Height Street Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1611 Height Street, Bakersfield, California 93305
- CMS Provider Number
- 555902
- Inspections on file
- 49
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Height Street Skilled Care during CMS and state inspections, most recent first.
A facility allowed several residents to keep cigarettes and lighters unsecured in their rooms, despite a smoking policy requiring secure storage. The facility also failed to properly check expired wander guards for two residents at serious risk for elopement, and one resident with dementia was not monitored for wandering as directed in the care plan; that resident was later found walking in the parking lot while the door alarm sounded, and staff did not follow the elopement response policy.
Failure to complete the required PASRR resident review for a resident with dementia, schizophrenia, and auditory hallucinations. The resident’s PASRR indicated that a new Level I screening as a Resident Review was required after 30 days, and the DON stated a new PASRR should have been submitted but was not. The facility policy states PASRR is used to screen applicants for mental illness and/or intellectual disability and coordinate with state agencies when indicated.
A resident was transferred to the hospital for low O2 saturation and oversedation, and the hospital discharge paperwork identified an accidental methadone overdose. The DON confirmed Narcan was ordered but not given, and there was no documentation that the methadone clinic was notified about the resident’s condition. The facility also stated it had just set up a new system to communicate with the methadone clinic.
A resident with bilateral conductive hearing loss and intact cognition had a care plan requiring a communication board, but staff repeatedly communicated verbally without using it. During observations, CNAs and another staff member spoke to the resident about care needs and comfort items, yet the resident stated he did not understand what was being said and wanted staff to use the whiteboard. The resident was also observed without a whiteboard or notepad available in the dining room, and the DON confirmed staff should have used written communication.
Failure to provide ADL grooming assistance for a dependent resident. A resident with encephalopathy and moderately impaired cognition was assessed as needing staff help with personal hygiene, including shaving and fingernail trimming, but was observed with a scruffy unshaven beard, dry saliva on the lips, and untrimmed fingernails with debris underneath. The ADON acknowledged the grooming needs during observation.
A resident with significant unintentional weight loss had a physician-ordered RD consult after a PPN documented clinically significant weight loss and ordered a dietary consult for a comprehensive nutritional assessment. The consult was not completed when ordered because staff did not notify the RD; the RD stated there was no process identifying who was responsible for informing her of consult orders, and the resident’s last RD consult had been months earlier.
A resident receiving enteral tube feeding was observed lying with the HOB elevated only 15 degrees while Glucerna was infusing at 60 ml/hr. An LVN started the feeding and was unsure of the correct HOB position, and an RN stated the HOB was not elevated properly to prevent aspiration. Records showed an order to keep the HOB elevated 30-45 degrees or as tolerated and a care plan noting tube feeding related to dysphagia.
Medication Administered in Excess of Physician Order: An RN administered Breo Ellipta inhaler to a resident and directed the resident to take two inhalations even though the active order and inhaler instructions specified 1 puff inhaled orally once daily. The DON confirmed the resident’s OSR reflected the current order, and facility policy stated medications are to be administered by a licensed nurse per the attending physician’s order.
Medication storage and labeling were not maintained for two residents. An LVN observed a resident’s methadone left on a bedside table, and the resident reported that staff sometimes left the bottle for her to take without supervision. In a separate observation, an LVN retrieved an unlabeled insulin pen from the med cart and stated it belonged to another resident, while the DON confirmed insulin pens should be labeled with resident identification.
Failure to Administer Ordered Skin Treatment: A resident with a Braden score indicating moderate skin risk had a physician order for Calmoseptine ointment to be applied to the buttocks and perineum every 2 hours for skin maintenance. Review of the TAR showed missing documentation for multiple scheduled applications, and the TN stated that without documentation the treatment was not administered. The DON confirmed the facility's wound management policy was not followed.
A resident with moderately impaired cognition experienced ongoing episodes of loose stools over multiple days, reaching the facility-defined threshold for a change of condition, but the physician was not notified until many days later despite policy requiring timely notification. When the physician was finally contacted, an order for loperamide 2 mg Q8H PRN was obtained; however, MAR review showed that no doses were administered even though documentation indicated the resident continued to have loose stools. The DON acknowledged that the medication should have been given and that there was a delay in treatment due to poor communication among nursing staff, and the resident ultimately requested transfer to the hospital for diarrhea and abdominal pain.
A resident with dementia, Alzheimer’s disease, depression, cognitive communication deficits, and a need for extensive assistance with eating and personal care was allegedly slapped on the face by a family member during a feeding interaction, resulting in facial discoloration. A CNA later reported that she witnessed the incident and stated she informed an LVN immediately, but that the LVN told her not to say anything. The LVN denied being told about the abuse and recalled only being told the resident was aggressive. The allegation was not reported to facility administration until several weeks after the incident, contrary to the facility’s abuse policy requiring prompt reporting of suspected abuse within specified timeframes.
Surveyors found that the facility did not ensure residents’ access to private telephone communication when an LTCO repeatedly could not reach residents because calls transferred from the receptionist to the nurses’ station went unanswered and to voicemail, which he could not use for confidential communication. A cognitively intact resident who relies on the facility phone reported that people told him they had called but their calls were not put through, and a family member reported that while she could reach her relative during daytime hours, she could not reach anyone by phone after the receptionist left. The facility’s own resident rights policy states that residents have the right to privacy and confidentiality in communications and to use a telephone in privacy.
A resident was admitted with documented personal items, including clothing and linens, listed on an Inventory List completed at admission. At the time of discharge, there was no documentation that these belongings were returned to the resident or a representative, and no signed receipt was obtained. The DON confirmed that the record lacked evidence that the resident’s property was provided at discharge, despite facility policy requiring completion of a resident inventory at admission and discharge, provision of the property and inventory copy to the resident or representative, and obtaining a signed receipt.
A resident was discharged without being provided a documented home medication list, contrary to the facility’s stated discharge process. An LVN reported that residents are supposed to receive their medications with a written list and instructions, and that staff educate the resident and obtain a signature to verify this education. Review of the resident’s Discharge Instruction Form showed medications were noted as provided and an attachment was referenced, but no medications were actually listed, and the DON confirmed there was no evidence the resident received a home medication list. The facility did not supply a related policy or procedure when requested by surveyors.
A resident with major depressive disorder and paraplegia did not receive required non-pharmacological interventions when expressing increased sadness, and was not monitored every shift for 72 hours after an increase in Lexapro dosage. Staff failed to follow the care plan and facility policy, resulting in the resident being found deceased with evidence of self-harm. Documentation and interviews confirmed that necessary interventions and monitoring were not provided or recorded.
Two residents experienced unsanitary conditions, including a foul-smelling bathroom and unclean shower rooms with stained tiles. Housekeeping staff confirmed difficulties in removing persistent odors and acknowledged buildup in shower areas, contrary to facility policy requiring clean and pleasant living spaces.
Two residents with high fall risk, identified by admission assessments and medical diagnoses such as muscle weakness, gait abnormalities, and Alzheimer's disease, did not have baseline care plans with fall prevention interventions developed within the required 48-hour timeframe. Instead, care plans were delayed by seven and 26 days, contrary to facility policy and confirmed by the DON.
A resident with Alzheimer's disease, muscle weakness, and high fall risk was found in a bed that was not kept in the low position as required by their care plan and facility policy. A family member and staff confirmed the bed was not lowered, despite the resident's risk and documented interventions.
