meet nutritional needs.
Failure to Change Oxygen Cannula Weekly
Penalty
Summary
The facility failed to ensure that Resident 62’s nasal cannula was changed weekly according to the facility’s policy and physician orders. Resident 62 was observed on April 21, 2026, receiving oxygen at 2 L/min via nasal cannula, and the cannula was labeled as last changed on April 12, 2026. During the observation, Resident 62 stated he used oxygen continuously. His record showed an admission date of September 29, 2024, diagnoses including shortness of breath, and a history and physical dated November 29, 2025, noting fluctuating capacity to understand and make decisions. The physician orders dated March 9, 2026, directed that oxygen tubing/cannula be changed every evening shift every Sunday, and the care plan identified that the resident required continuous oxygen with oxygen tubing changed as indicated. During interview, LVN 9 stated nasal cannulas are changed weekly on Sundays by licensed nurses and confirmed the cannula should have been changed on April 19, 2026. The Infection Preventionist also stated licensed nurses are responsible for changing nasal cannulas weekly on Sundays and confirmed the cannula should have been changed on April 19, 2026. The facility policy titled Prevention of Infection Respiratory Equipment stated the oxygen cannula and tubing are to be changed every seven days.
Pain Was Not Assessed or Managed After Resident Reported Pain
Penalty
Summary
The facility failed to ensure pain was assessed and managed for one resident who reported arm and shoulder pain. The resident, who had diagnoses including end stage renal disease, stated he asked for acetaminophen during the night shift in March 2026 and was told there was no physician order for it, even though he had previously received it without issue. The resident’s care plan identified acute pain and included a goal of expressing or exhibiting pain relief after medication as needed, with an intervention to administer medication as ordered. The resident’s MAR showed he reported pain rated 7 out of 10 during the night shift of March 24, 2026, but there was no documented evidence that non-pharmacological interventions were provided, that pain medication was ordered, or that he received pain medication after the complaint. Progress notes later documented that the physician was notified about the resident’s pain and lack of orders, with no response, and that the physician was notified again on March 31, 2026, regarding an order for acetaminophen. During interviews, the LVN stated she did not administer pain medication because there was no physician order and did not notify the DON when the physician did not respond. The RN supervisor stated the facility process required contacting the physician, documenting the attempt, and notifying the DON if there was no response, and that non-pharmacological interventions should have been provided. The ADON stated licensed nurses were expected to assess and address pain, notify the physician, and contact the on-call physician if the physician did not respond.
Failure to Obtain Ordered UA with C&S
Penalty
Summary
The facility failed to ensure a laboratory service was provided as ordered for one resident with an indwelling urinary/foley catheter and diagnoses including neuromuscular dysfunction of the bladder and urinary tract infection. The resident was observed alert and resting in bed with the catheter in place, and stated the catheter had been placed for safety reasons because he could not stand up to go to the restroom on his own and that he often got urinary tract infections. The resident’s record showed that after hematuria was noted in the foley catheter, the physician was notified and ordered a flush and a UA with C&S to rule out UTI. Record review showed the UA with C&S was ordered, but there was no documented evidence that the specimen was collected as ordered. There was also no documentation that the laboratory was notified of the new physician order. During interviews, an LVN verified the process was not followed and confirmed there was no order placed in the laboratory software for the UA with C&S. The DON stated the licensed nurse should have collected the urine specimen right away, placed it in the specimen refrigerator, and notified the laboratory for pick up, but this was not done.
Failure to Follow Up on Dental Treatment After Extractions
Penalty
Summary
The facility failed to ensure dental care services and follow-up treatment were provided for one resident who needed dentures after tooth extractions. The resident was observed with only a few remaining teeth in the front of the mouth and no teeth or dentures in the upper or lower posterior gums, and stated she did not have dentures and wanted them. Her record showed diagnoses including rheumatoid arthritis and enterocolitis, a nursing admission assessment noting own teeth, an MDS indicating swallowing/nutritional concerns with food held in the mouth and residual food after meals, and later MDS documentation showing broken or loosely fitting dentures and moderate cognitive impairment. The dental record showed the dentist recommended extraction of upper and lower teeth with full upper and lower dentures and immediate dentures, and the resident agreed to treatment. The dentist documented extraction of teeth 23, 24, and 25, but the record contained no documented evidence that the status of the resident's dentures was followed up with the dental provider after the extraction. The RDH later documented missing teeth in the upper and lower mouth and stated the resident was missing too many teeth to chew and break down food properly to swallow safely. The Social Services Manager stated she did not follow up with the dentist after the extraction and that the resident waited 9 months for dentures.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to ensure special adaptive eating equipment was provided during meals as ordered for one resident with Parkinson's disease and trembling hands. On April 20, 2026, during a concurrent observation and meal ticket review in the dining room, the resident was seen holding a spoon with the right hand shaking tremendously while feeding himself, and food particles were dropping onto the clothing protector and floor. The resident's meal ticket listed buildup fork, buildup knife, and buildup spoon, but these utensils were not on the meal tray. During a concurrent interview, the RNA stated the resident was missing the buildup fork, buildup knife, and buildup spoon and should have received buildup utensils to help with self-feeding. The OT later stated the physician had ordered weighted utensils with meals for the resident because of trembling hands, and that dietary staff should follow the order and provide the weighted utensils with meals. The Dietary Director also stated dietary staff should follow the meal ticket providing weighted utensils with meals, or the resident would have a hard time feeding himself and food would fall off the plate. The physician order dated October 23, 2024, specified weighted utensils with meals due to tremor, and the facility policy stated residents needing self-feeding devices should receive them with each meal or snack on their meal trays.
