Laguna Hills Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laguna Hills, California.
- Location
- 24452 Health Center Drive, Laguna Hills, California 92653
- CMS Provider Number
- 056110
- Inspections on file
- 54
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Laguna Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that medications were not stored securely when two medication bubble packs, including doxazosin for HTN and Xarelto for DVT prophylaxis, were left unattended on top of a hallway medication cart accessible to staff, residents, and visitors. Facility policy required all medications to be stored in locked compartments and not left unattended. An RN confirmed the medications should not have been left on the cart, and leadership was informed of the incident.
A resident with a history of T7–T8 compression fracture, HTN, muscle weakness, and capacity for medical decision-making was discharged home without complete discharge documentation. The facility’s discharge instruction/recapitulation form lacked entries for SNF therapy services received, medication education and reconciliation (including a current med list and next provider), social services and activities (dental, vision, hearing, speech, cognition, activities), emergency contact information, current medical diagnoses, functional status, and discharge-day assessments (skin, lungs, abdomen, bowel, urinary status). Although the form was checked to indicate that discharge information and a pharmacy discharge med summary were sent with the resident, the facility could not produce documentation or a copy showing the resident’s current medication list or actual discharge meds, despite active orders for multiple meds including antihypertensives and anticoagulants. The DON confirmed the discharge documentation and assessments were incomplete and that no record of the discharge medication list existed.
A resident experienced two falls on the same day, with the first fall documented on a change in condition form after being found on the floor during a morning med pass. Later that day, the resident was again found on the floor, but no post-fall assessment, change in condition evaluation, or physician notification was documented for this second incident. The care plan, which noted the initial fall, was not revised to include additional interventions to prevent further falls. Staff interviews confirmed awareness of multiple falls and the absence of required documentation and notifications, in violation of facility policies on change in condition and fall management.
A resident with moderate cognitive impairment, whose primary language was not English, was moved from a long-standing private room to a shared room so the private room could be used for an incoming isolation case. The facility’s policy required at least one hour advance written notice of room changes to the resident and representative, including reasons for the move and appeal rights, but staff only left a voicemail for the responsible party, did not wait for a response, and began moving the resident’s belongings despite a request for more time. The required Notification of Room Change form was incomplete, lacking dates, approval status, and signatures, and the explanation of the move was given to the resident only in English without use of a translator, even though translation resources were available. The resident and responsible party reported that the rushed move and packing were very distressing for the resident.
A resident who was cognitively intact and had generalized anxiety disorder loaned $500 to a CNA after hearing about the CNA’s financial hardships, despite facility policies prohibiting staff from soliciting or accepting loans from residents. The CNA repaid only part of the money, then blocked the resident’s calls and stopped communicating, leading the resident to feel worried and emotionally distressed. The CNA later asked the resident to lie and say the money was payment for work performed, further affecting the resident’s emotional well-being.
A cognitively intact resident with generalized anxiety disorder experienced a documented change in condition after voluntarily lending money to a CNA, which caused emotional distress and worry when only part of the loan was repaid. The ADON documented the incident and updated the care plan to address risk for emotional distress/anxiety, and facility policy required nursing assessments every shift for 72 hours after such a change in condition. However, no post-event nursing assessments or monitoring related to this psychosocial incident were documented, and the ADON confirmed that these required assessments were not completed, creating a risk for unrecognized psychosocial changes and delayed care.
A resident with severe cognitive impairment and total dependence on staff was found with unexplained bruising near the eye. Facility staff observed and documented the injury but did not immediately report it to required authorities as per policy. Reporting only occurred after a family member requested an investigation, and the administrator acknowledged the delay, citing uncertainty about the cause.
A resident with mobility issues and physician orders for a hospital bed and wheelchair was discharged without receiving the necessary DME, and was not informed that insurance would not cover the equipment. Discharge instructions lacked details about DME arrangements, and facility staff did not communicate the ineligibility or status of the equipment to the resident prior to discharge.
A resident was discharged from the facility at the request of their spouse without the required written notice of transfer/discharge being provided to the resident, their representative, or the State LTC Ombudsman. Facility policy mandates advance written notice and notification to the Ombudsman, but interviews and record review confirmed that no such documentation was present prior to the discharge.
The facility did not secure storage cabinets in all resident rooms, allowed a resident with cognitive impairment to have scissors at bedside, and failed to post required oxygen signage for a resident receiving oxygen therapy. These actions did not meet safety standards and posed risks to residents, staff, and visitors.
Surveyors identified multiple sanitation and food storage deficiencies, including uncovered food in the refrigerator, dirty and corroded kitchen equipment, improper storage of cleaning tools, and improper labeling and disposal of resident food items. Additionally, both the kitchen and resident ice machines lacked proper air gaps in their drainpipes, and the freezer used for resident food was not monitored for temperature. These issues were confirmed by staff during the survey.
A resident was not provided adequate privacy during bedside toileting, as the commode basin was visible from the hallway despite the privacy curtain being closed. The resident was unaware of the visibility and preferred more privacy. Staff acknowledged the issue and noted that a trash receptacle could have been used to block the view, but this was not done.
Residents were not permitted to self-administer medications even when it was clinically appropriate, as the facility did not assess or support their ability to do so.
Two residents with limited English proficiency did not receive appropriate communication accommodations, as staff relied on English and hand gestures instead of using available language-specific communication cards or interpretation services, despite facility policy and care plans indicating the need for such support.
The facility did not maintain required documentation of resident grievances, resulting in the inability to verify that grievances were reviewed and followed up on according to policy. Staff interviews confirmed that grievances had been filed but were missing from the designated binder, and key personnel were unaware of their responsibilities for filing and retaining grievance records.
Several residents received psychotropic medications without proper diagnoses, informed consent, or documentation of least restrictive measures and non-pharmacological interventions. Monthly behavior summaries and side effect monitoring were not consistently completed for residents on medications such as Seroquel, Ativan, Zyprexa, divalproex sodium, and Prozac, and required monitoring for orthostatic hypotension was omitted after a resident's readmission.
A resident with a documented diagnosis of schizophrenia was incorrectly recorded as having no serious mental illness on the PASRR Level 1 screening. This error was confirmed during a review of the medical record and PASRR documentation by the MDS Coordinator, who acknowledged the discrepancy between the resident's diagnosis and the information reported on the screening.
Multiple residents did not have comprehensive, individualized care plans addressing their specific needs, including diabetes device monitoring, pain management with narcotics, treatment for MASD, behavioral safety risks, and changes in medical condition. Staff interviews and record reviews confirmed the lack of required care plan documentation and interventions, despite physician orders and facility policy.