A resident with dementia and a history of pain reported arm pain to two CNAs, who did not provide pain relief or notify the LN. The LN became aware of the pain only after being approached by surveyors, and the resident continued to experience pain for at least 40 minutes. Facility policy required immediate communication and intervention for reported pain, which was not followed.
Two residents with significant care needs experienced long delays in call light response, with one waiting hours for incontinence care and another waiting 45 minutes for water at night. Both were cognitively intact and reported their concerns, and the DON acknowledged that such delays were not acceptable according to facility policy.
Two residents did not receive care as outlined in their care plans: one was not repositioned every two hours despite a history of pressure injuries, and another was left unsupervised during meals despite requiring assistance and redirection. Staff confirmed these lapses, and documentation showed both residents were dependent on staff for their respective needs.
The facility did not ensure that nursing services provided met professional standards of quality, as identified by surveyor observation and review of facility practices.
Three residents reported excessive delays in call light response, with wait times ranging from five minutes to two hours. These residents, who were cognitively intact and required assistance for brief changes and repositioning due to conditions such as pressure injuries, described staff walking by without responding and expressed feelings of anxiety, anger, and frustration. Facility policy requires prompt response to call lights, but this was not consistently observed.
Two cognitively intact residents were disturbed when a CNA entered their room at 4 a.m. singing and chanting loudly, waking them from sleep. Despite prior complaints and instructions to stop, the CNA continued this behavior, which did not align with facility policy requiring staff to treat residents with dignity and respect.
A resident with mild protein-calorie malnutrition experienced notable weight loss, and the RD's recommendations to liberalize the diet and increase nutritional supplements were not communicated to the physician or implemented. Facility policy requiring physician notification and documentation of RD recommendations was not followed, as confirmed by DON and ADON.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not report missing narcotic medications from the E-kit to CDPH as required by its own policy. The DON confirmed the discovery of missing oxycodone, Percocet, and Norco, and the Administrator acknowledged that the incident was not reported, despite clear policy requirements for timely notification of such occurrences.
A resident with multiple serious diagnoses was given Norco, a narcotic pain medication, outside the prescribed pain scale parameters, and staff failed to document reassessment of the medication's effectiveness as required by facility policy. The DON confirmed these lapses in both administration and documentation.
Surveyors found that medications, including ointments, tablets, inhalers, and controlled substances, were left on the bedside tables of several residents who were not authorized or assessed as capable of self-administering their medications. Nursing staff confirmed that these residents should not have had access to their medications at bedside, and facility policy prohibits this practice. The deficiency was identified through direct observation, record review, and staff interviews.
Milk was served to a resident at a temperature of 46°F, exceeding the facility's policy requirement of less than 41°F. This was confirmed by the Dietary Manager during a test tray delivery, and facility policies specify that milk should be kept at or below 41°F through refrigeration or an ice bath, with temperatures checked and recorded.
Dietary staff were observed using the dish machine at a wash temperature of 110 degrees, which did not meet the facility's policy requirement of 120-150 degrees. The required procedure to run several cycles to reach the proper temperature was not followed, resulting in the dishwasher being used at an insufficient temperature.
Surveyors found that three resident rooms were not kept clean and sanitary, with visible debris and dust present for several days. Two residents experienced sleep disturbances due to loud TV noise at night, with complaints documented but unresolved. Additionally, a resident's personal property, including cash and clothing, was not properly accounted for after death, as required by facility policy, and the inventory process was not completed or signed by staff and the family member.
Two residents were involved in a physical and verbal altercation, but the facility's investigation was incomplete, as the assigned LVN only interviewed direct witnesses and the involved residents, without reviewing medical records or consulting other staff. Additionally, the required 5-day investigation report was not submitted to CDPH or the LTC ombudsman, contrary to facility policy and state law.
The facility failed to administer a prescribed inhaler as ordered, did not complete post-seizure vital sign assessments for a resident after multiple seizure episodes, and did not provide a physician-ordered foot cradle for another resident. Nursing staff did not document or perform required actions, and residents confirmed the omissions. Facility policies required these actions to be completed and documented.
A resident who was fully dependent on staff for toileting hygiene waited two hours for assistance after activating the call light, remaining in a soiled brief during the night shift. The resident, who was cognitively intact, reported feeling frustrated and depressed due to the delay. A CNA acknowledged that call lights may not have been answered promptly, despite no reported staffing issues. Facility policy required prompt response to call lights.
A resident was moved from a private room to another room without receiving prior written notice or an explanation, as required by facility policy. The resident was not given the opportunity to acknowledge the change, and no documentation of notification was found in the clinical record, resulting in the resident feeling upset and confused.
Two residents were not properly notified of their Medicare coverage status because their ABN forms were left incomplete, with required options left blank. The Business Office Manager confirmed the forms were not filled out as required, contrary to facility policy that mandates proper notification when Medicare coverage requirements are not met.
A resident left the facility against medical advice without staff being informed of her intention to leave, and there was no documentation of an AMA form, no attempts to discuss the discharge with the resident, and no confirmation of her safety, contrary to facility policy.
A resident was transferred to the hospital on two occasions, but the facility did not provide required notification to the Ombudsman, as confirmed by the DON and absence of fax confirmation. Facility policy mandates timely Ombudsman notification for such transfers, but documentation was lacking.
A resident who had all teeth extracted and was awaiting dentures experienced weight loss and difficulty eating, as the facility did not fully implement the care plan interventions for nutrition. The resident received repetitive meals that were hard to eat, was not included in weekly weight monitoring, and had no specific goal weight set, resulting in inadequate tracking and support for his nutritional needs.
A resident with limited hand mobility was found with unclean teeth and food debris, indicating that oral care had not been provided as required. CNAs confirmed that oral care was missed, despite the resident's care plan and facility policy mandating assistance with daily oral hygiene.
A resident at moderate risk for pressure injuries did not receive required weekly skin assessments, and there was no documentation of repositioning or other preventive interventions. When an open wound was discovered, no wound assessment or monitoring was completed, and no treatment order was initiated. The resident was later hospitalized with an unstageable pressure injury, indicating a failure to follow the facility's pressure ulcer prevention policy.
A resident with contractures and limited mobility did not receive ordered active assisted range of motion (AAROM) exercises because the RNA program was not provided for an extended period. This lapse occurred after a change in the facility's electronic documentation system, which resulted in the resident being omitted from the printed logs used by staff. The issue was confirmed by staff interviews and review of documentation.
A resident assessed as needing supervision for smoking was found with cigarettes and a lighter left unattended at the bedside, contrary to facility policy requiring secure storage of smoking materials. A CNA and the DON confirmed that such items should be locked up, but the resident had access to them without supervision.
A resident with a nephrostomy catheter was found with the collection bag placed on the bed beside her head, above bladder level, despite facility policy and care plan instructions requiring the bag to be kept below the bladder. The resident was unable to reposition the bag due to contractures in both hands, and an LVN confirmed the improper placement during observation.
A resident with orders for pain medications based on pain severity received Tramadol for severe pain and Acetaminophen for moderate pain, contrary to the physician's specified parameters. The resident, who was cognitively intact, reported ongoing pain and insufficient relief, and the nurse did not administer medications according to the prescribed pain scale.