Inconsistent Storage of Food Brought in for Residents
Penalty
Summary
The facility failed to ensure safe and sanitary storage and consumption of food items brought to residents by family and visitors according to its policy and procedure. During interviews on April 21, 2026, staff gave inconsistent answers about how long outside food could be kept in the nourishment refrigerator: one LVN said three days, a CNA said seven days, and another LVN said 24 hours to three days. Review of the facility policy titled, "BRINGING IN FOOD FOR A RESIDENT," dated 2023, showed that food or beverage items without a manufacturer's expiration date are to be dated upon arrival in the facility and thrown away two days after the date marked.
Failure to Protect Resident Privacy From Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ rights to privacy when a cognitively impaired resident with known wandering behavior repeatedly entered other residents’ rooms and used their bathrooms without permission. Resident 1, admitted with a subarachnoid hemorrhage and assessed with a BIMS score of 6 indicating severe cognitive impairment, was care planned as an elopement risk and wanderer, but the care plan did not include interventions to address elopement or wandering behavior. Staff interviews confirmed that Resident 1 wandered throughout the facility and entered other residents’ rooms, requiring reorientation and redirection, and that staff were expected to keep an eye on her. On one occasion, Resident 2, who had a fractured right femur and a BIMS score of 12 indicating moderate cognitive impairment, reported that Resident 1 entered his bedroom and used his bathroom without his permission. Resident 2 stated he called for a nurse, and an LVN responded, opened the bathroom door, and found Resident 1 sitting on the toilet, then removed her from the bathroom. Resident 2 reported feeling upset and angry because Resident 1 entered his bedroom and used his bathroom despite his objections, and he stated that Resident 1 did not listen when he asked her to stay out and that staff did not monitor and keep her out of his room. The LVN confirmed the incident, acknowledged Resident 2’s distress, and stated she was unsure if she documented the event, though she believed she should have. On another occasion, a Central Supply Staff member heard Resident 3 yelling for someone to get out of his room and found Resident 1 inside Resident 3’s bedroom, then escorted her back to her unit and reported the incident to the Social Services Director. Resident 3, admitted with cerebral infarction and left-sided weakness and assessed as cognitively intact with a BIMS score of 14, told the Social Services Director that Resident 1 came into his bedroom to use his bathroom and that this had happened a couple of other times, questioning why staff did not do anything about it. The DON acknowledged that residents have the right not to have other residents enter their bedrooms or use their bathrooms without permission, confirmed that Resident 1 was not permitted to enter other residents’ rooms or use their bathrooms, and verified that Resident 1’s entry into Residents 2 and 3’s rooms without permission violated their right to privacy. The facility’s visitation policy stated that residents may receive visitors subject to their wishes and the protection of other residents’ rights, including the right to deny visitation at any time, underscoring that residents’ privacy rights were not upheld in these incidents.
Failure to Monitor Diabetes Control and Timely Address Recurrent Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the residents’ clinical needs for two residents. For one resident with type 2 diabetes mellitus and severe cognitive impairment, the record showed an elevated HgbA1C of 10.5% from a lab drawn in mid-February 2025, with a care plan problem of hyperglycemia and poor glycemic control. Physician orders included Lantus at bedtime and Humalog per sliding scale before meals and at bedtime. The MAR from early January through early February 2026 showed multiple blood glucose readings above 200 mg/dL with Humalog administered per sliding scale on multiple occasions. However, there was no evidence that the resident’s blood sugar control was evaluated through repeat HgbA1C testing after February 2025, nor that the frequent elevated blood sugars and repeated use of short-acting insulin were reported to the physician for possible adjustment of diabetic medications. During interview and concurrent record review, the DON confirmed that the last HgbA1C for this resident was in February 2025 and that the resident did not have a standing order for routine HgbA1C monitoring, despite the facility’s diabetes clinical protocol stating that A1C should be monitored on admission (if no recent result is available) and every six months thereafter for residents receiving insulin who are well controlled, with frequency adjusted based on glucose control. The protocol also stated that if short-acting insulin must be administered frequently, the provider should consider initiating or adjusting intermediate- or long-acting insulin, and that providers will order desired glucose targets, monitoring regimens, and parameters for reporting information related to blood sugar management. The DON stated that the resident’s blood sugar should have been evaluated and referred to the physician if there was a need to adjust diabetic medications, but this was not done. For another resident admitted with diagnoses including metabolic encephalopathy and sepsis, bowel continence documentation from mid- to late January 2026 showed multiple episodes of diarrhea recorded on numerous days and at various times. Despite these repeated episodes of loose stools beginning on January 17, 2026, there was no documented evidence that the episodes were addressed or that the physician was notified until a progress note on January 26, 2026, when the resident was documented as having nausea, vomiting, and diarrhea, multiple episodes of vomiting and diarrhea, fatigue, and mild abdominal tenderness. At that time, the physician ordered contact isolation and stool sample collection to rule out norovirus and C. difficile, and subsequent lab results on January 28, 2026, were positive for C. diff toxin. In interview, the DON acknowledged that the resident’s multiple episodes of loose stools starting January 17, 2026, were not addressed or referred to the physician within 72 hours, contrary to the facility’s “Change in a Resident’s Condition or Status” policy, which requires prompt notification of the physician for significant changes in a resident’s condition that will not normally resolve without intervention.