A resident receiving antihypertensive medication was not accurately monitored for orthostatic blood pressure as ordered by the physician. Documentation showed identical BP readings for both lying and sitting positions on multiple occasions, and an LVN admitted to errors in recording these values. The DON confirmed that such readings should not be the same, indicating a failure to follow physician orders and properly monitor the resident's cardiovascular status.
Two residents at risk for or with existing pressure injuries did not receive appropriate care, as their low air loss mattresses were not set according to their weights and required monitoring was not documented. One resident's heel protectors were not in place as per the care plan, and staff interviews confirmed lapses in following manufacturer guidelines and facility policy.
A resident with limited ROM and mobility needs did not receive or have documented restorative nursing assistant (RNA) services as ordered by the physician, including PROM exercises, hand splint application, and Omnicycle bike exercises. Staff and DON confirmed that missing documentation meant the services were not provided, in violation of facility policy.
Multiple residents did not receive respiratory care as ordered, including incorrect oxygen flow rates and inadequate cleaning and storage of equipment such as CPAP masks and oxygen tubing. Staff failed to follow infection control protocols, and documentation of respiratory care was incomplete or missing. Facility leadership and staff acknowledged these deficiencies during interviews.
Two residents requiring dialysis and physician-ordered fluid restrictions did not have their fluid intake accurately monitored or documented, with staff failing to follow facility policy and allowing unmonitored fluids at the bedside. Both nursing and dietary fluid allocations were not properly tracked, and communication lapses among staff contributed to the deficiencies.
Two residents were provided with elevated grab bars for mobility and repositioning without documented attempts to use less restrictive alternatives, as required by facility policy. Staff confirmed that alternatives were not offered or documented prior to grab bar installation, and relevant assessment sections were left blank in the medical records.
The facility failed to ensure accurate documentation of controlled medications and proper rotation of insulin injection sites for several residents. Controlled substances were removed without corresponding entries in the MAR, and insulin injections were repeatedly administered at the same sites without documentation of resident refusal or education. Nursing staff and leadership confirmed these lapses in practice and documentation.
A resident receiving heparin for DVT prophylaxis was not properly monitored for signs and symptoms of bleeding, despite physician orders and care plan interventions requiring such monitoring. Medical record review and staff interviews confirmed that documentation of bleeding assessments was missing for several days after the initiation of heparin therapy.
Surveyors found that drugs and biologicals were not properly labeled, stored, or disposed of, including expired tuberculin solutions without open dates, resident food stored in medication refrigerators, insulin pens lacking prescription labels, and expired or improperly stored supplies in medication carts. Staff interviews revealed a lack of knowledge about proper medication disposal, and facility policies were not consistently followed.
A resident who was prescribed a fortified, high protein diet did not receive the required 'super soup' with lunch as ordered by the physician. Instead, only the soup of the day was served, despite the meal ticket indicating both soups. Staff interviews confirmed the resident should have received the super soup in accordance with the therapeutic diet order.
Three residents who used bilateral grab bars for bed mobility and positioning did not have complete or accurate bed entrapment assessments, as required by facility policy. Documentation failed to indicate whether key entrapment zones passed or failed, and quarterly reassessments were not performed. Staff interviews confirmed these lapses, and facility leadership acknowledged the deficiencies.
The facility failed to maintain effective infection prevention and control practices, including inaccurate infection surveillance documentation, lack of follow-up on MDRO and UTI trends, improper use of PPE, mishandling of clean linens, unlabeled and improperly stored resident-care equipment, and environmental cleanliness issues. Staff did not consistently follow protocols for contact isolation, catheter care, and wound care, and these deficiencies were acknowledged by facility leadership.
The facility did not follow its antibiotic stewardship program, failing to ensure that physicians were notified when two residents received antibiotics without meeting McGeer's Criteria, and did not follow up on lab results for two other residents. Required documentation and surveillance logs were missing for several months, and staff interviews confirmed the lack of physician notification and follow-up.
A resident with moderate cognitive impairment and decision-making capacity was admitted with an advance directive, but the facility failed to obtain and maintain a copy in the medical record as required by policy. Although the Social Service department requested the document and contacted the resident's sister, there was no documented follow-up or evidence that the advance directive was ever received or filed.
A medication cart was left unattended in a hallway with its computer monitor displaying resident information, including a photo and medication details. Staff and a resident were present nearby, and multiple staff members walked past the cart while the information was visible. Facility policy requires PHI to be protected and computers to be logged off when unattended, but these procedures were not followed.
The facility did not update the care plans for two residents after significant changes in their conditions. One resident's care plan was not revised after a dialysis site developed green discharge, and another resident's care plan failed to include physician-ordered oxygen therapy for shortness of breath. These omissions were confirmed by facility nursing leadership.
Two of three outdoor garbage dumpsters were observed to be overfilled, preventing the lids from closing completely, with additional trash scattered around the area. The Maintenance Director and facility leadership acknowledged that the dumpsters could not be closed due to excess trash, in violation of facility policy and the USDA Food Code.
A facility's assessment did not include active involvement from direct care staff, residents, or their representatives, and lacked plans for recruitment, retention, and contingency staffing, as confirmed by the Administrator during an interview and document review.
The facility failed to ensure accurate and complete medical records for three residents, including missing start times for tube feeding orders, incorrect coding of therapy interventions, and discrepancies in the administration and documentation of controlled medications. These documentation errors were confirmed by staff and the DON during interviews and record reviews.
A resident with a history of multiple falls and moderately impaired cognition did not have floor mats placed on both sides of the bed as ordered by the physician and outlined in the care plan. Despite staff awareness of the fall risk and required interventions, only one floor mat was in use, with the other mat not positioned as directed. Nursing and administrative staff confirmed that the intervention was not implemented according to orders.
A resident did not receive appropriate pain management due to the facility's failure to conduct complete pain assessments and to follow physician orders for pain medication. Documentation of pain characteristics was missing, and acetaminophen was repeatedly administered for moderate to severe pain levels when hydrocodone-acetaminophen was ordered for such cases. Staff interviews confirmed the lack of assessment and documentation prior to medication administration.
Two residents experienced deficiencies in medical record documentation, including inaccurate recording of vital signs and fall risk assessments after a fall, incomplete neurological assessments, and missing entries in the Treatment Administration Record for wound care. Nursing staff acknowledged that required documentation was either omitted or inaccurately completed, resulting in incomplete clinical records.
A facility failed to maintain complete and accurate medical records for a resident, with missing documentation on the TAR for various physician's orders related to wound care and other treatments. The gaps in documentation were confirmed by an RN, and the DON acknowledged the findings.
A resident's call light was not within reach, leading to frustration and difficulty in obtaining assistance. The resident was observed yelling for help, and an LVN confirmed the call light was clipped out of reach, later placing it within the resident's reach.