A resident's discharge summary was found to be incomplete when the skin assessment section was left blank, and an LVN confirmed that no skin assessment was performed or documented at discharge. Facility policy requires that discharge summaries include a summary of the resident's status, but this was not followed in this case.
A nurse did not wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite clear signage and facility policy requiring both gown and gloves for such procedures. The nurse later acknowledged the omission.
A resident's room was found with three deep scrapes on the wall near the bed and thick debris on the floor. The Maintenance Supervisor was aware of the damage but stated repairs are only made if there is a hole to the next room. No maintenance report or repair was documented for the issue, despite facility policy requiring routine maintenance.
Unsecured Smoking Materials and Elopement Monitoring Failures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards when four residents were allowed to keep cigarette lighters unsecured in their rooms. Resident 86 was observed with a cigarette lighter in her hand in the smoking area and later had a red multi-purpose lighter on her wheelchair in her room, with her cigarettes and lighter kept in an unsecured clear bag. Resident 110 had a cigarette and lighter in a plastic container in the nightstand drawer, Resident 111 had a cigarette and lighter in a plastic container in the nightstand drawer, and Resident 85 had a cigarette and lighter in a plastic container on top of a cardboard box next to the bed and nightstand. The Social Service Director stated Resident 86 liked to keep her lighter and cigarettes with her, and the Assistant Director of Nursing stated there was no care plan to keep the cigarette lighters and cigarettes at bedside for these residents. The facility’s Smoking policy stated that all smoking materials were to be stored in a secure area and gave examples such as locked drawers, locked cupboards, or a locked box in the resident’s room. The record review and staff interviews showed that this was not being done for the four residents observed with unsecured smoking materials. The Assistant Director of Nursing confirmed that smoking assessments were to be completed quarterly and that there was no care plan directing bedside storage of the lighters and cigarettes. The facility also failed to follow its Elopement and Wandering policy for two residents with wander guards. Resident 96 had diagnoses including unspecified dementia, schizophrenia, anxiety disorder, and psychotic disorder with delusions, and his assessments showed severely impaired daily decision-making and daily use of a wander or elopement alarm. Resident 92 had unspecified dementia, severely impaired daily decision-making, daily use of a wander or elopement alarm, and was assessed as at serious risk for elopement. The DON and staff stated the wander guards were not being checked weekly for placement, testing, and expiration dates as required, and both residents were found wearing expired devices. Resident 92 was also not monitored for wandering as identified in the care plan. The care plan directed staff to identify the pattern of wandering, but the record contained no documentation that her wandering behavior was monitored. During the event, Resident 92 was found walking in the facility parking lot by a family member while the door alarm was sounding. Staff interviews showed that the alarm was not responded to immediately, no code green was announced, and staff did not conduct the missing resident response described in the facility policy. The DON stated the policy was not followed.
Failure to Complete Required PASRR Resident Review
Penalty
Summary
The facility failed to review and accurately complete the annual PASRR for one sampled resident with diagnoses of dementia, schizophrenia, and auditory hallucinations. The resident’s admission record showed these diagnoses, and during a concurrent interview and record review with the DON, the resident’s PASRR dated 2/11/25 was reviewed. The PASRR letter stated that if the individual remained in the NF longer than 30 days, the facility had to resubmit a new Level I Screening as a Resident Review on the 31st day. The DON stated there should have been a new PASRR submitted after 3/12/25. The facility policy titled Pre-admission Screening and Resident Review stated that PASRR is used to ensure all facility applicants are screened for mental illness and/or intellectual disability and to coordinate with the appropriate state agencies, if indicated.
Failure to Notify Methadone Clinic After Resident Overdose
Penalty
Summary
The facility failed to communicate with the outside methadone clinic when Resident 86 was transferred to the hospital for low oxygen saturation and oversedation. During interview and record review, the DON confirmed the resident had an order for Narcan but it was not administered. The hospital discharge paperwork identified the diagnosis as accidental methadone overdose. The DON also stated there was no documentation showing that the methadone clinic was notified about the resident’s condition, and said the facility had just set up a new system to communicate with the methadone clinic. The facility policy reviewed stated the Director of Social Services is responsible for locating agencies and programs that meet residents’ needs, facilitating service provider contracts, and referring residents to existing contracted providers.
Failure to Use Communication Board for Resident With Hearing Loss
Penalty
Summary
The facility failed to ensure effective communication for a resident with bilateral conductive hearing loss and a BIMS score of 14. The resident’s care plan indicated a communication problem related to hearing deficit and oral deformity and stated that the resident required a communication board, with communication by writing, yes/no pointing, or pointing to what was written on the board. During interview, the resident stated that staff did not use a whiteboard, that he could not hear what staff said when they came into his room, and that this bothered him and made him mad. Survey observations showed multiple instances in which staff communicated verbally with the resident without using the communication board or notepad. A staff member told the resident she would return to change him, using hand gestures, and the resident later stated he did not understand what was said. A CNA asked the resident questions about a blanket and whether he was okay, but the resident did not respond and later stated he had not understood and wanted staff to use the whiteboard. Another CNA asked if he was ready to get up for lunch and later told him she was going to clean him up and raise the bed, again without using written communication. At one point, the resident was observed in the dining room without a whiteboard or notepad available for communication. The DON stated staff should have been using the whiteboard or a notepad to communicate in writing with the resident.
Failure to Provide ADL Grooming Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for one sampled resident who was dependent on staff for personal hygiene, including shaving and fingernail trimming. The resident was admitted with diagnoses including encephalopathy, and the MDS indicated dependence on staff for personal hygiene. The BIMS score was 9, indicating moderately impaired cognition, and the ADL care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, and an acute condition. During observation, the resident was found lying in bed awake and alert with stringy dry saliva stuck on the lips, a scruffy unshaven beard about one quarter inch long, and untrimmed fingernails with dark brown debris underneath the fingernails of the right hand. During a concurrent observation and interview, the ADON acknowledged the resident had untrimmed fingernails with dirt underneath the nails and an unshaven beard, and asked the resident if he wanted to be shaved; the resident said yes. The facility policy on grooming care of fingernails and toenails stated that nail care is given to clean and keep the nails trimmed.
Failure to Complete Ordered RD Consult After Significant Weight Loss
Penalty
Summary
The facility failed to implement a physician order for a Registered Dietician (RD) consult for one sampled resident who had significant weight loss. The resident’s electronic health record showed a weight of 184 pounds on 3/1/26 and 166 pounds on 4/3/26. A physician progress note dated 4/6/26 documented clinically significant unintentional weight loss, including a 2-pound loss over the past month and a total of 17 pounds over the past six months, and ordered a dietary consult for a comprehensive nutritional assessment. The order summary showed a telephone physician order for an RD consult on 4/6/26, but the resident’s most recent RD consult had been completed on 8/22/25. During interview and record review, an LVN stated the resident should have had an RD consult completed for the 4/6/26 order. The DON stated the RD should assess the resident within 24 hours of the consult order being placed, and the RD stated facility staff were responsible for calling her to inform her of consult orders. The RD also stated there was no process in place identifying who was responsible for notifying her of consult orders, and she was not made aware of this resident’s consult order until 4/22/26, when she then completed the nutritional assessment.
