Golden Empire
Inspection history, citations, penalties and survey trends for this long-term care facility in Grass Valley, California.
- Location
- 121 Dorsey Drive, Grass Valley, California 95945
- CMS Provider Number
- 056391
- Inspections on file
- 33
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Golden Empire during CMS and state inspections, most recent first.
A resident with cerebral palsy and severe cognitive impairment was found in bed crying and curled in a fetal position while another resident with dementia and intact cognition sat at the edge of the bed with his pants or briefs down. CNAs observed the second resident with one hand under the first resident's gown and the other on his own genital area, and the first resident's penis was exposed. The distressed resident verbally requested that the other be removed. The ADON characterized the incident as sexual abuse, and the facility's abuse policy states that residents must not be subjected to abuse by anyone, including other residents.
Two residents sharing a room were involved in an alleged sexual abuse incident when CNAs twice found one cognitively intact resident with his pants or briefs down, touching his own genitals and physically contacting a severely cognitively impaired resident whose genitalia were exposed and who became tearful and asked for the other resident to be removed. Although the CNA reported the incident to the Nurse Supervisor, the ADM later confirmed that the allegation was not reported to the state survey agency until the following day, exceeding the facility’s abuse policy requirement that mandated reporters notify the Department of Public Health within two hours of an abuse allegation.
The facility did not complete required annual performance reviews for a CNA, as the CNA’s personnel file showed the last documented review occurred several years after hire with no subsequent evaluations. The DSD confirmed that annual performance reviews are required for all CNAs to ensure they are performing their job, and acknowledged that no more recent review was on file. Facility policy on competency evaluation requires ongoing assessment of employee competencies and skills, including subsequent and/or annual evaluations based on the facility assessment, training program evaluation, and job performance evaluations.
A resident with a history of THC substance abuse was admitted with multiple diagnoses, and THC products were found in their room on two occasions. Despite this, staff did not develop a substance abuse care plan or notify the physician, as confirmed by interviews and record review. Facility policy required care planning and physician notification for such changes in condition, but these actions were not taken.
Meal tickets containing residents' personal and medical information, including names, photos, and room numbers, were left unattended and visible in the dining area and then discarded in regular trash, making the information accessible to other residents and visitors. Staff confirmed that these practices did not protect the confidentiality of residents' information, contrary to facility policy.
The facility did not ensure accurate MDS assessments for four residents, including those on hospice care and one using a C-PAP machine. Errors included incorrectly marking a resident as receiving invasive mechanical ventilation, failing to document terminal prognosis and hospice care for two residents, and inconsistent coding of hospice status and prognosis for another. These inaccuracies were confirmed by the MDS Coordinator and contradicted by medical records and staff interviews.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards.
Trash dumpsters and containers near the kitchen were found with open lids or no lids, containing items such as used gloves and a cigarette butt. Facility staff confirmed the issue, and policy review showed that daily inspections and closed lids are required to maintain sanitation.
Surveyors identified multiple infection control deficiencies, including incorrect assignment of enhanced barrier precautions signage, failure of staff to use required PPE during high-contact care, open doors for rooms on COVID-19 isolation, improper disinfection of BP equipment, and improper labeling and storage of respiratory equipment. These lapses were confirmed by staff interviews and record reviews, with staff acknowledging that facility policies were not followed.
Flies were observed in the kitchen, landing on food and surfaces, despite recent pest control services. The Dietary Supervisor, Maintenance Supervisor, Registered Dietitian, and DON all confirmed the ongoing fly problem and the risk of food contamination, indicating the facility's pest control measures were not effective.
Surveyors found expired medications and medical supplies in multiple medication carts, incomplete and unchecked crash carts with expired equipment, and a medication bottle stored in a refrigerator meant for resident food. LNs and the DON confirmed these deficiencies, which were not in accordance with facility policies requiring removal of expired items, daily crash cart checks, and separate storage of medications and food.
A resident with severe cognitive impairment slapped another resident, also with severe cognitive impairment, across the face while both were near a door to the courtyard. The incident was witnessed by a CNA and confirmed by staff interviews. Facility policy prohibits abuse of any kind, but the event occurred, resulting in a failure to protect a resident from physical abuse.