Failure to Implement Correct Isolation Precautions and Hand Hygiene for C. diff and Respiratory Infections
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies and CDC guidance for residents on isolation precautions for C. diff and respiratory infections. During an unannounced visit related to gastrointestinal and respiratory outbreaks, surveyors observed that staff did not consistently use appropriate PPE or perform required hand hygiene when entering and exiting rooms of residents on contact enteric precautions for C. diff. For one resident with C. diff, the Administrator and Social Services Director entered the room wearing only surgical masks, without donning the required gown and gloves indicated on the contact enteric signage posted at the door. Both staff members left the room without washing their hands, despite the sign instructing everyone to wash or gel hands when entering and wash on leaving the room. For another resident with C. diff, a staff member serving meals and coffee donned a mask, gown, and gloves before entering the room but removed the PPE and used only alcohol-based hand rub (ABHR) after exiting, without washing hands with soap and water as required by the facility’s C. diff and norovirus policies. The staff member also did not perform hand hygiene before donning PPE on re-entry. The Infection Preventionist confirmed that residents with C. diff are placed on contact enteric precautions and that staff should wear gown and gloves before entering and wash their hands after leaving the room, and that handwashing with soap and water is superior to ABHR for removal of C. diff spores. A physical therapist entering the room of a resident with C. diff wore appropriate PPE but, after removing it and exiting, used only ABHR and did not wash hands with soap and water before proceeding to another area. Additional deficiencies were identified in the accuracy of isolation signage for residents on transmission-based precautions. One resident with a diagnosis of human metapneumovirus had a physician’s order for strict single-room isolation with droplet precautions, but the door signage incorrectly indicated contact precautions for C. diff. Another resident with a positive C. diff laboratory result and an order for contact precautions had a sign that indicated contact precautions for C. diff/norovirus but instructed staff to use ABHR before entering and when leaving the room, rather than specifying handwashing with soap and water after leaving as required for contact enteric precautions. A further resident with a physician’s order for isolation with droplet precautions due to influenza had a door sign indicating Enhanced Barrier Precautions instead of droplet precautions. The Director of Nursing and Infection Preventionist acknowledged that the signage for these residents did not reflect the ordered type of isolation precautions. A certified nursing assistant assigned to the resident with metapneumovirus reported redirecting the resident from the hallway back into the room while wearing only an N95 mask and no gown or gloves, then donning PPE inside the room without performing hand hygiene beforehand. The CNA stated the resident was on contact precautions for C. diff based on the posted sign, even though the physician’s order and the Infection Preventionist’s review confirmed the resident was actually on droplet precautions for metapneumovirus. Review of facility policies on isolation, C. diff, norovirus, and influenza showed that the facility required appropriate signage at room entrances specifying the type of CDC precautions and PPE instructions, and required soap-and-water handwashing after care of residents with C. diff or norovirus. The observed practices and incorrect signage did not conform to these written policies and CDC guidance. These failures had the potential for the spread of communicable disease among residents, staff, and visitors.
Failure to Communicate Pharmacist Lab Recommendations to Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a consultant pharmacist’s medication regimen review (MRR) recommendation was communicated to the physician for one resident. During an unannounced visit, surveyors reviewed the record of Resident A, who had diabetes mellitus and severe cognitive impairment with a BIMS score of 3. Resident A’s orders included Lantus 25 units at bedtime and Humalog insulin before meals and at bedtime per sliding scale, with a prior HgbA1C order and result of 10.5%. The Medication Administration Record from early January through early February showed blood glucose levels above 200 mg/dl with Humalog administered per sliding scale. The resident’s care plan documented hyperglycemia and poor glycemic control related to Type 2 diabetes mellitus, evidenced by the elevated HgbA1C and use of sliding scale insulin, with instructions to reassess nutritional status and glycemic control routinely. A review of the consultant pharmacist’s MRR dated December 22, 2025, showed a recommendation to clarify with the physician the need for HgbA1C and Vitamin D 25 OH lab tests. Further review of the resident’s record revealed no documented evidence that this recommendation was implemented or referred to the physician after it was made. In an interview, the DON confirmed that the pharmacy consultant’s recommendation for lab tests for this resident was not communicated to the physician and acknowledged that it should have been discussed. The facility’s Medication Regimen Review policy stated that the consultant pharmacist is to review each resident’s medication regimen monthly, identify and report medication-related problems and irregularities, and provide written reports to attending physicians, the DON, and the Medical Director, with copies and physician responses maintained in the permanent medical record. This process was not followed for Resident A’s recommended lab monitoring.