Improper Head-of-Bed Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure that Resident 6’s head of bed was elevated to prevent aspiration while receiving enteral tube feeding. During an observation, Resident 6 was lying in bed with the head of bed elevated at a 15-degree angle while an LVN connected the resident to the enteral feeding pump and set it to deliver Glucerna at 60 ml per hour. The LVN then left the room after starting the feeding, and during a concurrent interview stated he was not sure how elevated the head of bed was and believed it should have been elevated to 90 degrees during enteral feeding. During a concurrent interview, an RN observed Resident 6 in the same position with the head of bed still at a 15-degree angle and stated it was not elevated properly to prevent aspiration, noting it was below 30 degrees and should have been elevated to 50 degrees during enteral feedings. Record review showed an active physician order to keep the head of bed elevated 30-45 degrees or as tolerated to prevent aspiration, and the care plan identified that the resident required tube feeding related to dysphagia. The facility did not provide the requested policy and procedure for enteral tube feedings.
Medication Administered in Excess of Physician Order
Penalty
Summary
The facility failed to administer medication according to physician orders for one resident who had an active order for Breo Ellipta Inhalation Aerosol Powder 200-25 mcg/actuation, 1 puff inhaled orally one time a day. During a concurrent observation and interview, an RN stated she was going to administer the inhaler, removed it from the box, and handed it to the resident. The resident inhaled one dose, and the RN then directed the resident to inhale a second dose. The resident inhaled the second dose, and the RN returned the inhaler to the medication cart. The administration instructions attached to the inhaler indicated one puff inhale orally daily. During interview and record review, the DON provided the resident’s OSR and stated it contained the resident’s current physician medication orders. The OSR listed Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 mcg/act, 1 puff inhale orally one time a day, with an order date of 3/11/26 and status active. Facility policy titled Medication - Administration stated medication will be administered by a licensed nurse per the order of an attending physician.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage was not maintained as required for one resident who was receiving methadone. During a concurrent observation and interview, the resident had methadone 90 mg found on the bedside table, with a label showing the resident’s name and the medication strength and a small amount of pink fluid remaining in the bottle. The LVN stated the methadone had been given by the night shift nurse and that the bottle still had 1 mL left, and also stated the medication should not be left at bedside. The resident stated that some nurses watched her take her medication, while other nurses left the bottle on the bedside table for her to take unsupervised, and that on the observed date a medication bottle had been left on the bedside table and she may not have finished it before falling asleep. Medication labeling was also not maintained for another resident’s insulin pen. During a concurrent observation and interview, an LVN retrieved an unlabeled insulin pen from the medication cart and stated it was the resident’s insulin pen, but the pen had no resident identification. The LVN stated the label with the resident’s identification had fallen off. The DON later stated that insulin pens should be labeled with the resident’s identification. Facility policy reviewed by surveyors stated that labels are permanently affixed to the outside of the prescription container.
Failure to Administer Ordered Skin Treatment
Penalty
Summary
The facility failed to ensure that a physician-ordered treatment was administered for Resident 6. Resident 6's Nursing Quarterly Assessment dated 2/26/26 documented a Braden Skin Risk Score of 13, indicating moderate risk for skin breakdown. The resident's Order Summary Report dated 4/23/26 showed an order for Calmoseptine ointment to be applied to the left and right buttocks and perineum every two hours for skin maintenance. During a concurrent interview and record review with the Treatment Nurse, Resident 6's Treatment Administration Record for April 2026 showed no documentation that Calmoseptine was administered on 4/14/26 at 12 p.m., 2 p.m., 8 p.m., and 10 p.m. The Treatment Nurse stated that if there was no documentation on the TAR, the Calmoseptine was not administered, and that failure to administer it as ordered would put Resident 6 at risk for skin breakdown. During a later interview and record review with the DON, the facility's Wound Management policy was reviewed, which stated that a resident with a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, and that wound treatment should be implemented per physician's order. The DON stated the policy was not followed.
Failure to Timely Notify Physician and Administer Ordered Antidiarrheal Medication
Penalty
Summary
The facility failed to ensure timely physician notification and appropriate medication administration for a resident experiencing ongoing diarrhea, resulting in a delay in care. The resident had a BIMS score of 8, indicating moderately impaired cognition. Point of Care documentation showed the resident had multiple episodes of loose stools beginning on 2/9/26, with at least three episodes within a 24-hour period by 2/10/26 and continued frequent loose stools on subsequent days. The DON stated that three episodes of loose stools within 24 hours constituted a change of condition and acknowledged that the physician should have been notified on 2/10/26. However, the physician was not notified of the resident’s change in condition until 2/21/26, 11 days after the change of condition occurred, contrary to the facility’s Change of Condition Notification policy requiring timely notification when there is a need to alter treatment due to a change in condition. On 2/21/26 at 8:10 a.m., a CNA informed the charge nurse that the resident had three bowel movements with diarrhea, and the primary clinician recommended loperamide 2 mg every eight hours as needed. The Order Summary Report reflected a physician order for loperamide on 2/21/26. Despite this order and continued documentation of loose stools on 2/21/26 and 2/22/26, the Medication Administration Record showed no loperamide was administered on those dates. The DON confirmed that the loperamide should have been given because the resident continued to have loose stools. On 2/22/26, an alert note documented that the resident requested transfer to an acute hospital due to diarrhea and abdominal pain, and the nurse practitioner ordered the resident to be sent out. The DON stated there was a delay in treatment due to poor communication between the nursing staff.
Failure to Timely Report Alleged Physical Abuse by Family Member
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident within the required timeframe. The resident had diagnoses including unspecified dementia, anxiety, Alzheimer’s disease, depression, cognitive communication deficit, and a need for assistance with personal care. An MDS assessment indicated the resident was rarely or never understood, had memory problems, severely impaired decision-making, and required substantial/maximal assistance with eating. A Change in Condition Evaluation dated 2/26/26 documented that a CNA reported witnessing the resident’s sister slap the resident on the right side of the face, with green/yellow discoloration noted on the right cheek upon evaluation. The facility’s 5-Day Investigation Summary indicated that on 2/26/26 the CNA reported having observed the family member strike the resident during a feeding interaction approximately three weeks earlier, on 2/1/26, and acknowledged not reporting the alleged incident to administration at the time it occurred. In an interview, the Administrator confirmed that the CNA did not report the alleged physical abuse until 2/26/26 and acknowledged there was a delay in reporting. In a separate interview, the CNA stated she had immediately informed an LVN on the date of the incident and that the LVN told her to “shut up,” not say anything, and to mind their own business. The LVN stated he did not recall the date and reported that the CNA only told him the resident was being aggressive, denying that the alleged abuse was reported to him. The facility’s abuse policy required immediate reporting of suspected abuse, with specific timeframes of no later than two hours for abuse involving serious bodily injury and no later than 24 hours for other reportable incidents, based on real time rather than business hours.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had reasonable access to and privacy in their use of telephones and outside confidential communication. The Long-Term Care Ombudsman (LTCO) reported difficulty contacting residents by phone, stating that calls to the facility were often unanswered or routed to voicemail, which he could not use due to the need to maintain confidentiality. On multiple occasions, including several calls made on different days, the LTCO’s calls were answered by the receptionist and then transferred to the nurses’ station, where they went unanswered and were ultimately sent to voicemail. The LTCO stated that, as a result, residents’ rights to private and confidential communications were being violated. Resident 2’s MDS dated 11/19/25 showed a BIMS score of 14, indicating cognitively intact status. Resident 2 reported not having a cell phone and relying on the facility phone to receive calls, and stated that others had told him they called the facility but their calls were not put through to him. A family member of Resident 3 stated that during daytime hours she could reach Resident 3 by phone, but after the receptionist left for the day she could not get anyone on the phone and described it as a “nightmare.” Review of the facility’s Resident Rights policy, revised 10/1/17, showed that residents have the right to privacy and confidentiality in oral, written, and electronic communications and the right to use a telephone in privacy, and that the facility is to ensure residents can exercise their rights without interference.