A resident with end-stage Alzheimer's disease and other diagnoses was enrolled in hospice care, but the required significant change in status assessment (SCSA) was not completed as mandated by facility policy. Both the MDSC and DON confirmed that the assessment should have been done following hospice enrollment.
Two residents did not receive care according to professional standards when a nurse failed to document a required PICC line arm measurement for one resident, and another resident's insulin administration record was altered without proper late entry documentation. These actions resulted in incomplete and inaccurate medical records, contrary to facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Surveyors found that after emergency insulin vials were removed from the E-Kit, staff did not ensure the kit was replaced within the facility's required 72-hour timeframe. The E-Kit remained unreplaced for six days, as confirmed by a nurse and the DON, despite facility policy and documentation logs.
A resident with terminal dementia receiving hospice services did not have required hospice documentation, such as the plan of care, visit schedules, or visit notes, in their clinical records. Nursing staff and the DON confirmed the absence of these documents and were unclear about the hospice staff's schedule and care coordination process, despite facility policy and agreements mandating such documentation and communication.
The facility did not ensure the Medical Director attended any QAPI committee meetings over several months, as required by policy. Despite being invited, the MD declined participation and did not send a designee, and did not acknowledge written reports provided by the facility. This resulted in the QAPI committee lacking required medical oversight for a census of 137 residents.
A resident with severe cognitive impairment and a high risk for wandering was able to leave the facility in a wheelchair without staff awareness and was found near a busy street by a staff member arriving for work. Staff interviews and record reviews confirmed that the resident required supervision and had a history of exit-seeking behaviors, but staff did not notice the resident's absence until after the incident.
The IP did not report two infectious disease outbreaks—one gastrointestinal and one respiratory—to CDPH within the required 24-hour period, despite facility policy mandating prompt notification. The gastrointestinal outbreak involved five residents with symptoms such as nausea and vomiting, while the respiratory outbreak affected three residents with fever and cough. The IP confirmed awareness of the reporting requirement and acknowledged the delays.
The infection preventionist did not report a flu and RSV outbreak to the Department of Health Services within the required 8-24 hour window, as mandated by facility policy. The delay occurred because the outbreak happened over a weekend when the IP was not present, and she was unaware of the reporting requirement.
A resident with cognitive impairments was found with a bruise on her hip, but the facility failed to investigate the injury as required by their Abuse policy. The DON confirmed no documentation or investigation was conducted to determine the cause of the bruise.
A resident with neurocognitive disorder and dementia experienced two incidents: a bruise of unknown origin on the hip and lacerations on fingers caused by a CNA during nail trimming. The facility failed to develop care plans for these injuries, contrary to their policy, potentially impacting the resident's care and well-being.
A resident with cognitive impairments suffered lacerations on her fingers due to improper nail trimming by a CNA, and the facility failed to reeducate the CNA or investigate the incident. Additionally, an LVN did not follow the physician's wound care orders, leaving the resident's fingers without the required dressings. The facility's wound care policy was not followed, and staff interviews confirmed the lack of corrective actions.
The facility failed to report an outbreak of scabies to the California Department of Public Health when three residents and one staff member tested positive. Despite policies requiring such reporting, the infection preventionist confirmed that the outbreak was not reported. One resident had a rash that led to all 20 residents in the dementia unit being treated preventatively, and the first case was identified in another resident.
A facility failed to monitor the effectiveness of Haloperidol (Haldol) prescribed to a resident with dementia and severe major depressive disorder with psychotic features. Despite the care plan requiring staff to monitor and document behaviors, no monitoring was in place, which was confirmed by the DON.
Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident was found inappropriately touching another resident. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was discovered in bed in a fetal position, curled up and crying, with his penis exposed. Resident 2, who had a diagnosis of unspecified dementia and intact cognition per his MDS, was found sitting at the edge of Resident 1's bed with his pants or briefs pulled down, one hand under Resident 1's gown and the other on his own genital area. After the incident, Resident 1 was tearful and stated, "Get him away from me." According to IDT notes and staff interviews, CNA 1 and CNA 2 entered Resident 1's room for a recheck and observed Resident 2 at the end of Resident 1's bed with his pants or briefs down, his back to the door, and his hand extended toward Resident 1. CNA 1 reported seeing Resident 2 with his right hand on his own genitals and his left hand on Resident 1's hip, and when Resident 1's covers were pulled back, Resident 1's penis was exposed out of his brief. CNA 2 corroborated that Resident 2 had no brief or underwear on, his brief was on the floor, his right hand was under Resident 1's gown, and Resident 1's penis was exposed. The Assistant Director of Nursing stated she would consider this incident sexual abuse and affirmed that every resident has the right to be free from abuse, consistent with the facility's abuse policy stating that residents must not be subjected to abuse by anyone, including other residents.
Failure to Timely Report Alleged Sexual Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the appropriate authorities within the required time frame. Resident 1, who had cerebral palsy, a right elbow contracture, and severe cognitive impairment per a recent MDS, was allegedly subjected to sexual abuse by a cognitively intact roommate, Resident 2, who had a diagnosis of unspecified dementia. According to IDT notes, two CNAs entered the shared room for a recheck and found Resident 2 sitting at the end of Resident 1’s bed with his pants down, his back to the door, one hand under Resident 1’s gown, and his other hand on his own genital area. In a separate interview, CNA 1 reported that on the evening prior, he had entered the room after providing evening care and found Resident 2 sitting on Resident 1’s bed with his briefs pulled down, his right hand on his own genitals, and his left hand on Resident 1’s hip; when CNA 1 pulled back the covers, Resident 1’s penis was exposed, and Resident 1 became tearful and stated, “Get him away from me.” CNA 1 stated he reported this to the Nurse Supervisor on duty that evening. The Administrator confirmed in interview that the abuse allegation occurred on 2/8/26 and that the report to the California Department of Public Health (CDPH) was not made until 2/9/26 at 4:12 p.m. The facility’s policy and procedure on Abuse, Neglect, Exploitation, and Misappropriation, revised 10/12/23, requires all mandated reporters to report incidents or alleged violations of abuse not later than two hours after the allegation is made, including a written report to the local Department of Public Health Licensing and Certification office. The Administrator also stated that her expectation was that the initial incident report of the abuse allegation be sent to CDPH and other enforcement agencies within two hours of the allegation. The delay between the time the allegation was made and the time it was reported to CDPH constituted a failure to follow the facility’s abuse reporting policy and the federal requirement for immediate reporting of alleged abuse.
Missed Annual Performance Review for CNA
Penalty
Summary
The facility failed to complete annual performance reviews for a CNA, resulting in a missed evaluation for one of three sampled CNAs (CNA 1). Review of CNA 1’s employee file showed that the CNA was hired on 5/1/2018 and the most recent performance review on file was dated 5/17/2021, with no subsequent annual reviews documented. In an interview on 2/6/26 at 9:22 a.m., the Director of Staff Development (DSD) confirmed that the most recent documented performance review for CNA 1 was from 2021 and stated that performance reviews are supposed to be done annually for all CNAs, with the purpose of ensuring the staff member is doing their job. Review of the facility’s 2024 policy and procedure titled “Competency Evaluation” indicated that it is the facility’s policy to evaluate each employee to assure they meet appropriate competencies and skills for performing their job, and that subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of training programs, and/or job performance evaluations. This failure had the potential for the facility to be unaware of staffing performance concerns for CNA 1, with the potential for all resident care to be negatively affected.