A facility failed to report an alleged staff-to-resident abuse incident involving a resident and an LVN in a timely manner, as required by their policy and section 1150B of the Act. The incident was reported internally on the day it occurred, but the facility delayed reporting to the CDPH for five days, contrary to the policy requiring immediate reporting. This posed a risk of continued abuse.
A resident experienced a three-pound weight loss in one week, and the facility failed to notify the physician as required by the care plan. The resident had fluctuating capacity to understand and make decisions, and the care plan included monitoring and reporting significant weight loss. Interviews with staff confirmed the oversight, which had the potential to negatively affect the resident's health.
A CNA failed to perform hand hygiene after removing gloves while caring for a resident, contrary to the facility's infection control policy. This lapse occurred after changing the resident's soiled brief and was acknowledged by the facility's administration.
A resident did not receive their scheduled morning medications within the required timeframe, as per the facility's policy. The resident's blood pressure was high, and medications were delayed until late morning due to distractions faced by the LVN. The DON confirmed the failure to adhere to the medication administration policy.
The facility failed to maintain clean AC units for a resident and another non-sampled resident, potentially affecting their health and well-being. Observations revealed black ash residue on the air outlet blade of the AC unit in one room and thick dust, stone-like dirt, and a rusty grill in another. Despite records indicating regular cleaning, the Maintenance Director confirmed the units were not clean. The Administrator acknowledged these findings.
A resident was discharged from the facility without proper documentation and adherence to the discharge protocol. The facility's policy required a review of the discharge plan with the resident and family, but records showed incomplete discharge instructions and lack of documentation. Interviews with the ADON confirmed the absence of necessary documentation and protocol adherence.
A resident was improperly administered oxycodone-acetaminophen for pain levels below the prescribed threshold of 8-10, contrary to the physician's order. The facility's policy required safe medication administration, but the ADON and an RN confirmed the medication was given inappropriately, risking unnecessary exposure to adverse effects.
The facility failed to follow food safety and sanitation guidelines, with unlabeled and undated food in the refrigerator, unclean food contact surfaces, and improper hair restraint use by staff. Additionally, the manual ware washing process was inadequate, and maintenance tools were stored unsanitarily. These deficiencies were confirmed by the DSS and Maintenance Director.
Unattended Medication Bubble Packs Left on Hallway Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when two medication bubble packs were found left unattended on top of Medication Cart A in a hallway accessible to staff, residents, and visitors. The facility’s policy titled “Medication Labeling and Storage” dated 2/2023 stated that all medications and biologicals must be stored in locked compartments under proper environmental controls and that medications should not be left unattended. During an observation and concurrent interview with RN 1, two bubble packs were observed on top of the cart by a resident room, and RN 1 confirmed that medications should not be left unattended to ensure protection of residents’ safety and privacy. The unattended medications included a bubble pack of doxazosin mesylate 1 mg tablets for one resident, ordered once daily for hypertension with instructions to hold if systolic blood pressure was less than 110 mmHg, and a bubble pack of Xarelto 10 mg tablets for another resident, ordered once daily for DVT prophylaxis. The doxazosin bubble pack contained nine white tablets, and the Xarelto bubble pack contained four red tablets. Both residents had active physician orders for these medications as documented in their Order Summary Reports. The Administrator and DON were later informed of and acknowledged these findings.
Incomplete Discharge Documentation and Missing Medication Reconciliation
Penalty
Summary
The facility failed to complete required discharge information and assessments for one of seven sampled residents. Facility policy titled "Discharging the Resident" required that when a resident is discharged home, staff must ensure the resident and/or responsible party receive teaching and discharge instructions, and that the resident’s condition at discharge, including a skin assessment, is assessed and documented if the medical condition allows. For this resident, who had a history of T7–T8 compression fracture, hypertension, and muscle weakness and had capacity to make medical decisions, the Discharge Instruction Form/Recapitulation of Stay dated 3/20/26 contained multiple blank sections. These included therapy services received while in the SNF, medication education and reconciliation (including provision of a current reconciled medication list to the next provider and identification of that provider), social services and activities (dental condition, vision, hearing, speech, cognition, and activities), emergency contact information for urgent problems or worsening symptoms, current medical diagnoses, functional status, and discharge day status (skin assessment and condition, lung sounds, abdomen, bowel, and urinary status). The resident’s physician orders included multiple medications and treatments, such as alendronate sodium, amlodipine besylate for hypertension, calcium citrate with vitamin D, apixaban for atrial fibrillation, and wound care orders for a back surgical incision, as well as ongoing PT and OT. A physician order dated 3/17/26 directed discharge back to prior living arrangements with home health RN for medical management and home health PT for safety evaluation after the last covered day of 3/16/26. The discharge instruction form indicated by check mark that a Discharge Information/Recap of Stay and a Pharmacy Discharge Medication Summary were sent with the resident; however, the facility could not provide documentation or a copy of any form showing the current medication list or what medications the resident was discharged with. During interview and concurrent record review, the DON verified that the discharge instruction form information and assessments were incomplete and that there was no documentation of the current medication list or discharge medications.
Failure to Assess and Notify Physician After Second Fall and to Update Fall Prevention Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for change in condition and fall management after a resident experienced multiple falls on the same day. According to the facility’s policies, nursing staff must notify the physician after an accident or incident involving a resident, complete a change of condition (COC) assessment, and evaluate and document falls within 24 hours, including identifying possible causes and revising the care plan as needed. Medical record review showed that the resident was first found on the floor next to the bed during a routine morning medication pass at 0635 hours, and an eINTERACT Change in Condition Evaluation form was completed for that fall. Later the same day at 1900 hours, the resident was again found lying on the floor on her left side with her head on a pillow, with no complaints of pain or discomfort documented. Despite this second fall, further review of the medical record showed no evidence that a post-fall assessment or a second COC evaluation was completed, and no documentation that the physician was notified of the second incident, contrary to facility policy. The resident’s care plan, which had been updated after the first fall to note the incident, did not contain revised or additional interventions to prevent injury or recurrence of falls following the second event. Interviews with an LVN and an RN confirmed that the resident had two falls on the same day and that there was no COC initiated or physician notification documented for the second fall, even though the RN acknowledged that such actions should have occurred. The DON was informed of and acknowledged these findings during the survey.