Failure to Return and Document Resident Personal Belongings at Discharge
Penalty
Summary
The facility failed to ensure a resident received all personal belongings upon discharge, as required to provide a safe, clean, comfortable, and homelike environment. The resident was admitted with documented personal items, including two grey t‑shirts and one white sheet, as recorded on an Inventory List completed at admission. Upon review of the resident’s records after discharge, the Director of Nursing confirmed there was no evidence that the resident’s belongings were provided to the resident or their representative at the time of discharge, nor was there documentation of a signed receipt. The facility’s own Theft Prevention policy required staff to complete a resident inventory at admission and discharge, provide the resident or representative with a copy of the inventory and the resident’s property upon discharge, and obtain a signed receipt, but this process was not documented as having been followed for this resident. The deficiency centers on the lack of documentation and confirmation that the resident’s inventoried personal items were returned at discharge, despite clear policy expectations for securing and accounting for resident property.
Failure to Provide Home Medication List at Discharge
Penalty
Summary
The facility failed to provide a home medication list to a discharged resident as required by its process. During an interview, an LVN stated that at discharge residents are given their medications along with a home medication list that includes instructions on how to take each medication, and that nurses educate the resident on this list and obtain the resident’s signature to confirm the education was completed. However, review of the resident’s Discharge Instruction Form (DIF) dated 12/8/25 showed that while the form indicated medications were provided at discharge and referenced an attachment, no medications were actually listed on the DIF. The DON confirmed there was no evidence that the resident received a home medication list upon discharge. When requested on multiple dates, the facility did not provide a policy and procedure related to this process.
Failure to Provide Required Behavioral Health Interventions and Monitoring
Penalty
Summary
The facility failed to follow its policy and procedure on psychotherapeutic drug management for a resident diagnosed with major depressive disorder and paraplegia. The resident had a history of increased sadness and was prescribed Lexapro, with the dosage recently increased due to verbalized sadness. Despite this, staff did not provide non-pharmacological interventions as required by the care plan and facility policy when the resident expressed increased sadness. Documentation showed that on the day the resident verbalized increased sadness, no non-pharmacological interventions were provided or documented, even though the care plan and physician's order specified such interventions should be attempted prior to medication administration. Additionally, after the increase in Lexapro dosage, the resident was not monitored every shift for 72 hours as required by both the care plan and facility policy. Nursing notes and medication administration records revealed gaps in monitoring, with several shifts lacking documentation of the required checks for side effects, including suicidal ideation. Interviews with staff confirmed that the expected monitoring and documentation did not occur, and that staff relied on CNAs to report any unusual findings rather than conducting direct assessments as required. The failure to provide non-pharmacological interventions and to monitor the resident after a medication change resulted in the resident being found deceased in his room, with evidence of self-harm and no signs of life. The coroner determined the cause of death was neck compression. Staff interviews and record reviews confirmed that the required interventions and monitoring were not implemented or documented, directly leading to the deficiency cited in the report.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for two residents. One resident reported a strong, foul, and unpleasant smell in his bathroom, which was confirmed by both the resident and housekeeping staff. The housekeeping staff acknowledged that another resident had previously urinated on the bathroom floor, and that the odor was difficult to remove despite cleaning efforts. The smell was described as a combination of urine and bleach. Another resident expressed dissatisfaction with the cleanliness of the shower rooms, stating that the soiled conditions were disgusting. Upon inspection, the housekeeping supervisor confirmed that three out of four shower rooms had dark stains on the tiles, which were identified as buildup from steam. The facility's policy required all rooms to be kept clean and as free as possible from germs and contaminants, while maintaining a pleasant and homelike atmosphere, but these standards were not met in the observed areas.
Failure to Timely Develop Baseline Fall Prevention Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to timely develop baseline care plans with fall prevention interventions for two residents who were identified as high risk for falls upon admission. Both residents had diagnoses including muscle weakness, abnormalities of gait and mobility, and, in one case, Alzheimer's disease. Fall risk assessments conducted at admission indicated high risk scores for both individuals. Despite these findings, no baseline care plan addressing fall prevention was created within the required timeframe for either resident. For one resident, the fall prevention care plan was not developed until 26 days after admission, and for the other, it was created seven days after admission. The Director of Nursing confirmed that both residents were assessed as high risk for falls at admission but acknowledged that baseline care plans with fall prevention interventions were not developed as required. Facility policy mandates that a person-centered baseline care plan be developed within 48 hours of admission, and that nursing staff create a care plan with interventions to reduce fall risk, which was not followed in these cases.
Failure to Maintain Bed in Low Position for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention for a resident identified as high risk for falls. The resident, who had diagnoses including Alzheimer's disease, muscle weakness, gait abnormalities, and pain, was assessed with a high fall risk score. The resident's care plan specifically required that the bed be kept in the low position as a safety measure. However, during an observation, the resident was found lying in a bed that was not in the low position, contrary to the care plan and facility policy. A family member expressed concern about the resident's risk of falling, noting that the resident attempted to get out of bed unassisted. A licensed nurse confirmed that the bed was not in the low position and subsequently lowered it. The Director of Nursing also acknowledged that the bed should have been kept low according to the resident's care plan. The facility's fall management policy required beds to be placed in the lowest position as a universal fall prevention measure, which was not followed in this instance.
Failure to Communicate and Address Resident Pain
Penalty
Summary
A resident with Alzheimer's disease, muscle weakness, gait abnormalities, and pain was admitted to the facility and was able to communicate needs despite dementia. During care provided by two CNAs, the resident reported experiencing pain in his arms. The CNAs left the room without providing any pain relief interventions or notifying the licensed nurse responsible for the resident's care. Approximately 40 minutes later, the licensed nurse was informed of the resident's pain only after being approached by surveyors. Upon assessment, the resident reported arm pain at a level five on a zero to ten scale. Facility policy required staff to help residents manage pain and for CNAs to immediately inform the licensed nurse when a resident reports pain, which was not followed in this instance.
Failure to Timely Respond to Call Lights for Two Residents
Penalty
Summary
The facility failed to answer call lights in a timely manner for two residents, resulting in delays in addressing their needs. One resident, who had diagnoses including hemiplegia, hemiparesis, muscle weakness, and incontinence, reported that night staff did not answer the call light and that it took hours for his request to be addressed, specifically when he needed his brief changed. This resident was cognitively intact and expressed feeling ridiculed and helpless due to the delay. His care plan indicated a need for assistance with activities of daily living and incontinence care due to his medical conditions. Another resident, also cognitively intact, reported that it took approximately 45 minutes at night for staff to respond to her call light when she requested water. The Director of Nursing confirmed that waiting 45 minutes to an hour for call light response was not acceptable, especially when residents required assistance with changing briefs or obtaining water. The facility's policy required nursing staff to answer call bells promptly and return to residents with requested items or responses in a timely manner.