Failure to Develop and Implement Substance Abuse Care Plan and Notify Physician
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional nursing standards for a resident with a known history of THC (tetrahydrocannabinol) substance abuse. The resident was admitted with multiple diagnoses, including a right knee fracture, major depressive disorder, anxiety, and difficulty walking. Documentation showed that the resident had a social history of THC use, and on two separate occasions, THC products were found in the resident's room. Despite these findings, there was no evidence that a care plan addressing substance use was developed, nor was there documentation of physician notification regarding the resident's substance abuse. Interviews with facility staff, including licensed nurses, a CNA, the Social Service Director, and the Social Services Assistant, confirmed that no substance abuse care plan was created and the physician was not notified after THC was found. Staff members stated that they would have expected a care plan to be implemented and the physician to be notified to ensure the resident's safety and appropriate care. The resident herself confirmed that she was not provided with an individualized substance abuse care plan upon admission or after the discovery of THC in her room, and expressed that such a plan would have been helpful. A review of facility policies indicated that comprehensive care planning and physician notification are required following resident assessments and any change in condition, including incidents involving substance abuse. The facility's failure to follow these policies resulted in the lack of monitoring, care planning, and physician involvement for the resident's substance abuse, as documented in the resident's records and confirmed by staff interviews.
Failure to Protect Resident Confidentiality in Meal Ticket Handling
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information for all 137 residents, as evidenced by meal tickets containing identifiable information being left unattended and easily accessible in the main dining room. Observations showed that returned breakfast trays had meal tickets displaying residents' names, facility identification numbers, colored photographs, room numbers, bed numbers, and dining locations in plain view, while other residents and visitors were present. Additionally, a dietary assistant was seen discarding these meal tickets into a regular trash can during tray cleanup, with the trash later compacted and disposed of in an outside dumpster. The registered dietician confirmed that this practice made residents' personal information easily accessible to others and acknowledged that disposing of the tickets in regular trash did not protect confidentiality. Review of the facility's HIPAA policy indicated a requirement to protect resident information and comply with federal guidelines.
Inaccurate MDS Assessments for Residents on Hospice and Special Treatments
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for four residents. For one resident with sleep apnea, the MDS was incorrectly marked as receiving an invasive mechanical ventilator, despite documentation and staff interviews confirming the resident only used a C-PAP machine at bedtime and had never been on a ventilator. The MDS Coordinator acknowledged the error, and the Director of Nursing confirmed that such inaccuracies could impact the quality of care provided. Another resident, admitted with severe cognitive impairment and a terminal prognosis, had a Certification of Terminal Illness and physician orders indicating hospice care for end-stage dementia. However, the MDS did not reflect the resident's terminal status or hospice care, as confirmed by the MDS Coordinator, who admitted to miscoding the assessment. Similarly, a third resident with a terminal diagnosis and on hospice care was not identified as such in two separate MDS assessments, and the MDS also failed to indicate a life expectancy of less than six months, contrary to medical documentation. A fourth resident, admitted under hospice services for dementia with severe agitation, had multiple MDS assessments that did not consistently reflect the terminal prognosis or hospice care status. The MDS Coordinator acknowledged that these assessments contained conflicting and inaccurate information, which could affect care planning. Facility policy requires that qualified staff conduct accurate assessments reflective of each resident's status, but this was not followed in these cases.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Improper Storage of Trash and Open Dumpsters
Penalty
Summary
Trash dumpsters outside the kitchen backdoor were observed with open lids, and an additional trash container containing used gloves, a hairnet, and a cigarette butt was found without a lid. These observations were made during a concurrent observation and interview with the Head of the department, who confirmed the lids were open. The Registered Dietitian also confirmed that open dumpsters and trash cans near the kitchen could attract flies, which could enter the kitchen when the back door was opened. A review of the facility's policy indicated that garbage and trashcans must be inspected daily to ensure lids are closed and no debris is present on the ground or surrounding area.