Failure to Provide Adequate Written and Language-Appropriate Notice of Room Change
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and written notice of a room change, in accordance with its own policy and resident rights requirements, for one of five sampled residents. The facility’s policy on Room Change/Roommate Assignment, revised 3/2021, required that residents and their representatives receive at least one hour advance written notice of any room or roommate change, including the reason for the change and information to help them become acquainted with a new roommate. For this resident, who had been in a private room for five years and had a BIMS score of 9 indicating moderate cognitive impairment, the facility initiated a move from a private to a shared room because the private room was needed for an incoming resident requiring isolation. The Social Services Director (SSD) left a voicemail for the resident’s responsible party about the move but did not wait for a response before proceeding, and staff began moving the resident’s belongings despite the responsible party’s request for more time. The Notification of Room Change form for this resident was incomplete and did not contain the date of notification for either the resident or the responsible party, their approval status, or the required signatures and dates. The SSD stated that the purpose of the form was to notify all parties of the room change and inform them of their rights to appeal, but acknowledged that the form was not completed and that the move proceeded even though they had not actually spoken with the responsible party. Additionally, the resident’s facesheet identified a primary language other than English (Farsi), yet the SSD communicated the room change to the resident only in English and did not use a translator or translation service, despite the facility having access to a translator line or staff translators. The resident and responsible party reported that the rapid packing and moving of belongings was very distressing for the resident. The Admissions Director and Administrator both confirmed that the Notification of Room Change form was incomplete and that the resident spoke very little English, confirming the failures in written notification and communication in the resident’s primary language.
Failure to Prevent Financial Exploitation and Emotional Distress of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of financial exploitation by a CNA. The facility’s abuse, neglect, exploitation, or misappropriation prevention policy stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and the employee handbook prohibited staff from soliciting or accepting loans or borrowing money from residents. Despite these policies, a cognitively intact resident with a history of generalized anxiety disorder loaned $500 to a CNA after the CNA shared personal and financial hardships. The resident reported that the CNA agreed to repay the money within two weeks, but only repaid $250 and then blocked the resident’s phone and stopped communicating. The resident’s medical record documented a change in condition related to lending money to staff and a care plan identifying risk for emotional distress and anxiety related to the incident. Progress notes showed the resident told the ADON that she felt bad for the CNA’s financial struggles and voluntarily loaned the money, but became worried when the remaining amount was not repaid. During an interview, the resident stated that as the situation progressed and repayment was not completed, she became worried, especially as it was close to Christmas, and that she did not initially want to report the matter. The resident further reported that the CNA later contacted her and asked her to lie and say the money was payment for work the CNA had done for her, which made the resident feel emotional. The SSA confirmed that the resident expressed sadness about the CNA’s situation and a desire to simply have the rest of the money returned.
Failure to Perform Post–Change of Condition Assessments After Psychosocial Incident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care following a documented change in condition for one resident. The resident, who had generalized anxiety disorder, was cognitively intact and had documented capacity to understand and make medical decisions. An SBAR Communication Form dated 12/29/25 identified a change in condition related to the resident lending money to a CNA, and the care plan was updated the same day to address the resident’s risk for emotional distress and anxiety related to this incident. Progress notes from 12/29/25 documented that the ADON met with the resident, who reported having loaned $500 to a CNA due to the CNA’s reported financial struggles, and that only $250 had been repaid, causing the resident worry about the remaining amount. During interview and concurrent medical record review on 2/2/26, the ADON stated that, following a change in condition, nurses are required to conduct nursing assessments related to the change in condition every shift for 72 hours to address any potential complications from the specific event. Review of the resident’s progress notes showed no post-event nursing assessments or monitoring related to the change in condition incident involving the loan to the CNA. The ADON verified that these required nursing assessments were not completed. This failure posed the risk for changes in the resident’s psychosocial well-being not being identified and potentially delayed necessary care and treatment.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to implement its policy and procedure for timely reporting of a reasonable suspicion of a crime related to an injury of unknown source for one resident. A resident with severely impaired cognition and total dependence on staff for mobility was found with a coin-sized skin discoloration to the right eyebrow region. The discoloration was first observed by a CNA and assessed by an LVN, who could not determine the cause. The resident was unable to communicate how the injury occurred, and there were no witnesses. The facility's policy required immediate reporting of suspected abuse, neglect, exploitation, or injury of unknown source to the administrator and appropriate authorities, with 'immediate' defined as within two hours for serious bodily injury or within 24 hours otherwise. Despite these requirements, the facility did not report the injury to the California Department of Public Health (CDPH), Licensing & Certification Program, Long-Term Care Ombudsman, and local law enforcement until prompted by a family member who visited the resident and requested an investigation. The administrator acknowledged that the injury was of unknown origin and should have been reported, but delayed reporting, considering it a 'gray area' due to the resident's history of being prone to accidents. The delay in reporting was confirmed through interviews with staff and review of documentation.
Failure to Inform Resident of DME Coverage and Arrange Safe Discharge
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a resident prior to discharge, specifically regarding the arrangement and coverage of physician-ordered durable medical equipment (DME), including a hospital bed and wheelchair. The resident, who had diagnoses of cellulitis and lymphedema and required assistance with mobility, was discharged home without receiving the ordered DME. The discharge instructions did not specify what DME was arranged, the company to contact, or the expected delivery timeframe. Medical record review did not show evidence that the DME arrangements were completed prior to discharge. Interviews with facility staff revealed that although the social services staff was aware the resident's insurance would not cover the DME, this information was not communicated to the resident before discharge. The social services director confirmed that there was no documentation indicating the resident had been notified about the DME ineligibility or the status of the equipment prior to or after discharge. The administrator acknowledged these findings during the investigation.
Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident, the resident's representative, and the State Long-Term Care Ombudsman prior to the resident's discharge. According to the facility's policy, a thirty-day advance written notice is required for planned transfers or discharges, and a copy must be sent to the Ombudsman at the same time. In this case, the resident was readmitted and later discharged at the request of the resident's wife, but there was no documented evidence that the required notice was given to any of the parties involved before the discharge occurred. Interviews with social services staff and review of the closed medical record confirmed that the notice of transfer/discharge was not provided as required. The staff stated that the notice would typically be given two days prior to discharge or when the resident expressed a desire to leave, but in this instance, no documentation was found to support that the notice was issued to the resident, the representative, or the Ombudsman prior to the discharge. This omission was verified by both the social services staff and the social services director during the review.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for several residents. During an observation of a resident's room, it was found that the closet/storage cabinet was unsecured. The Maintenance Director confirmed that all 103 resident rooms in the facility had unsecured closet/storage cabinets due to ongoing refurbishment, and that new secured cabinets had been ordered but were not yet installed. This left all resident rooms with unsecured storage, which could pose a risk of tipping and injury, especially during events such as earthquakes. In another instance, a resident with moderate cognitive impairment was observed with a pair of long scissors on their overbed table. Interviews with nursing staff confirmed that the resident was not permitted to have scissors at the bedside, and staff were unsure how the resident obtained them. The resident was noted to be independent and ambulatory within the facility. The facility's policy allowed residents to retain personal possessions unless it posed a health or safety risk, but the presence of scissors at the bedside was not permitted for any resident. Additionally, a resident receiving oxygen therapy was found to have a portable oxygen cylinder in their room without the required signage indicating oxygen use. Facility policy required a "No Smoking" sign on the room entrance and an "Oxygen in Use" sign over the resident's bed when oxygen therapy was being administered. Observations and interviews with nursing staff confirmed that the necessary signage was not posted in the resident's room, despite an active physician's order for oxygen therapy.