Failure to Follow Droplet Precaution PPE Protocols for Residents with Influenza
Penalty
Summary
Facility staff failed to implement infection control precautions in accordance with established policies and procedures for two residents who required droplet precautions due to influenza. Certified Nurse Assistants (CNAs) were observed at the bedsides of both residents wearing only face masks, without donning the required gown, gloves, and face shield, despite clear signage and available personal protective equipment (PPE) outside the rooms. Both CNAs acknowledged during interviews that they were aware of the requirement to wear full PPE when entering rooms under droplet precautions, and admitted they should have been wearing all required PPE while interacting with the residents. Resident 4 had a diagnosis of immunodeficiency and influenza, with care plans and physician orders specifying the need for contact and droplet isolation precautions. Signage outside the resident's room detailed the sequence for donning PPE, including gown, mask or respirator, goggles or face shield, and gloves. Despite these instructions, CNA 1 was observed at the bedside wearing only a face mask. The Infection Preventionist (IP) confirmed that all staff, visitors, and contractors were required to wear full PPE when entering rooms with droplet precautions, regardless of the nature of the interaction. Similarly, Resident 3, who had bronchitis and was also on contact and droplet precautions due to influenza, was observed in her room when CNA 2 entered wearing only a face mask. Resident 3 reported that staff did not always wear a gown and face shield when providing care. The care plan and physician orders for Resident 3 also specified the need for isolation precautions and in-room care. The IP reiterated that full PPE was required for anyone entering the room, as indicated by the posted signage and facility policy. Facility policies reviewed confirmed the necessity of transmission-based precautions, including the use of gloves, gown, and goggles or face shield when there is a risk of exposure to respiratory secretions.
Failure to Timely Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse between two residents and did not report the results of the investigation to the state survey agency within the required five-day timeframe, as outlined in the facility's policy. The incident involved two residents, who were married but roomed separately, and escalated from a verbal argument to a physical altercation over a television. Both residents reported being struck by the other, and law enforcement was notified, resulting in one resident being detained and escorted out of the facility by sheriffs. Medical records and progress notes indicated that both residents had significant medical and psychiatric histories, including schizoaffective disorder, psychosis, bipolar disorder, cerebral infarction, and COPD. Documentation showed that the altercation was reported to the DON and law enforcement, and that the residents were separated following the incident. However, the facility's initial five-day report was submitted 15 days after the incident and lacked witness interviews, contrary to policy requirements. Subsequent investigation revealed that the wrong resident was initially identified as a witness, and the actual witness was not interviewed until after the state agency began its investigation. The DON was unaware of the revised report and the correct witness information prior to its submission to the state. The facility's policy required timely and thorough investigation, including interviews with all witnesses and documentation of findings, which was not followed in this case.
Failure to Provide Timely Care and Care Planning for Critically Low Hemoglobin
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with critically low hemoglobin levels. The resident, who had diagnoses including dementia and cognitive communication deficit, was admitted with low hemoglobin and had physician orders for biweekly CBC labs. On October 6, a lab result showed a critically low hemoglobin of 6.8 g/dl, which was reported to the facility multiple times by the laboratory, but staff were not reached until later. The licensed nurse documented notifying the physician the following afternoon and was awaiting a response, but there was no documentation that the physician addressed the critical result or that the resident was sent to the emergency room as per facility protocol for hemoglobin levels below 7 g/dl. Additionally, after the resident was readmitted from the hospital following a blood transfusion, there was no evidence of the required 72-hour monitoring. The resident's care plan did not include interventions for low hemoglobin at any point since admission, and there was no documented review to determine the cause of the low hemoglobin for further physician orders. The facility's policy required prompt physician notification and care plan revision for significant changes in condition, but these steps were not documented or implemented for this resident.
Delay in Ordering Orthotic Consultation and Device
Penalty
Summary
The facility failed to ensure that an orthotic consultation, as recommended by physical therapy, was ordered in a timely manner for a resident with significant mobility impairments. The resident, who had diagnoses including paraplegia, hemiplegia, and hemiparesis, was identified as being at risk for decline in activities of daily living and mobility. Physical therapy documented the need for an orthotist consult for a left ankle-foot orthosis (AFO) and communicated this need to the interdisciplinary team. However, there was no corresponding order for the orthotic device or referral for consultation found in the resident's medical record. Interviews revealed that the social services director was unaware of the recommendation and had not received communication from rehabilitation regarding the need for the brace. Further review indicated that the process for obtaining orthotic devices involved assessment and recommendation by the rehab department, followed by communication to social services and nursing to obtain an order and schedule an appointment with the vendor. Despite the physical therapist's and director of rehabilitation's efforts to communicate the need for an AFO, including emails to the social services assistant and the DON, no action was taken for nearly a month. The DON acknowledged that this delay was excessive and that there was no policy in place for orthotic consults. This lack of timely coordination and communication resulted in a delay in the resident receiving the necessary orthotic device.
Failure to Conduct Effective Antibiotic Surveillance Program
Penalty
Summary
The facility failed to ensure an effective antibiotic surveillance program was conducted for 11 out of 12 residents who were prescribed antibiotics, as required by the facility's policy and procedure. During an unannounced visit, the Infection Preventionist (IP) reported that antibiotic use was monitored by printing a daily list of residents on antibiotics and following up with licensed nurses to confirm administration and check for adverse effects. However, upon review of documentation, it was found that antibiotic surveillance assessments, which should include a review of the resident's symptoms and appropriateness of antibiotic use, were not completed for residents on antibiotics from August 2024 to January 2025. The IP was unable to provide surveillance documentation for this period, confirming that the required monitoring was not performed. The facility's policy outlined that surveillance tools, culture reports, sensitivity data, and antibiotic usage reviews should be included in infection prevention and control activities. Despite this, the lack of documented surveillance meant that the appropriateness of antibiotic use for residents with various infections, including UTIs, sepsis, pneumonia, and infections at other sites, was not evaluated according to policy. This lapse was acknowledged by the IP, who stated that the absence of infection surveillance and antibiotic stewardship placed residents at risk for improper antibiotic use and ineffective infection control.