Infection Control Lapses in PPE Use, Equipment Disinfection, and Respiratory Care
Penalty
Summary
The facility failed to maintain effective infection prevention and control measures in several instances, as observed and documented by surveyors. In one case, enhanced barrier precautions (EBP) signage was incorrectly assigned to the wrong resident's bed, leading to confusion among staff about which resident required EBP. A certified nursing assistant (CNA) entered a room with an EBP sign without wearing the required personal protective equipment (PPE) and assisted a resident with incontinence care, only using gloves instead of both gown and gloves. The infection preventionist (IP) later clarified that the EBP sign was misplaced and should have been for a different resident, but this error was not corrected in a timely manner, resulting in improper infection control practices. In another instance, nursing staff did not implement EBP for a resident who had colonized bacteria and a skin tear requiring dressing. Despite the EBP sign being posted and the care plan indicating the need for gown and glove use during high-contact care, two CNAs performed an incontinence brief change without wearing gowns. One CNA was unaware of the EBP sign, and both confirmed that proper PPE should have been used. Additionally, the facility failed to enforce isolation precautions for COVID-19 positive residents, as doors to rooms with special droplet/contact precautions were left open, contrary to facility policy and posted signage instructing that doors remain closed. Further deficiencies included improper disinfection of blood pressure (BP) cuffs and machines, with staff using hand sanitizer wipes or alcohol prep pads instead of EPA-registered disinfectants as required by facility policy. There were also lapses in the handling of respiratory equipment: a resident's nebulizer mask was found unlabeled and not stored in a bag, and another resident's oxygen humidifier was left open and not replaced as ordered. These failures were confirmed through staff interviews and record reviews, with staff acknowledging the lapses and referencing facility policies that were not followed.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of flies in the kitchen. During an observation with the Dietary Supervisor, flies were seen flying around and landing on kitchen counters, food processors, cooking utensils, dishes, and food. The Dietary Supervisor confirmed the presence of flies and acknowledged the risk of food contamination. The Maintenance Supervisor also confirmed the ongoing fly problem in the kitchen and stated that the last pest control service was conducted earlier in the month, but the issue persisted. Further interviews with the Registered Dietitian and the Director of Nursing confirmed the infestation of flies in the kitchen and the potential for food contamination. The facility's policy required maintenance to ensure insects were not present and to contact the outside vendor for additional treatments if insects were found. Despite monthly pest control services, the flies remained, indicating the measures taken were not effective in maintaining a pest-free environment in the kitchen.
Expired Medications, Incomplete Crash Carts, and Improper Medication Storage Identified
Penalty
Summary
Surveyors observed that medications and medical supplies stored in three medication carts were expired, including haloperidol, isopropyl alcohol, Microkill One wipes, Maxorb II wound dressing, antiseptic skin cleanser, extra protective cream, anti-itch cream, iodoform packing strip, hydrogen peroxide, phenazopyridine tablets, skintegrity wound cleanser, biofreeze gel, syringes, and catheter stabilization devices. Additionally, an unlabeled pill identified as methadone was found in a narcotic box, and opened petrolatum dressings were present in the cart. Licensed nurses confirmed the presence of these expired and improperly stored items, acknowledging the importance of removing expired medications and supplies to prevent their use. Crash carts, which are essential for emergency situations, were not checked daily as required by facility policy, with multiple days missed from May to August. Inspections revealed that the crash carts did not contain the required number of normal saline containers, instead containing sterile water, and included a suction connection tubing that had expired in 2011. The Director of Nursing confirmed these discrepancies and the lack of regular checks, which are necessary to ensure the readiness and completeness of emergency equipment and supplies. A medication bottle containing acidophilus probiotic was found stored in a refrigerator designated for resident food in the memory unit. Both a certified nursing assistant and a licensed nurse confirmed that medications were being stored with food, which posed a risk for cross contamination. The Director of Nursing stated that medications requiring refrigeration should be kept in a secured medication refrigerator, not with resident food. Facility policies reviewed indicated that outdated, contaminated, or deteriorated medications should be removed from stock and that refrigerated medications must be kept separate from foods.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident with severe cognitive impairment slapped another resident, also with severe cognitive impairment, across the right side of the face. The incident occurred when one resident was attempting to open a door to the courtyard and the other resident, standing nearby, spontaneously slapped her. This event was witnessed by a CNA, who reported that her back was initially turned and she did not see the events leading up to the slap, but turned around in time to see the physical contact occur. Both residents involved had diagnoses of dementia and were assessed as having severe cognitive impairment according to their MDS records. The facility's policy and procedure on abuse, dated April 2025, states that each resident has the right to be free from abuse, including physical abuse, and that residents must not be subjected to abuse by anyone. Interviews with staff, including a CNA, a licensed nurse, and the DON, confirmed the occurrence of the incident and acknowledged that such behavior constitutes abuse and is not tolerated according to facility policy.