Multiple Sanitation and Food Storage Deficiencies Identified in Kitchen and Resident Food Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, as evidenced by multiple observations during a survey. Uncovered sheet pans filled with cake were found in the walk-in refrigerator, and various kitchen equipment, including a stand mixer, can opener, whisks, and utensils, were observed to be dirty, corroded, or in poor repair. Additionally, a broom and dustpan were stored directly on the floor in a food service area, contrary to professional standards for maintenance tool storage. Food brought in by visitors for residents was not properly labeled, sealed, or dated in the designated refrigerator, and expired or perishable items were not consistently discarded as required by facility policy. The freezer used for resident food lacked a thermometer and was not monitored for temperature, and there was no temperature log available. These issues were verified by staff during the survey, and it was acknowledged that perishable foods should not be kept for longer than 24 hours, but this was not consistently practiced. Both the kitchen and Station A ice machines had drainpipes that did not maintain the required air gap between the water outlet and the flood level of the drain, creating a risk of backflow and potential contamination. The kitchen ice machine’s drainpipe was observed touching the drainage inlet and surrounded by a puddle of water, and the Station A ice machine’s pipe extended into the floor sink drain. These findings were confirmed by the Dietary Services Supervisor and Maintenance Director during the survey.
Failure to Maintain Resident Privacy During Bedside Toileting
Penalty
Summary
The facility failed to ensure that a resident was provided care in a manner that promoted dignity and respect, specifically by not maintaining privacy during bedside toileting. Observation revealed that the resident was transferred to a bedside commode with the privacy curtain pulled closed, but the commode basin was still visible from the hallway due to a gap between the curtain and the floor. The resident had declined to have her room door closed, and the commode basin, which was placed on the floor under the commode, remained visible during use. The facility's policy required staff to maintain and protect resident privacy during personal care, but this was not achieved in this instance. Interviews with the CNA and the resident confirmed that the resident was unaware her commode basin was visible from the hallway and expressed a preference for it not to be seen during use. The CNA acknowledged the visibility issue and, upon testing, found that a trash receptacle could have been used to block the view but had not been utilized. The deficiency was identified through observation, interview, and review of facility policy and procedures.
Failure to Allow Self-Administration of Medications
Penalty
Summary
Residents were not allowed to self-administer their medications, despite it being clinically appropriate to do so. The facility failed to assess and permit residents to manage their own drug administration when it was determined to be suitable for their clinical condition. This deficiency was identified based on the facility's inaction in supporting resident autonomy in medication management as appropriate.
Failure to Accommodate Communication Needs for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the communication needs of two residents with limited English proficiency. Observations revealed that staff communicated with these residents primarily in English and relied on hand gestures, despite the residents' primary languages being Chinese and Korean, respectively. Communication cards in the residents' preferred languages were available and posted in their rooms, but staff did not utilize these resources or seek assistance from language interpretation services as outlined in facility policy. For one resident, staff members acknowledged that the resident could not understand English and required communication in Chinese. Despite this, care was provided using only English and gestures, and communication cards or translation services were not used. The resident's care plan and medical records confirmed the need for language accommodation, and staff interviews verified the lack of appropriate communication methods during care interactions. In the case of the second resident, staff believed the resident spoke Japanese, but the resident's primary language was Korean. Staff relied on hand gestures and the presence of the resident's wife for translation, even when she was not present. Communication boards in the resident's language were available but not used, and staff did not contact charge nurses for oral interpretation services. Interviews with facility leadership confirmed that staff did not follow established procedures for accommodating communication needs.
Failure to Maintain and Track Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to ensure that all grievances filed during 2025 were available for review and appropriately followed up on, as required by their grievance policy. According to the facility's policy, once a grievance is filed, the Social Services Director (SSD) is responsible for reviewing and investigating the allegations, submitting a written report of findings to the administrator within five working days, and ensuring that a copy of the written summary is filed in the business office and maintained for three years. During the survey, it was found that the grievance binder, which should have contained records for each month, was empty. The SSD, who had only recently started working at the facility, and Social Services Staff 1 confirmed that there had been grievances filed during the year but were unable to locate most of them, with only one grievance eventually found. Interviews with the Administrator and Business Office Manager revealed that neither kept copies of the grievances, and the Business Office Manager was unaware that the policy required her to file copies of the written summaries. This lack of documentation prevented the state agency from verifying whether grievances were followed up on according to policy. The absence of grievance records indicated that the facility did not maintain the required documentation or ensure that grievances were handled and tracked as outlined in their procedures.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and that appropriate monitoring and documentation were in place for those receiving such medications. For one resident with dementia, Seroquel and Ativan were administered without a documented diagnosis of bipolar disorder or psychosis, and informed consent was not obtained prior to starting Seroquel. Additionally, there was no evidence that least restrictive measures or non-pharmacological interventions were attempted before initiating these medications, and side effect and behavioral monitoring were not implemented until several days after the medications were started. Another resident was prescribed divalproex sodium and Prozac, but the facility did not complete monthly behavior summaries for the targeted behaviors associated with these medications. Furthermore, after the resident was readmitted, the facility failed to obtain an order for orthostatic hypotension monitoring related to the resident's ongoing use of Zyprexa, an antipsychotic medication known to carry this risk. The absence of required monitoring and documentation was confirmed by facility leadership during interviews and record reviews. A third resident was prescribed Zyprexa for schizophrenia, with the targeted behavior for monitoring changed in the medical record. However, the facility did not complete monthly behavior summaries for the new targeted behavior after the change was made. Staff interviews confirmed that the required documentation was not completed, and facility policy requires such summaries to be updated whenever there are changes in medication orders, diagnoses, or manifestations.