Failure to Implement Care Plans for Repositioning and Meal Supervision
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies related to skin integrity and nutritional supervision. For one resident with a history of pressure injuries, the care plan required repositioning every two hours due to altered skin integrity and a re-opened pressure injury to the sacrococcyx. Observations revealed that the resident remained seated in a wheelchair at a 45-degree angle for an extended period, with staff confirming that the resident had not been repositioned since 11 a.m. The resident was dependent on staff for transfers and mobility, as documented in the Minimum Data Set, and the Director of Nursing acknowledged the care plan's requirement for frequent repositioning. Another resident's care plan indicated the need for supervision and assistance with all meals, as well as staff presence during mealtimes to redirect the resident from feeding others. Observations showed that the resident was eating alone in her room without staff supervision, and a CNA confirmed that no staff were present to assist or monitor the resident during the meal. The Director of Nursing noted that the resident's behavior of feeding others could pose a safety issue, especially for those with swallowing problems. The facility's policy emphasized the importance of care plans in addressing residents' medical, nursing, and psychosocial needs, but these plans were not followed in the observed cases.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines and expectations for quality in nursing services. No additional details regarding specific residents, staff actions, or particular incidents are provided in the report excerpt.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for three of six sampled residents. Observations and interviews revealed that one resident reported call light wait times ranging from five to forty-five minutes, with some staff walking by without responding. This resident used the call light for assistance with brief changes and repositioning due to a pressure injury, and expressed feeling anxious and unwell during long waits, noting that being left wet could worsen her bed sore. The resident calculated wait times by observing a clock in her room. Two additional residents reported call light wait times ranging from twenty minutes to two hours, also using a clock to track the delay. These residents used the call light for brief changes and requests for water or ice water. One resident stated the wait made him angry, while the other expressed significant frustration, stating he called the police due to the delay. Review of the facility's policy indicated that nursing staff are required to answer call bells promptly and courteously, but this was not consistently followed.
Residents Awakened by CNA Singing and Chanting at 4 a.m.
Penalty
Summary
Certified Nursing Assistant (CNA 1) entered the rooms of two cognitively intact residents at approximately 4 a.m., singing and chanting loudly, which resulted in both residents being awakened. Resident interviews confirmed that the CNA's actions disturbed their sleep and were not welcomed, with one resident specifically mentioning the singing and another referencing loud chanting in a foreign language. Both residents expressed that this behavior was disruptive and did not align with their expectations for respectful and dignified care. The Director of Staff Development (DSD) acknowledged receiving previous complaints about CNA 1's behavior, including singing, dancing, and praying during early morning hours. Despite being instructed not to engage in these activities, CNA 1 continued the behavior, stating she was happy and liked to sing. Facility policy requires all staff to treat residents with respect and dignity, and to promote an environment that enhances residents' quality of life. The actions of CNA 1 were inconsistent with these policies, resulting in a failure to honor the residents' rights to a dignified and respectful environment.
Failure to Communicate and Implement Dietitian Recommendations for Resident with Weight Loss
Penalty
Summary
A resident with a diagnosis of mild protein-calorie malnutrition experienced significant weight loss, dropping from 126 lbs to 119 lbs over a ten-day period. The registered dietitian (RD) made recommendations to liberalize the resident's diet by discontinuing the no added salt restriction and to increase the frequency of a nutritional supplement (Boost) from twice to three times daily. These recommendations were documented in the resident's nutrition notes but were not communicated to the physician for approval, nor were they implemented. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility's policy and procedure on Assessment and Management of Resident Weights was not followed. The policy required licensed nurses to notify the physician of the RD's recommendations and to document the physician's response, including any refusal and rationale. The DON acknowledged that there was no documentation showing the RD's recommendations were carried out or communicated as required.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Missing Narcotic Medications as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding Unusual Occurrence Reporting when missing narcotic controlled medications were not reported to the California Department of Public Health (CDPH). On 6/18/25, it was discovered that four oxycodone, four Percocet, and four Norco tablets were missing from the emergency kit (E-kit), which contains a pre-determined supply of medications, including controlled substances, for immediate patient needs. Despite this discovery, the incident was not reported to CDPH as required by the facility's policy. During interviews and record reviews, the Director of Nursing (DON) confirmed the discovery of the missing narcotics, and the Administrator acknowledged that the facility had not reported the incident, even though the policy clearly states that such occurrences must be reported to the appropriate state or federal agencies within 24 hours by telephone and then confirmed in writing. The policy also specifies that allegations of misappropriation of resident property and other occurrences affecting the welfare, safety, or health of residents, employees, or visitors must be reported. The failure to report the missing narcotics was a direct violation of the facility's established procedures.
Failure to Administer and Monitor Narcotic Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer narcotic pain medication according to the physician's orders for one resident. The resident, who had diagnoses including osteomyelitis, complete traumatic amputation of the left lower leg, unspecified pain, and inguinal hernia, had a physician's order for Norco 5-325 mg to be given by mouth every 12 hours as needed for pain levels between 4 and 10 on the pain scale. However, the Medication Administration Record (MAR) showed that Norco was administered on multiple occasions when the resident's pain scale was documented as 0, which was outside the prescribed parameters. Additionally, there was no documentation of reassessment or re-evaluation of the effectiveness of the narcotic medication after administration on several dates. The facility's pain management policy required licensed nurses to assess and document pain and the resident's response to interventions, but this was not done as required. The Director of Nursing confirmed that the medication was given outside the ordered parameters and that reassessment documentation was missing.
Medications Improperly Left at Bedside for Residents Not Authorized for Self-Administration
Penalty
Summary
Surveyors identified a deficiency in the facility's medication management practices, specifically regarding the storage and administration of drugs and biologicals. During multiple observations, medications were found left on the bedside tables of six residents who did not have orders or documented capability for self-administration. These medications included ointments, tablets, inhalers, and controlled substances such as methadone. Nursing staff, including LVNs and RNs, confirmed during interviews that these residents were not capable of self-administering medications and should not have had access to them at their bedside. Record reviews for each resident showed that self-administration assessments had been completed, and all indicated that the residents were not capable of self-administering or securely storing their medications. Despite this, medications were left within reach of the residents, contrary to facility policy and professional standards. Staff interviews consistently acknowledged that medications should not be left at the bedside, and that the observed situations were not in compliance with facility procedures. The facility's policies on drug storage and medication administration require that drugs and biologicals be stored securely and not left at the bedside unless a resident is assessed and authorized for self-administration. The failure to adhere to these policies resulted in medications being accessible to unauthorized individuals, as confirmed by both direct observation and staff interviews.
Milk Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure that milk served to residents was maintained at the appropriate temperature, as required by both facility policy and food safety standards. During an observation in the kitchen, the milk temperature was measured at 46 degrees Fahrenheit, which exceeds the facility's policy requirement of less than 41 degrees. This was confirmed during a test tray delivery, where the Dietary Manager also recorded the milk temperature at 46 degrees and acknowledged it was above the acceptable limit. Facility policies reviewed indicated that milk should be kept at or below 41 degrees, either by refrigeration or by using an ice bath during meal service, and that temperatures should be checked and recorded. The failure to maintain proper milk temperature was directly observed and confirmed through staff interview and record review.