Failure to Complete Significant Change Assessment After Hospice Enrollment
Penalty
Summary
A significant change in status assessment (SCSA) was not completed for one of the sampled residents after the resident was enrolled in a hospice program. The resident, who had diagnoses including frontotemporal neurocognitive disorder and major depressive disorder, was admitted with a terminal prognosis related to end-stage Alzheimer's disease. Physician orders and hospice documentation confirmed the resident's terminal status and enrollment in hospice care. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) acknowledged that a SCSA should have been completed following the resident's enrollment in hospice but was not done. The Director of Nursing (DON) also confirmed that a SCSA is required when a resident is admitted to hospice. Facility policy states that a SCSA must be completed within 14 days of identifying a significant change, including hospice enrollment, but this was not followed in this case.
Failure to Follow Professional Standards in PICC Line Monitoring and Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure professional standards of care were followed for two residents. For one resident with a PICC line in the right arm, the physician's order required weekly measurement and documentation of the mid-upper arm circumference to monitor for complications. On review, the MAR/TAR was missing a signature for the required measurement on a specified date, and both the DON and a licensed nurse confirmed that the absence of documentation indicated the task was not completed. The facility's policy also required weekly measurement and documentation, which was not followed in this instance. For another resident with type I diabetes and a history of diabetic ketoacidosis, the physician ordered daily administration of Tresiba insulin. The MAR for a specific month showed that the resident did not receive insulin on two dates, and there was no documentation explaining the missed doses. The DON confirmed the absence of documentation and the increased risk to the resident due to their medical history. Later, the MAR was found to have been altered to indicate that the insulin was administered on those dates, but there was no corresponding late entry or explanation in the nursing progress notes as required by facility policy. Interviews with nursing staff revealed that the nurse responsible for the insulin administration acknowledged correcting the MAR after being questioned about the missing documentation, but did not follow the facility's process for late charting. The facility's documentation policy required that late entries be clearly indicated and explained in the progress notes, which was not done in this case. These failures resulted in incomplete and inaccurate medical records for both residents.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Timely Replace Opened Emergency Medication Kit
Penalty
Summary
The facility failed to implement an efficient process to accurately document and secure emergency medications (E-Kit) for its residents. During an inspection of the medication storage room, it was observed that the E-Kit containing insulin was stored in the medication refrigerator with a red tag, indicating it had been opened. The E-Kit logs showed that vials of Humalog and Lantus insulin were removed on two separate dates, and the E-Kit had not been replaced for six days after the last removal. A licensed nurse confirmed the delay in replacement and stated that it takes longer for refrigerated E-Kits to be replaced. The Director of Nursing confirmed that the E-Kit had not been replaced in a timely manner and acknowledged that staff should have followed up to ensure prompt replacement. Review of the facility's policy indicated that open E-Kits should be replaced with sealed kits within 72 hours of opening. The failure to replace the E-Kit within the required timeframe was directly observed and confirmed by staff interviews and record review.
Failure to Maintain and Document Hospice Coordination for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the hospice team and facility staff for a resident with a terminal diagnosis of dementia who was admitted under hospice services. Despite an agreement and facility policy requiring communication and documentation of hospice care, the resident's clinical records and dedicated hospice binder lacked essential hospice documents, including the hospice plan of care (POC), visit schedules, and visit notes. The only hospice-related document present was the consent for hospice services, and the hospice sign-in and visit log were blank. Licensed nurses and the DON confirmed that there was no documentation of hospice visits or communication, and staff were unaware of the hospice staff's schedule or the disciplines assigned to the resident. Interviews with nursing staff and leadership revealed a lack of understanding and implementation of the process for coordinating care with the hospice agency. The DON acknowledged that the absence of hospice documentation in the resident's records meant that staff might not be aware of the resident's current care needs or any changes in their condition. The facility's own policy and the service agreement with the hospice agency required the maintenance of medical records, including progress and clinical notes describing all inpatient services, but these were not present for the resident receiving hospice care.