Failure to Complete and Document TB Testing per Facility Policy
Penalty
Summary
The facility failed to ensure tuberculosis (TB) testing was completed according to its own policy and procedure for two of three residents reviewed. Interviews with multiple licensed vocational nurses (LVNs) revealed that TB tests were required to be completed within 24 hours of admission and documented in the electronic Medication Administration Record (eMAR). However, record reviews showed that for one resident, there was no documentation that a TB test was completed within 24 hours of admission, and for another resident, there was no documentation that the first step of the TB test was conducted. Additionally, for the second resident, although the first step TB test was administered, there was no documentation that the test was read within the required 72-hour window, nor was there documentation that the second step TB test was completed. The Infection Preventionist confirmed that newly admitted residents should receive TB testing within 24 hours, with results read within 72 hours, and that documentation should be consistent across the immunization record and eMAR. Review of the facility's policy indicated that a two-step Mantoux Tuberculin Skin Test (TST) should be performed and documented for residents not previously admitted. The lack of documentation and failure to follow the established TB testing protocol for these residents constituted a deficiency in the facility's infection prevention and control program.
Failure to Investigate and Suspend Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure regarding the investigation of an abuse allegation for one resident. A resident reported that a Physical Therapy Assistant (PTA) had roughly squeezed her while assisting her into a wheelchair, resulting in a skin tear on her right arm. The resident, who was cognitively intact according to her most recent assessment, informed the Director of Rehabilitation (DOR) and requested a different PTA. The Occupational Therapist (OT) and Physical Therapist (PT) were also made aware of the allegation, and the OT reported it to the DOR. The DOR was believed to have reported the incident to the Director of Nursing (DON). Despite the facility's policy requiring all abuse allegations to be thoroughly investigated and for the accused employee to be suspended pending investigation, the DON did not conduct an investigation or report the allegation because she did not observe a bruise on the resident. The PTA was not suspended and continued to have resident contact. The resident's medical record did not contain documentation of the abuse allegation. The facility's policy, revised in September 2022, specifies that any employee accused of abuse is to be placed on leave with no resident contact until the investigation is complete, and that a follow-up investigation report is to be provided within five business days.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required timeframe after a resident reported being roughly handled by a Physical Therapy Assistant (PTA), resulting in a skin tear. The resident, who was cognitively intact with a BIMS score of 15 and had a history of gait and mobility abnormalities, stated that the Director of Rehabilitation (DOR) was made aware of the incident when she requested a different PTA. The Occupational Therapist (OT) reported the allegation to the Physical Therapist (PT) and then to the DOR, believing the DOR would inform the Director of Nursing (DON). The PTA was aware of the allegation but was not suspended from duties following the report. The DON confirmed that she and the DOR checked on the resident after learning of the allegation but did not report the incident to CDPH, citing the absence of visible bruising as the reason. The resident's records did not document the abuse allegation, and facility policy required all reports of abuse to be reported to appropriate agencies and thoroughly investigated. The failure to report the allegation as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Timely Care and Treatment for Skin Tear
Penalty
Summary
A resident with a history of impaired skin integrity, including a tendency to bruise easily and use of anticoagulant medication, sustained a skin tear on the right wrist after a blood pressure cuff was applied. The resident was observed with a wound dressing on the wrist and reported the injury during an interview. Review of the resident's care plan indicated that staff were to check skin during daily care and notify the physician of abnormal findings. However, there was no documented evidence that the skin tear was identified, monitored, or addressed for care and treatment in the resident's medical record. Further review and interviews with facility staff, including an LVN and the DON, confirmed that there were no change in condition notes, physician's orders, or care plan updates related to the skin tear. The facility's wound care policy required a physician's order for wound care procedures, but this was not obtained. The lack of documentation and physician notification resulted in the skin tear not being properly assessed or treated according to facility policy and the resident's care plan.
Black Mold Observed in Resident Shower
Penalty
Summary
A deficiency was identified when black mold was observed in the shower area of one resident's bathroom. The resident reported the presence of black mold, and both the housekeeper and housekeeping supervisor confirmed the observation during interviews and inspections. The housekeeping supervisor acknowledged that the substance appeared to be black mold and stated it should not be present in the resident's shower or anywhere in the facility. The administrator also confirmed that black mold should not be present in the facility. The facility's policy on cleaning and disinfection requires that housekeeping surfaces be cleaned regularly, when spills occur, and when surfaces are visibly soiled. The affected resident had a diagnosis of chronic obstructive pulmonary disease (COPD) and was cognitively intact, as indicated by a BIMS score of 14. The presence of black mold in the resident's shower indicated a failure to maintain a sanitary environment as required by facility policy, particularly for a resident with a chronic lung disease. The deficiency was based on direct observation, staff interviews, and review of the resident's medical record and facility policies.