Inaccurate PASRR Level 1 Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that the PASRR Level 1 screening contained accurate information regarding a resident's mental illness. Specifically, a resident with a documented diagnosis of schizophrenia, as evidenced by a physician's order for Zyprexa to treat schizophrenia, was incorrectly recorded on the PASRR Level 1 screening as having no diagnosis of a serious mental illness. This discrepancy was identified during a review of the resident's medical record and PASRR documentation. During an interview and concurrent record review, the MDS Coordinator confirmed that the PASRR Level 1 screening for the resident did not reflect the resident's actual diagnosis of schizophrenia. The MDS Coordinator acknowledged that the information on the PASRR Level 1 screening was incorrect and verified that the resident did, in fact, have a diagnosis of schizophrenia as documented in the medical record.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by its own policies and federal regulations. For one resident with diabetes using a Dexcom continuous glucose monitoring sensor, the care plan did not include specific interventions for monitoring the sensor site or ensuring site rotation, and there was no documentation by licensed nurses regarding the location or assessment of the sensor. Interviews with staff confirmed the lack of documentation and care plan interventions related to the sensor's use and site monitoring, despite physician orders and manufacturer guidelines requiring such oversight. Another resident receiving oxycodone for pain management did not have a care plan addressing their pain or the use of narcotic pain medication, even though the resident regularly reported pain and was administered the medication as needed. Staff interviews and medical record reviews confirmed the absence of a care plan problem for pain management, despite ongoing administration of pain medication and the resident's complaints of pain. Additional deficiencies included the lack of a care plan for a resident with moisture-associated skin damage (MASD) to the abdominal fold, despite a physician's order for daily topical treatment. There was also no care plan addressing a resident's behavioral safety risk after a pair of scissors was found at the bedside, nor was there a care plan for another resident's change in condition involving popped boils on the forearm. In each case, staff interviews and record reviews confirmed the absence of appropriate care plan development and documentation, contrary to facility policy and best practices.
Failure to Accurately Monitor and Document Orthostatic Blood Pressure
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident who was being monitored for unnecessary medications, specifically regarding the monitoring of orthostatic blood pressure (BP) as ordered by the physician. The physician's orders required daily monitoring of orthostatic BP in both lying and sitting positions. The resident's care plan addressed altered cardiovascular status and risk for hypertension and hypotension, with interventions including administration of antihypertensive medications and monitoring for side effects such as orthostatic hypotension. Medical record review showed that, on multiple occasions, the BP readings documented for both lying and sitting positions were identical, which is inconsistent with proper orthostatic BP measurement. During interviews, an LVN acknowledged that the matching BP readings were an error and could not provide evidence that accurate orthostatic BP readings were taken on several days. The DON also confirmed that BP readings for lying and sitting positions should not be the same each time. This failure to accurately monitor and document orthostatic BP as ordered constituted a deficiency in care.
Failure to Ensure Proper Pressure Ulcer Prevention and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for two residents. For one resident with a Stage 3 pressure injury on the sacrum, the low air loss (LAL) mattress was not set according to the resident's weight, as required by the manufacturer's guidelines. Observations showed the mattress was set significantly higher than appropriate for the resident's weight, and there was no documentation of regular monitoring of the mattress's functionality or placement, despite physician orders and facility policy requiring such monitoring. Another resident, identified as being at high risk for skin breakdown and with paraplegia, was also found to have deficiencies in pressure ulcer prevention. The LAL mattress for this resident was set above the recommended weight setting and was left in 'statique' mode, which is intended only for short-term use during care activities. Additionally, the resident's heel protectors, which were part of the care plan to prevent pressure injuries, were not in place while the resident was in bed. Staff interviews confirmed that the heel protectors had not been applied and that the mattress settings were not consistently checked or adjusted according to the resident's current weight. Facility policies required the use of pressure-reducing surfaces and adherence to manufacturer guidelines for support surfaces, as well as regular monitoring and documentation. However, the care plans and interventions for both residents did not include specific instructions for mattress settings or monitoring, and staff were unable to provide documentation of required checks. These failures were confirmed through observations, interviews, and medical record reviews.
Failure to Provide and Document Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide and document restorative nursing assistant (RNA) services as ordered by the physician for a resident with limited range of motion (ROM) and mobility needs. The resident, who had moderate cognitive impairment but was able to understand and make decisions, was observed and interviewed, stating that she had not received ROM exercises as ordered. Medical record review confirmed missing documentation for passive range of motion (PROM) exercises for the left upper extremity and use of a hand splint, as well as for bilateral lower extremity exercises using the Omnicycle bike on multiple dates when these services were ordered to be provided. Interviews with RNA staff and the Director of Nursing (DON) verified that if RNA services were not documented, they were not performed, and that "not applicable" entries indicated the service was not provided. The facility's policies required that restorative nursing care be provided as needed and that documentation be objective, complete, and accurate. The DON confirmed the findings and acknowledged that the required RNA services were not provided or documented as ordered for the resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to multiple residents, as evidenced by observations, interviews, and medical record reviews. Several residents did not receive oxygen therapy as ordered by their physicians. For example, one resident was administered oxygen at a higher rate than prescribed, while another was not given the continuous oxygen at the specified rate. In both cases, staff verified the discrepancies between the physician's orders and the actual administration of oxygen. Infection control practices related to respiratory equipment were not consistently followed. Observations revealed that oxygen tubing and CPAP masks were not stored in sanitary conditions, with some tubing touching trash bins or the floor, and some masks not being kept in storage bags when not in use. Additionally, equipment such as nebulizer masks and oxygen humidifiers were found unlabeled and undated, contrary to facility policy. Staff interviews confirmed that these practices were not being adhered to, and in some cases, staff were unaware of their responsibilities regarding cleaning and storage of respiratory equipment. Documentation of respiratory care was also found to be lacking. There was no evidence in the medical records of the administration and effectiveness of PRN oxygen therapy for certain residents, despite facility policy requiring such documentation. Staff interviews further revealed confusion about who was responsible for cleaning and documenting the use of respiratory equipment, with some licensed nurses relying on CNAs for cleaning tasks, even though facility policy assigned this responsibility to licensed nurses. These failures were acknowledged by facility leadership during interviews.
Failure to Implement and Monitor Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents who required fluid restrictions as part of their treatment. For one resident with a physician's order for a 1000 ml daily fluid restriction, the medical record and Medication Administration Record (MAR) did not document the specific amount of fluid consumed in milliliters, only showing check marks for monitoring. There was also no documentation in the progress notes of the resident's fluid intake per shift or per day. During observation, an open can of carbonated drink was found at the resident's bedside, and the assigned CNA was unaware of the fluid restriction, stating that this information was not communicated during shift change or by the charge nurses. The ADON confirmed the lack of documentation and communication regarding the fluid restriction, and acknowledged that unmonitored fluids should not be present at the bedside for residents on fluid restrictions. For the second resident, who had a physician's order for a 1500 ml daily fluid restriction, observations revealed a water pitcher, glass of water, soda cans, and bottles of flavored drinks at the bedside. The resident's fluid intake records for the past 30 days showed daily totals that exceeded the prescribed dietary fluid intake, with some days reaching 1440 ml from meal trays alone. The MAR again only showed check marks for monitoring, without specific amounts documented. The CNA assigned to the resident was aware of a fluid limit but did not know the exact amount, and verified the presence of multiple fluid sources at the bedside. The RN confirmed that the recorded fluid intake was not accurate, as only dietary fluids were documented and nursing-provided fluids were not consistently recorded. The DON verified these findings during review. The facility's policy and procedure for encouraging and restricting fluids required staff to follow specific instructions for fluid intake, accurately record intake in milliliters, remove water pitchers and cups from rooms of residents on fluid restrictions, and maintain intake and output records. These procedures were not followed for either resident, resulting in a failure to ensure physician's orders for fluid restrictions were implemented and monitored as required.