Medical Director Absence from QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director (MD), a required member of the Quality Assurance and Performance Improvement (QAPI) committee, attended any of the QAPI meetings from January to May 2025. Despite holding monthly QAPI meetings to review quality reports, identify care concerns, discuss safety issues, and implement corrective actions, the MD did not participate in these meetings. Attendance records confirmed the MD's absence, and the facility did not have a designee attend in the MD's place. Interviews with the Administrator (ADM) and Director of Nursing (DON) revealed that the MD was invited to each meeting but declined, citing being too busy. The ADM reported that the MD was verbally notified of issues and provided with written reports, but the MD did not acknowledge receipt of these reports. The facility's QAPI policy required the MD or a designee to be part of the committee, but this requirement was not met during the specified period, affecting oversight for a census of 137 residents.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents, specifically in the case of a resident with severe cognitive impairment and a high risk for wandering or elopement. The resident, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, COPD, and Diabetes Mellitus, was able to leave the facility in a wheelchair without staff awareness. The resident was found by a kitchen staff member on a driveway ramp near a busy street, and staff were unaware that the resident was missing until the kitchen staff returned the resident to the unit. The facility's policy required immediate action if a resident was found missing, but this was not followed as staff did not notice the resident's absence. Record reviews confirmed that the resident had a high score on the facility's Wandering Risk Scale and required supervision and permission to be outside. Interviews with staff and review of progress notes indicated that the resident regularly demonstrated exit-seeking behaviors and that the incident occurred without staff knowledge. The Director of Nursing and Administrator confirmed that the resident was confused, required supervision, and that staff were unaware of the resident's exit and location at the time of the incident.
Delayed Reporting of Infectious Disease Outbreaks to Public Health Authorities
Penalty
Summary
The infection preventionist (IP) failed to report two potential infectious disease outbreaks to the California Department of Public Health (CDPH) within the required 24-hour timeframe, as outlined in the facility's policies. Specifically, a gastrointestinal outbreak affecting five residents with symptoms of nausea, vomiting, and loose stool began on 4/8/2025 but was not reported to CDPH until 4/11/2025, resulting in a three-day delay. Similarly, a respiratory outbreak involving three residents with fever, cough, and congestion started on 5/3/2025 and was reported to CDPH on 5/5/2025, two days late. Facility policies reviewed indicated that unusual occurrences, including outbreaks and suspected outbreaks, must be reported to the appropriate health authorities within 24 hours. During an interview, the IP acknowledged awareness of the 24-hour reporting requirement and confirmed the delays in reporting both outbreaks. These actions were not in accordance with the facility's Unusual Occurrences, Infection Prevention and Control Program, and Outbreak of Communicable Diseases policies.
Failure to Timely Report Flu and RSV Outbreak
Penalty
Summary
The infection preventionist (IP) failed to report an outbreak of influenza and Respiratory Syncytial Virus (RSV) in the facility within the required 8-24 hour timeframe as outlined in the facility's policy on unusual occurrences. The policy specifies that epidemic outbreaks or prevalence of communicable diseases must be reported to the Department of Health Services within this period. During an interview, the IP acknowledged that the outbreak occurred over a weekend when she was not working and admitted she did not know she was required to report it within 24 hours, resulting in a delayed notification.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse policy and investigate an injury of unknown origin for a resident who was found with a bruise on her left hip. The facility's policy requires that any complaints, observations, suspicions, or reports of incidents, including bruises of unknown origin, be investigated to rule out abuse. However, in this case, there was no documentation or investigation conducted to determine the cause of the bruise, nor were there any witness accounts, resident representative accounts, or employee interviews documented as required by the policy. The resident involved was admitted with diagnoses including frontotemporal neurocognitive disorder, tremors, and dementia, which affected her memory, recall, and decision-making abilities. Despite the presence of a bruise on the resident's hip, the Director of Nursing (DON) confirmed that no investigative report or follow-up was conducted, and she could not recall which staff member discovered the bruise or when it was discovered. This lack of action and documentation was contrary to the facility's established procedures for handling such incidents.