Failure to Follow Narcotic Count and Documentation Procedures
Penalty
Summary
The facility failed to follow its policy and procedure for accounting for narcotic controlled substances, specifically regarding the verification and documentation of liquid Ativan for a resident with an anxiety disorder. During an end-of-shift narcotic count, two LPNs did not have the narcotic count sheet present while verifying the amount of liquid Ativan stored in the medication room refrigerator. Instead, one nurse relied on memory and prior knowledge of the count, and both nurses acknowledged that the narcotics book should have been with them to accurately verify the medication, resident, and remaining amount. The Director of Nursing confirmed that the expectation was for nurses to have the narcotics sheets present during the count to ensure accuracy. Additionally, a review of the facility's Narcotic and Controlled Substance Shift-to-Shift Count Sheet for a specific month revealed multiple instances where either the off-going or on-coming nurse did not sign the sheet after completing the shift-to-shift narcotic count. Interviews with registry nurses indicated that they were unaware of the requirement to sign the count sheet, and in some cases, the sheet was not available for signature. Both nurses confirmed that the medication count was performed, but the required documentation was not completed. The facility's policy requires that controlled substances be counted at the end of each shift by both the off-going and on-coming nurses, with both individuals signing the designated record. The policy also states that any discrepancies should be reported to the Director of Nursing. The observed failures included not having the narcotics sheet present during the count and not signing the shift-to-shift count sheet, which were confirmed by staff interviews and record review.
Failure to Honor Resident's Preference Regarding Use of Bleach in Room
Penalty
Summary
The facility failed to honor a resident's expressed preference to not use bleach or bleach-containing products when cleaning her room. Despite the resident's repeated requests over several months to avoid bleach due to its strong smell and the fact that it caused her to cough, staff continued to use bleach products in her room. Housekeeping and environmental services staff were aware of the resident's request and had communicated it to their supervisors, but the information was not consistently relayed to all staff members responsible for cleaning the resident's room. On one occasion, a CNA, unaware of the resident's preference, used a bleach wipe to clean the resident's bedside table, which caused the resident to become upset due to the strong smell. The CNA attempted to mitigate the situation by wiping the area with a wet towel, but the resident remained distressed. Interviews with other staff, including the LVN and DON, revealed that while some staff were aware of the resident's request, there was no formal documentation in the resident's medical record, no physician's order, and no signage in the room to alert all staff to the resident's preference. The resident's medical record indicated a diagnosis of depression and modified independence in decision-making. The lack of consistent communication and documentation regarding the resident's preference led to repeated use of bleach products in her room, resulting in her preference not being honored and causing her distress.
Failure to Report Financial Abuse Allegation
Penalty
Summary
The facility failed to notify the police and Adult Protective Services (APS) of an allegation of financial abuse involving a resident, as required by their policy and procedure. The incident involved a resident with mild cognitive impairment, who was reportedly involved in a financial transaction where a significant sum of money was given to an acquaintance. The Social Services Director (SSD) was informed of the situation but did not notify the police or APS within the required two-hour timeframe, citing a lack of details and confusion about jurisdictional responsibilities. The facility's policy mandates immediate reporting of suspected abuse to the administrator and relevant authorities, including APS and law enforcement, within two hours. However, the SSD failed to document the notifications on the SOC 341 form, and during interviews, admitted to not notifying the police and APS due to confusion and lack of awareness. The administrator confirmed that all suspicions of abuse should be reported to all relevant agencies within the specified timeframe, which was not adhered to in this case.
Failure to Administer HIV Medications as Ordered
Penalty
Summary
The facility failed to administer HIV medications to Resident 2 according to the physician's orders, which were crucial for managing the resident's HIV condition. Resident 2 was admitted with a diagnosis of HIV and had physician's orders for Dolutegravir Sodium and Rilpivirine Hydrochloric acid to be administered daily. However, the Medication Administration Record indicated that these medications were not given from January 8 to 29, 2025, despite the care plan specifying that HIV medications should be administered as ordered. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding the provision of HIV medications. LVN 1 and LVN 2 indicated that it was the facility's policy for newly admitted residents to supply their own HIV medications due to their high cost. RN 1 explained that if residents could not provide their medications, the facility's Social Service or Case Manager should be notified to seek assistance from local organizations, and if medications were not obtained promptly, the facility's pharmacy should supply them. However, there was no documentation of physician notification about the unavailability of the medications, and the facility did not provide the medications until January 30, 2025. The Administrator acknowledged that the facility did not provide the HIV medications in a timely manner and expressed disappointment in the delay. The facility's policies required contacting the prescriber if medication delivery was delayed and ensuring documentation and communication with the pharmacy. Despite these policies, the facility failed to ensure Resident 2 received the necessary HIV medications, potentially compromising the resident's health by increasing the risk of a higher viral load and opportunistic infections.