Failure to Attempt Less Restrictive Alternatives Before Grab Bar Use
Penalty
Summary
The facility failed to ensure that less restrictive alternatives were attempted prior to the installation and use of elevated grab bars for two residents. For both residents, medical record reviews showed that the required sections documenting the use of less restrictive alternatives and the residents' responses to those alternatives were left blank in the Side Rail Utilization assessments. Staff interviews confirmed that less restrictive measures were not offered or attempted before implementing the use of grab bars, despite facility policy requiring such steps. In both cases, staff indicated that the residents requested the grab bars, but acknowledged that alternatives should have been tried and documented as part of the assessment process. One resident, who had moderate cognitive impairment and required moderate to dependent assistance for mobility, was observed using bilateral grab bars for repositioning in bed. The other resident also had a physician's order for bilateral grab bars for bed mobility, transfers, and repositioning, and was observed using them. Facility policy required interdisciplinary evaluation, resident assessment, and informed consent, as well as the use of alternatives such as roll guards or foam bumpers before bed rails or grab bars were installed. The failure to follow these procedures was verified by the ADON, DON, and other staff during interviews and record reviews.
Failure to Accurately Document Controlled Medications and Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for four residents, resulting in inaccurate administration and documentation of medications. For one resident, there were discrepancies between the removal of controlled substances (oxycodone 10 mg and 15 mg) from the controlled drug record and the documentation in the Medication Administration Record (MAR). Specifically, the controlled medications were removed at certain times, but there was no corresponding documentation in the MAR to confirm administration. The Director of Nursing (DON) confirmed that licensed nurses are required to document both the removal and administration of narcotic medications, but this was not done for the identified instances. Additionally, three residents receiving insulin therapy did not have their injection sites rotated as required by facility policy and physician orders. Medical record reviews showed repeated administration of insulin at the same anatomical sites over multiple dates, with no documentation indicating that residents refused site rotation or that risks and benefits were explained to them. Interviews with nursing staff and the DON confirmed that injection sites should be rotated to prevent complications, and that the MAR should be checked to determine the last site used. However, this practice was not consistently followed, and there was no documentation of resident preference or education regarding site rotation. The facility's policies require accurate documentation of controlled substances and proper rotation of injection sites for subcutaneous medications. Despite these policies, the observed failures in documentation and administration practices were verified by nursing staff and facility leadership during interviews and record reviews. These deficiencies were acknowledged by the Administrator and DON.
Failure to Monitor for Bleeding in Resident Receiving Heparin
Penalty
Summary
The facility failed to ensure that a resident receiving heparin, an anticoagulant medication, was properly monitored for signs and symptoms of bleeding as required. The resident was readmitted and had physician's orders to receive heparin injections for DVT prophylaxis, with an additional order to monitor for bleeding every shift. The resident's care plan also included interventions to monitor for bruising and bleeding and to notify the physician if these were observed. A review of the medical record revealed there was no documented evidence that the resident was monitored for bleeding from the start of the heparin therapy until several days later. Interviews with an LVN and the DON confirmed that monitoring for bleeding should have begun when the medication was started, and both acknowledged the lack of documentation for this monitoring during the specified period.
Deficient Medication Storage, Labeling, and Disposal Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's management of drugs and biologicals, including improper storage, labeling, and disposal of medications. In Medication Room A, a vial of tuberculin solution was found labeled with an open date exceeding the recommended 30-day discard period, and another tuberculin vial lacked an open date entirely. Additionally, ice cream belonging to a resident was stored in the medication refrigerator, and three insulin pens for a resident were missing pharmacy prescription labels. A container of Super Sani Cloth Wipes was also observed with an illegible expiration date. In Medication Room B, the medication refrigerator was found to be operating below the required temperature range, with ice buildup present, and a tuberculin solution stored past its discard date. Further deficiencies were observed in the medication carts. Medication Cart B contained a bottle of nitroglycerin tablets stored with IV supplies, and an expired IV Luer lock cap was found. Medication Cart D contained opened and exposed single-use dressings, skin staple remover, and steri-strips, as well as expired wound dressings. Expired medications and supplies were not removed from Medication Carts B and D. In Medication Cart C, a container was found filled with melted and dried medications, indicating improper disposal of refused or discontinued medications. Staff interviews confirmed a lack of knowledge regarding proper medication disposal procedures. Facility policy reviews indicated that medications should be labeled, stored, and disposed of according to state and federal laws and standards of practice. However, observations and staff interviews revealed that these policies were not consistently followed, resulting in expired, improperly stored, and unlabeled medications and supplies remaining accessible in medication rooms and carts. The Director of Nursing and Administrator acknowledged these findings during interviews.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received the appropriate therapeutic diet as ordered by the physician. According to the medical record and the registered dietician's recommendation, the resident was to be provided with a fortified, high protein diet with regular texture and thin liquids consistency. The resident's lunch meal ticket indicated that both the soup of the day and a 'super soup' were to be provided, with the 'super soup' specifically associated with the fortified diet order. However, during meal service observation, the resident was only served the soup of the day and did not receive the super soup as indicated on the meal ticket. Interviews with staff confirmed the discrepancy. A CNA verified that the super soup was not present on the resident's tray, and the Dietary Services Supervisor (DSS) stated that residents on fortified diets should receive the super soup instead of the soup of the day. The DSS further clarified that if both soups were listed, only the super soup should be served. This failure resulted in the resident not receiving the diet as ordered by the physician.
Incomplete and Inaccurate Bed Entrapment Assessments for Residents Using Grab Bars
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed grab bars were accurate and complete for three residents who used these devices for mobility and positioning. Observations and interviews confirmed that these residents regularly used bilateral grab bars while in bed, and their medical records included physician orders for the use of these devices. However, review of the Bed Entrapment assessments for these residents revealed that critical information was missing, specifically whether certain entrapment zones (Zones 6 and 7) passed or failed the assessment. Additionally, the required quarterly reassessments of bed entrapment risk were not completed for these residents. Facility policy required that all beds, bed rails, and mattresses be inspected to ensure no gaps wide enough to entrap a resident’s head or body, with inspections documented and reported to facility leadership and the QAPI committee. Despite this, the maintenance staff did not consistently communicate assessment results to licensed nurses, and the Maintenance Director was unfamiliar with the assessment forms being used. The documentation for the entrapment assessments was incomplete, and there was no evidence that the assessments were performed at the required quarterly intervals. Interviews with facility staff, including the Maintenance Director, ADON, and DON, confirmed the lapses in both the completion and documentation of the entrapment assessments. The staff acknowledged that the assessments were not performed as required and that the forms did not indicate whether the relevant zones passed or failed. These failures were identified through observation, record review, and staff interviews, and were acknowledged by facility leadership.