Dishwasher Operated Below Required Temperature
Penalty
Summary
Surveyors observed that dietary staff operated the facility's dishwasher at a wash temperature of 110 degrees, which was below the required range of 120-150 degrees as specified in the facility's policy and procedure for dish machine temperature recording. This was confirmed during two separate observations and interviews with dietary aides while the dishwasher was in use. The facility's policy required allowing the dish machine to run through several cycles to bring the water temperature up to the proper level, but this procedure was not followed, resulting in the dishwasher operating at an insufficient temperature.
Deficiencies in Cleanliness, Noise Control, and Protection of Resident Property
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in three resident rooms, as observed by surveyors. In one room, thick debris and dust, including white particles, were found under the beds and on the sliding door frame, with a resident present in the room. Housekeeping staff acknowledged the dust and debris, and another resident reported that dirt, food wrappers, and dust had been present for several days. Facility policy required regular sweeping, mopping, or vacuuming of all floors, which was not followed in these instances. Noise levels in the facility were not kept at a comfortable level for two residents. One resident reported being unable to sleep due to another resident's TV being excessively loud at night, resulting in headaches and the need for medication. The issue was documented in a grievance report, and another resident also reported sleep disturbances due to a roommate's loud TV. Staff interviews confirmed awareness of the complaints, but the issue remained unresolved at the time of the survey. Facility policy emphasized the importance of maintaining comfortable noise levels in resident rooms. The facility also failed to protect a resident's personal property after the resident's death. A family member reported that clothing and $620 in cash were missing when collecting the resident's belongings. The inventory list completed at admission included these items, but at discharge, the inventory was not completed or signed by staff and the family member, as required by facility policy. The policy mandated that all property be accounted for and a signed receipt obtained upon discharge or death, which did not occur in this case.
Failure to Conduct Thorough Abuse Investigation and Timely Reporting
Penalty
Summary
The facility failed to follow its Elder Abuse Prohibition and Prevention policy and procedure in response to a resident-to-resident physical and verbal altercation involving two residents. The investigation was incomplete, as the staff member assigned to investigate, an LVN, only interviewed the staff witnesses and the residents directly involved. The LVN did not interview other residents, review the medical records of the involved residents for prior history of aggression or behaviors, or speak to other staff who had provided care to the residents before the incident. The LVN also stated she was not trained to investigate abuse and was only instructed to interview witnesses and the involved residents. The documentation was limited to statements on the SOC 341 form, without a comprehensive review as required by facility policy. Additionally, the facility did not submit a 5-day investigation report to the California Department of Public Health (CDPH) or the LTC ombudsman, as required by both facility policy and state law. The administrator confirmed that such reports were not sent, indicating a failure to report the results of the investigation to the appropriate authorities within the mandated timeframe. This omission resulted in the potential for an incomplete investigation and lack of protection for the residents involved.
Failure to Follow Physician Orders and Complete Required Assessments
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident. During medication pass, a nurse was unable to locate the prescribed Albuterol inhaler for a resident with chronic obstructive pulmonary disease and did not administer the 9 a.m. dose as ordered. The nurse did not notify the physician about the missed dose, and the medication was still not given nearly three hours later. The resident, who was cognitively intact and receiving oxygen, confirmed that the breathing treatment had not been received as scheduled. Facility policy required that medication errors, including omissions, be reported to the Director of Nursing, attending physician, and administrator. The facility also failed to complete vital sign assessments after seizure episodes for another resident. A family member reported that the resident appeared distressed and had a fever prior to experiencing multiple seizures. Documentation showed that vital signs were only taken before the seizures, with no record of vital signs or temperatures being taken after the episodes. Nursing staff confirmed that post-seizure vital signs were not documented or performed, and the Director of Nursing acknowledged that documentation of seizure times and post-episode vital signs was missing. Facility policy required that vital signs be obtained and recorded after seizure activity, along with detailed documentation of each episode. Additionally, the facility did not follow physician orders for the use of a foot cradle for a resident with a wound. The resident reported never having a foot cradle, and nursing staff confirmed that the device was not in use, despite a standing physician order for its use every shift. Review of facility policy indicated that supplies and equipment required to carry out physician orders should be provided and verified for completeness and accuracy.
Delayed Call Light Response Resulting in Prolonged Exposure to Soiled Brief
Penalty
Summary
The facility failed to ensure that a resident's call light was answered in a timely manner, resulting in the resident waiting for two hours in a soiled brief during the night shift. The resident, who was alert, oriented, and cognitively intact with a BIMS score of 15, was fully dependent on staff for toileting hygiene according to the Minimum Data Set. The resident reported feeling frustrated and depressed due to the prolonged wait, and verified the duration using her cell phone. A CNA working the night shift confirmed that call lights may not have been answered promptly, despite having no reported staffing issues and being responsible for 12-14 residents. Facility policy required nursing staff to answer call bells promptly and courteously.
Failure to Provide Written Notice Prior to Room Change
Penalty
Summary
A resident was admitted to the facility and initially placed in a private room. Approximately one week later, after returning from a shower, the resident found staff collecting his belongings and was informed that he was being moved to another room. The resident reported that he was not notified in advance of this decision and did not sign any acknowledgment regarding the room change. This unexpected move caused the resident to feel upset and confused. A review of the resident's clinical record by the Social Services Director confirmed there was no documentation of written notification provided to the resident about the room change, nor was there a documented reason for the move. The facility's policy and procedure require that residents receive timely, written notice—including the reason for the change—prior to any room or roommate assignment changes. The policy also states that such information should be documented in the resident's medical record. These steps were not followed in this instance.
Failure to Complete Advanced Beneficiary Notice of Non-coverage (ABN) Forms
Penalty
Summary
The facility failed to ensure that the Advanced Beneficiary Notice of Non-coverage (ABN) was properly completed for two of three sampled residents. During interviews and record reviews with the Business Office Manager, it was found that the ABN forms for both residents had the required options section left blank, indicating that the residents had not selected or been assisted in selecting one of the available choices regarding their Medicare coverage and potential financial responsibility. The Business Office Manager confirmed that the ABNs were incomplete. Review of the facility's policy indicated that Medicare beneficiaries should be properly notified when they do not meet requirements for covered skilled services, but this process was not followed for the two residents involved.
Failure to Follow AMA Discharge Policy and Documentation
Penalty
Summary
The facility failed to follow its policy and procedure for Discharge Against Medical Advice (AMA) for one resident. According to the discharge summary, the resident was discharged AMA, but there was no documentation of an AMA form in the resident's chart, no evidence of attempts to discuss the discharge with the resident, and no documentation confirming the resident's safety upon leaving. Interviews with staff revealed that the resident left the facility without informing staff of her intention to leave or dissatisfaction with care, and staff only became aware of her absence after she had already exited the building. The facility's policy required staff to attempt to encourage the resident to remain for continued treatment and to have the resident review and sign an AMA form upon discharge, neither of which occurred in this case.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital on two separate occasions, as required by facility policy. During an interview and record review with the DON, it was confirmed that there was no fax confirmation or other documentation to show that the Ombudsman had been notified when the resident was transferred to an acute care facility. The facility's policy states that notification to the Ombudsman must occur as soon as practicable for facility-initiated discharges, including temporary transfers to hospitals. This lack of documentation and notification was identified through review of the resident's discharge summaries and facility procedures.