Failure to Provide Restorative Nursing Services as Ordered
Penalty
Summary
The facility failed to provide Restorative Nursing Services (RNA) as ordered by the physician for a resident, identified as Resident 2, which could potentially lead to muscle contractures and decreased range of motion (ROM) and mobility. The deficiency was identified during an unannounced visit to investigate a complaint regarding quality of care. RNA 1, responsible for providing RNA treatments, confirmed that treatments were not administered to Resident 2 during the week of February 2 through 8, 2025, due to the resident's refusal on one day and RNA 1 being unavailable on the other scheduled days. Resident 2, who was admitted with diagnoses including abnormalities of gait and muscle weakness, had a care plan that required RNA treatments three times a week. However, RNA 1 did not report the missed treatments to a supervisor, which was against the facility's expectations. The RNA Weekly Summary inaccurately documented that Resident 2 was seen three times, which RNA 1 clarified as a misunderstanding, thinking it referred to visual checks rather than actual treatment sessions. Interviews with the facility's staff, including the Registered Nurse (RN) and the Administrator, revealed that there was an expectation for RNA staff to report any inability to provide treatments so that alternative arrangements could be made. The facility's policy emphasized the importance of individualized and resident-centered restorative goals, but the lack of proper documentation and communication led to a failure in executing the care plan for Resident 2.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure the effectiveness of interventions to address multiple falls for a resident, leading to repeated unwitnessed falls. The resident, who was under hospice care with a history of falls and moderate cognitive impairment, experienced several falls in January 2025. Despite having interventions such as a bed alarm, low bed position, and padded floor mats, the resident continued to fall, indicating that these measures were ineffective. The Director of Nursing (DON) acknowledged that the interventions in place were not preventing the falls and that additional measures, such as a sitter, were not evaluated or implemented. The resident's care plan included interventions like keeping the call light within reach and using a bed alarm, but these were not sufficient given the resident's confusion and non-compliance with using the call light. The facility's policy required re-evaluation and implementation of new interventions if falls continued, but this was not adequately done. The report highlights that the facility did not provide a sitter, which was identified as a potentially effective intervention. The resident's representative had temporarily hired a private sitter, which prevented falls during that period, but the facility did not take over this responsibility. The DON admitted that the facility should have provided a sitter to ensure the resident's safety, as the existing interventions were not effective in preventing further falls.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a Restorative Nursing Assistant (RNA) and a resident to the California Department of Health (CDPH) within the required timeframe. The incident involved a resident who reported that the RNA had inappropriately touched him. The resident, who had a history of cerebral infarction, chronic kidney disease, depressive disorder, anxiety disorder, type 2 diabetes mellitus, legal blindness, and congestive heart failure, informed his family member about the incident. The family member then reported the allegation to the Director of Nursing (DON) on December 3, 2024. Despite being informed of the allegation, the DON did not initiate an investigation or report the incident to the state agency until December 7, 2024, which was four days after the initial report. This delay was contrary to the facility's policy, which requires allegations of abuse to be reported immediately, defined as within two hours. The failure to report the incident promptly resulted in a delayed investigation by the CDPH and had the potential to expose the resident to further abuse.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. On January 6, 2025, at 4:50 p.m., two of five dumpsters at the loading dock were found overflowing with boxes, with lids not fully closed, and trash scattered on the ground beneath them. This observation was made in the presence of the Food Service Director (FSD), who acknowledged that the lids should be properly closed and trash should not be on the ground to prevent attracting pests and rodents. Further, on January 9, 2025, during an interview with a Registered Dietitian (RD), it was confirmed that improperly closed dumpster lids could attract pests and flies, posing a risk of them entering the kitchen when the door is open, thus creating an infection control issue. The facility's policy, dated 2023, mandates daily inspection of garbage and trashcans to ensure no debris is on the ground and lids are closed, emphasizing the need to keep the area clean to prevent it from becoming a feeding ground for vermin and rodents.
Failure to Assess Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper assessment for safe self-administration of medication for three residents, leading to medications being improperly stored and potentially misused. Resident 101 was found with an opened Ventolin HFA inhaler in her desk drawer, despite having fluctuating capacity to understand and make decisions. The resident's family members were aware of the inhaler and would remind nurses to administer it, as Resident 101 could not effectively self-administer. The facility's records indicated that Resident 101 did not want to self-administer medications, and no further assessments were conducted, yet the medication was documented as unsupervised self-administration. Resident 265 had three opened medications on her bedside drawer, including Trelegy Ellipta, Combivent Respimat, and MAX STRENGTH Aspercreme. The resident stated she self-administered the medications, particularly Trelegy, when experiencing shortness of breath. However, there were no physician orders for Combivent and Aspercreme, and the facility's records showed that Resident 265 did not want to self-administer medications at the time of assessment, with no further assessments conducted. Resident 19 was found with two opened respiratory inhalers, Symbicort Aerosol and Combivent Respimat, on her overbed table. The resident self-administered the medications for shortness of breath without informing the nurses each time. The facility's policy required an assessment for self-administration, which was not conducted for Resident 19. The DON acknowledged that the facility's policy and procedure regarding self-administration assessment and medication administration were not followed, posing a risk of residents not receiving medications according to physician orders and not being monitored for adverse effects.