Failure to Develop Care Plans for Resident Injuries
Penalty
Summary
The facility failed to develop care plans for a resident who experienced two separate incidents. The first incident involved a bruise of unknown origin found on the resident's left hip. Despite the facility's policy requiring a care plan to be implemented or updated when a skin condition is identified, no care plan was developed for this bruise. The resident was admitted with diagnoses including frontotemporal neurocognitive disorder, tremors, and dementia, which could complicate the identification and management of such conditions. The second incident involved lacerations on two fingers of the resident's right hand, caused by a CNA while trimming the resident's fingernails. The lacerations were treated with normal saline and wrapped with gauze, but again, no care plan was developed to address this injury. The Director of Nursing confirmed that care plans should have been developed for both the bruise and the lacerations, but they were not, which could have led to the resident's needs not being properly identified and managed.
Failure to Provide Proper Wound Care and Staff Reeducation
Penalty
Summary
The facility failed to provide quality care for a resident who was unable to make decisions on her own due to conditions such as frontotemporal neurocognitive disorder, tremors, and dementia. A Certified Nursing Assistant (CNA) trimmed the resident's fingernails and accidentally cut the skin, causing lacerations on two fingers of her right hand. The facility did not conduct corrective reeducation with the CNA to prevent recurrence of such incidents. Additionally, the Licensed Vocational Nurse (LN) did not follow the physician's wound care treatment directions for the resident's lacerated fingers, as the treatment was not administered on specified dates, and the fingers were observed without the required dressings. The facility's policy on wound care was not adhered to, as the licensed nurse did not track the effectiveness of treatments or contact the Medical Director for a change in treatment orders when the wound was not healing. Observations revealed that the resident's fingers were not wrapped in dressing as ordered by the physician, and the LN admitted to not following the treatment orders because the fingers were not bleeding or appearing infected. Interviews with facility staff confirmed the lack of reeducation for the CNA and the absence of an investigation into the incident, highlighting a failure in ensuring proper care and adherence to physician orders.
Failure to Report Scabies Outbreak
Penalty
Summary
The facility failed to report an outbreak of scabies to the California Department of Public Health (CDPH) when three residents and one staff member tested positive for the condition. The facility's infection preventionist (IP) confirmed that the outbreak was not reported, despite the facility's policies requiring such reporting. The review of the undated policy titled 'Outbreak Reporting' and the policy titled 'Reporting Communicable Diseases' dated 7/1/14 indicated that the IP was responsible for reporting outbreaks to CDPH and the local public health officer. However, this was not done in this case. During the investigation, it was found that Resident 1 had a rash that spread all over their body, leading to all 20 residents in the dementia unit being treated for scabies as a preventative measure. The IP's line listing indicated that Resident 3 was the first to be diagnosed with scabies, and in total, one staff member and three residents tested positive. Additionally, two residents were being treated empirically for scabies. The IP confirmed that the outbreak was not reported to CDPH, which was a failure to adhere to the facility's own policies and state requirements.
Failure to Monitor Antipsychotic Medication Effectiveness
Penalty
Summary
The facility failed to monitor a resident who was prescribed an antipsychotic medication, Haloperidol (Haldol), for effectiveness. The resident, who had a diagnosis of dementia and severe major depressive disorder with psychotic features, was admitted to the facility and prescribed Haldol due to extreme paranoia. Despite the facility's policy requiring close monitoring of antipsychotic medications, there was no monitoring in place to evaluate the response or effectiveness of the medication from the time it was prescribed until the time of the survey. The Director of Nursing confirmed that there should have been a monitor in place to track the resident's behaviors and symptoms. The resident's care plan indicated that staff would monitor and document behaviors and symptoms of extreme paranoia, but this was not done. The Medication Administration Record (MAR) from the relevant period showed no data collected from behavior monitoring, which was supposed to be used by the facility physician and pharmacist to determine the appropriate dose and effectiveness of the antipsychotic medication. This lack of monitoring could result in the unnecessary use of the medication and a potential decline in the resident's overall health status.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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