Failure to Implement Individualized Nutrition Care Plan After Dental Extraction
Penalty
Summary
The facility failed to implement a complete and individualized care plan for a resident who had recently undergone full dental extraction and was awaiting dentures. The resident expressed concerns about weight loss and difficulty eating due to the lack of teeth. Despite these concerns, the care plan interventions, which included honoring food choices, monitoring food intake, offering substitutes for refused foods, and updating food preferences, were not fully carried out. The resident reported receiving repetitive meals such as sandwiches and chicken soup, which were difficult to eat, and was unaware of alternative food options available to him. Record reviews showed that the resident was not included in the weekly weight monitoring for two consecutive months, and his meal intake consistently remained below 75%. The care plan lacked a specific goal weight, making it difficult to assess whether nutritional goals were being met. Documentation confirmed a one-pound weight loss over the period in question, and the resident's meal ticket did not reflect his updated food preferences. These findings indicate that the facility did not ensure the care plan was effectively implemented to address the resident's nutritional needs following his dental procedure.
Failure to Provide Oral Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands was observed in bed with food particles between her teeth, brownish discoloration, and several missing teeth. Certified Nursing Assistants (CNAs) interviewed acknowledged that the resident's teeth appeared not to have been brushed for days, and one CNA admitted to not returning to provide oral care after finding the resident asleep. The resident's care plan required setup and assistance with oral care, and the facility's policy stated that residents with teeth should have them brushed twice daily. Despite these directives, oral care was not provided as required.
Failure to Implement Pressure Ulcer Prevention Policy Resulting in Pressure Injury
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for one resident, resulting in the development of a pressure injury on the coccyx area. Multiple interviews and record reviews revealed that required weekly skin assessments were not completed or documented, including on the weekly summary and shower sheets. Both the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that skin assessments were missing for several dates, and there was no documentation of interventions such as repositioning for a resident identified as being at risk for pressure injuries. The resident in question had a history of being at moderate risk for pressure injuries, as indicated by a Braden score of 17, and was noted to be chairfast, very moist, and requiring partial to moderate assistance with mobility and hygiene. Despite these risk factors, there was no evidence that the care plan addressed necessary interventions such as moisture control, pressure reduction, or repositioning. Additionally, there was no documentation that the resident received education on the causes and prevention of pressure injuries. When an open wound was eventually discovered on the resident's buttocks, there was no wound assessment, measurement, or wound monitoring record completed, and no treatment order was initiated. The facility's policy required immediate implementation of a wound monitoring record and care plan revision upon identification of a wound, but these steps were not taken. The resident was later admitted to the hospital with an unstageable pressure injury, further confirming the lack of appropriate preventive and responsive care.
Failure to Provide Ordered Restorative Nursing Program Due to Documentation System Change
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to provide a Restorative Nursing Assistant (RNA) program for a resident with contractures in both hands and limited mobility. The resident reported not receiving exercises or being out of bed for some time. Review of the resident's Order Summary Report showed an active order for RNA staff to perform active assisted range of motion (AAROM) exercises to both lower extremities three times per week, once daily, as tolerated. However, the Restorative Nursing Assessment Log indicated that no RNA program was provided to the resident for an 11-day period, and the assigned RNA confirmed that she had not performed the exercises due to lack of access to the electronic health record system and the resident not being included in the printed log used for tracking RNA services. Further interviews revealed that a recent change in the facility's electronic documentation system resulted in the RNA program orders not being accessible or printed for staff, leading to the resident being missed for the entire month. The Director of Staff Development acknowledged the issue, stating that the transition to a new software system disrupted RNA access and that paper logs were being used temporarily. Facility policy required the RNA to carry out the restorative program according to the care plan and document daily, but this was not followed for the resident in question.
Unsupervised Access to Smoking Materials
Penalty
Summary
A deficiency occurred when a resident who was assessed as requiring supervision for smoking was found with a pack of cigarettes and a lighter on the bedside table, accessible and unattended. Certified Nursing Assistant (CNA) 12 confirmed that smoking materials are supposed to be locked at the nurses' station and not left with residents. During an interview, the resident stated that her cigarettes and lighter were in her purse, which was in her lap at the time. The Director of Nursing (DON) reiterated to the resident that facility policy requires smoking articles to be locked up. Review of the resident's Smoking Assessment indicated the need for supervision, and facility policy mandates that all smoking materials be stored securely based on individual assessments. Despite these requirements, the resident had unsupervised access to smoking materials.
Improper Placement of Nephrostomy Catheter Collection Bag
Penalty
Summary
A nephrostomy catheter collection bag for Resident 28 was observed placed on the bed beside the resident's head, positioned higher than the level of the bladder, while the resident was lying upright in bed. The collection bag contained yellowish urine-like liquid. The resident had contractures in both hands, rendering her unable to lift or move objects. During the observation, an LVN confirmed that the catheter bag should be placed lower than the bladder. The resident's care plan indicated monitoring of the nephrostomy drain and its site, and the facility's policy specified that collection bags must always be kept below the level of the bladder, including during transport.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to follow the physician's orders for pain management for one resident. Specifically, the resident had physician orders for Tramadol to be administered for moderate pain (pain rating 4-6) and Acetaminophen for mild pain (pain rating 1-3). However, documentation showed that Tramadol was administered when the resident reported severe pain (pain ratings of 7 and 8), and Acetaminophen was given when the resident reported moderate pain (pain rating of 4). During observation, the resident was noted to be moaning and reported a pain level of over 10, while the nurse prepared to administer Tramadol, which was not in accordance with the prescribed pain scale parameters. The resident, who was cognitively intact according to the MDS assessment, reported that Tramadol provided only partial relief and that her pain would return. The facility's policy required licensed nurses to administer pain medication as ordered, but the records and interviews indicated that pain medications were not consistently given according to the specified pain rating parameters. This resulted in the resident experiencing unrelieved pain and pain management that did not align with the physician's orders.
Incomplete Discharge Summary Due to Missing Skin Assessment
Penalty
Summary
The facility failed to complete a discharge summary for one resident, as required by its own policy and accepted professional standards. During a review of the resident's discharge summary, it was found that the section for skin assessment was left blank, indicating that no skin assessment was completed at the time of discharge. This was confirmed during an interview with an LVN, who stated that the skin assessment was not performed or documented. The facility's policy specifies that a discharge summary must include a summary of the resident's status, including a description of medically defined conditions and prior medical history, but this requirement was not met in this instance.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to wear a gown while providing wound care to a resident who was under Enhanced Barrier Precautions. The resident had signage above the bed indicating that both a gown and gloves were required during any wound care involving a dressing. The LVN acknowledged after the procedure that a gown should have been worn. Review of the facility's policies confirmed that staff are required to wear appropriate personal protective equipment, including gowns, when performing tasks likely to soil clothing with blood, body fluids, secretions, or excretions. The policies also specify that Enhanced Barrier Precautions require targeted gown and glove use during high-contact resident care activities, such as wound care, to reduce the transmission of multidrug-resistant organisms.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident's room in good repair, as evidenced by three deep scrapes on the wall by the head of the bed and thick debris on the floor. During observation, a resident was found lying in bed in this room. The Maintenance Supervisor acknowledged awareness of the scrapes, stating that repairs are not made unless there is penetration through to the next room. Review of the facility's maintenance concerns list showed no report or repair for the damaged wall, despite the facility's policy requiring routinely scheduled maintenance service to all areas.
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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