Delayed Call Light Response Leads to Care Deficiency
Penalty
Summary
The facility failed to ensure that call lights were answered within a reasonable time for three residents, leading to delays in care. Resident 95 expressed frustration over the call light system, stating that staff would either not respond or turn off the light without addressing his needs. This issue had persisted for over two months. Resident 95, who has a history of cerebral infarction and muscle weakness, was found to have moderate cognitive impairment. A Certified Nursing Assistant (CNA) confirmed the resident's complaints and noted that some staff members were not conducting hourly rounds as required. Resident 5, who suffers from paraplegia and polyneuropathy, reported that during the night shift, the facility was understaffed, with only two CNAs for the entire unit. She stated that her call light often went unanswered for hours, resulting in her lying in her own waste for extended periods. Her care plan indicated a need for assistance with activities of daily living due to her condition. The resident also noted that the issue was exacerbated when registry agency staff were on duty. Resident 464, who is cognitively intact and self-responsible, also experienced long wait times for call light responses, citing facility understaffing as a contributing factor. Interviews with staff, including a CNA and an LVN, revealed that the facility had been relying heavily on registry staff during night shifts, leading to delays in care. The facility's policy requires call lights to be answered within five minutes, but this standard was not being met, as confirmed by the Director of Nursing.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to uphold residents' rights by not offering the formulation of an Advance Directive (AD) to several residents or their representatives. Specifically, seven out of thirteen residents reviewed did not receive education or resources about ADs, nor was there documentation of such offers in their medical records. For instance, Resident 514, who was cognitively intact, did not have an AD, and there was no evidence that the Social Service Assistant (SSA) provided the necessary information or documented any efforts to do so. Similarly, Resident 116, who had the capacity to make decisions, also lacked documentation of being offered AD education. In another case, Resident 123, who was cognitively intact, did not have an AD in their record, and there was no documented evidence that the formulation of an AD was offered. The Registered Nurse (RN) and SSA both acknowledged the absence of an AD and the lack of documentation regarding the offer. The Social Services Director (SSD) confirmed that ADs should be offered upon admission and reviewed quarterly, but this process was not followed for Resident 123. Additionally, Resident 263, who had moderate cognitive impairment but the capacity to make healthcare decisions, also did not have an AD or documentation of an offer to formulate one. Furthermore, the facility failed to maintain copies of existing ADs in the medical records. For Resident 13, who had an AD, there was no copy available in the medical record, and no follow-up was conducted to obtain it. The SSA admitted to not following up with Resident 13 to secure a copy of the AD. The facility's policy required that information about ADs be prominently displayed and retrievable in the medical record, but this was not adhered to, leading to potential non-compliance with residents' wishes regarding medical treatment.
Failure to Maintain Homelike Environment Due to Peeling Wallpaper
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for five residents, as observed through the presence of peeled and damaged wallpaper in their rooms. Specifically, the wallpaper was found to be peeling behind the headboards in rooms 808, 212, 213, 113, and 609. Resident 63 expressed discomfort with the peeling wallpaper above her headboard, and the Maintenance Supervisor acknowledged that the damage was caused by the bed scraping against the wall. Resident 265 noted that the wallpaper had been peeling since her admission, and Licensed Vocational Nurse 3 confirmed the issue, stating that maintenance should have been notified. The Maintenance Supervisor admitted that there was no system in place under prior management to regularly check and maintain the condition of the rooms. Further observations revealed that the wallpaper behind Resident 27's headboard had been peeling since her transfer to the room months prior, and similar issues were noted in the rooms of Residents 73 and 28. The Administrator acknowledged that the maintenance staff should have addressed the damaged wallpaper to ensure a homelike environment. The facility's policy on providing a homelike environment, dated February 2021, emphasized the importance of maintaining a safe, clean, and comfortable setting for residents, which was not upheld in these instances.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for five out of ten residents reviewed. The Resident Assessment Instrument Manual specifies that Quarterly Assessments should be transmitted no later than 28 days from the Assessment Reference Date (ARD). However, the assessments for the residents were transmitted between 40 to 43 days after the ARD, which is beyond the required timeframe. Interviews with the MDS coordinator and the Director of Nursing (DON) revealed that the facility was aware of the backlog in MDS submissions, which had been an issue since October 2024. The MDS coordinator acknowledged the delay and mentioned that efforts were being made to address the backlog. The DON confirmed that she was aware of the late submissions and had sought assistance from the corporate office to manage the backlog. Despite these efforts, the facility remained out of compliance with federal regulations due to the delayed transmission of MDS assessments.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to consistently provide activities that met the individual preferences of three residents, leading to a deficiency in resident engagement and activity. Resident 10, who was a former beautician, expressed a desire to engage in hair services and styling, yet was observed spending her time watching TV and sleeping, with no activities related to her past interests being provided. Her care plan indicated a need for independent leisure activities, but this was not reflected in her daily routine. Resident 48, a former bartender, reported a lack of engaging activities and expressed interest in socializing and serving drinks, which aligned with his past occupation. However, he was left with minimal interaction and activities that did not cater to his interests, leading to feelings of boredom and isolation. The Activity Assistant was unaware of his background and did not provide activities that matched his preferences, despite his care plan indicating a need for enjoyable and meaningful activities. Resident 128, a former teacher who taught sign language, was observed with limited access to reading materials and music, despite her care plan indicating a need for such resources. She was often found sleeping or inactive, with no activities provided that aligned with her interests. The Director of Nursing and Activity Director acknowledged the lack of personalized activities and the need for activities that reflect residents' past occupations and interests, as outlined in the facility's policies.
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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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