Widespread Infection Control Failures and Documentation Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, documentation, and implementation of infection control practices. There were discrepancies in the facility’s infection surveillance logs and line listings, with missing documentation for several months and inaccurate reporting of residents who received antibiotics and those with multidrug-resistant organism (MDRO) infections. The Infection Control Committee minutes did not accurately reflect the number of residents affected, and there was no documented evidence of recommendations or follow-up actions to address the high incidence of E. coli and proteus mirabilis infections. Additionally, the committee failed to discuss the antibiogram and its correlation with urinary tract infections (UTIs) or to document protocols to address the MDRO infection rate. Observations revealed lapses in infection control practices, including the absence of Enhanced Barrier Precaution (EBP) signage and personal protective equipment (PPE) outside a resident’s room, and staff not wearing gowns during high-contact care activities such as wound and catheter care. Clean linens were improperly handled and stored, with staff placing them on used surfaces without protective covering. Shared resident-care equipment, such as basins and bedpans, were found unlabeled and improperly cleaned or stored in shared restrooms, and a urinal was found unlabeled on a bedside table. In another instance, a resident’s urinary catheter tubing was observed lying on the floor, contrary to facility policy. Further deficiencies included staff not donning appropriate PPE when entering a contact isolation room, as required by posted signage and facility policy. There were also environmental cleanliness issues, such as brown stains on the floor and wall in a resident’s room on contact precautions, and soiled items found on the floor of a medication room. In one case, a staff member attempted to reapply a used diaper with visible drainage to a resident after catheter care, rather than using a clean diaper. These failures were verified through interviews with staff, including the Infection Preventionist, DON, and other facility personnel, who acknowledged the findings.
Failure to Implement Antibiotic Stewardship and Ensure Physician Notification
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as outlined in its policies and procedures. Specifically, the facility did not ensure that physicians were informed when residents received antibiotics without meeting McGeer's Criteria for true infection, as documented in the May and June 2025 surveillance logs. Two residents received antibiotics without meeting the criteria, and there was no documentation that their physicians were notified. Additionally, for two other residents, the facility did not follow up on urine laboratory results or communicate findings to the prescribers, nor was there documentation of physician notification or follow-up regarding repeat cultures or pending results. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that surveillance logs and line listings for antibiotic use and infections were missing for several months, and the current IP only began documenting antibiotic use as of mid-May 2025. The IP and DON confirmed the lack of documentation and inability to verify that appropriate notifications and follow-ups occurred. The facility's failure to maintain required records and ensure communication with physicians regarding antibiotic use and laboratory results led to the identified deficiency.
Failure to Obtain and Maintain Resident Advance Directive
Penalty
Summary
The facility failed to obtain and maintain a copy of an advance directive for one resident who was identified as having such a document upon admission. The resident, who had moderate cognitive impairment but was assessed as having the capacity to make decisions, indicated the existence of an advance directive on an acknowledgement form. The facility's policy required that a copy of the advance directive be requested and maintained in the resident's medical record. Documentation showed that the Social Service department requested the document and left a voicemail for the resident's sister, but there was no evidence of further follow-up or that the document was ever obtained. Interviews with Social Service staff and review of the medical record confirmed that the required copy of the advance directive was not available in the resident's file. The Social Service department acknowledged that, according to facility policy, follow-up attempts should have been made and documented if the initial request was unsuccessful. The absence of the advance directive in the medical record was verified by both the Social Service staff and the facility's Administrator and DON during the survey.
Unattended Medication Cart Exposes Resident PHI
Penalty
Summary
The facility failed to safeguard residents' medical records and protect confidential health information as required by its own policies and procedures. Specifically, Medication Cart A was observed in a hallway with its computer monitor turned on and unattended, displaying resident information. During this time, a staff member and a resident were sitting nearby, and six other staff members walked past the cart, making the information visible to unauthorized individuals. The computer screen showed a resident's photo and medication information, and the cart was left without clear responsibility assigned for its supervision. Interviews with staff revealed that the expectation was for the computer monitor to be locked or logged off when the medication cart was left unattended to ensure privacy. The DON confirmed that all PHI should be covered and that licensed nurses are responsible for logging off the computer when leaving the cart. The facility's policies require all personnel to manage and protect resident information to prevent unauthorized disclosure, but these procedures were not followed in this instance.
Failure to Revise Care Plans for Changes in Condition and New Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were revised to reflect their current care needs and interventions. For one resident with renal insufficiency undergoing dialysis, a change in condition was documented when the resident's right arm became swollen and the dialysis site exhibited green discharge. Although the care plan included monitoring and reporting signs of infection, it was not updated to specifically address this new change in condition. Both the ADON and DON confirmed that the care plan was not revised following the incident. For another resident with a respiratory problem, the care plan addressed difficulty breathing but did not include the administration of oxygen as an intervention, despite a physician's order for oxygen use as needed for shortness of breath. The resident was observed with a portable oxygen tank, and staff verified the existence of the physician's order, but acknowledged that the care plan had not been updated to include this intervention. The DON confirmed these findings during a review.
Improper Storage and Overflow of Garbage Dumpsters
Penalty
Summary
The facility failed to properly store garbage in accordance with its own policies and the USDA Food Code. During an observation with the Maintenance Director, two out of three outdoor garbage dumpsters were found to be overfilled, preventing the lids from fully closing. Additionally, trash items such as used gloves, paper, masks, corn, and condiment packets were scattered around the dumpsters. The Maintenance Director acknowledged that the lids could not close due to the excess trash inside. These findings were confirmed in interviews with the DON, Administrator, and DSS, who acknowledged the situation. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Facility Assessment Lacks Required Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure that its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. The assessment also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. This was identified through interviews and a review of facility documents, which showed that the Facility Assessment dated 7/1/24 did not reflect the updated CMS guidance issued in June 2024. During an interview and document review, the Administrator confirmed that he was unaware of the new CMS requirements and acknowledged that the Facility Assessment had not been updated accordingly. The Administrator verified that there was no evidence of active involvement from the required parties in developing the assessment, nor were there plans addressing recruitment, retention, or contingency staffing needs included in the document.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, resulting in discrepancies in physician orders, medication administration records, and therapy documentation. For one resident, the physician's order for tube feeding did not specify a start time, leading to inconsistent administration of enteral nutrition. Observations showed the resident's feeding pump was turned off at times, and staff interviews confirmed that all enteral feedings were typically started at a set time, despite the lack of a specified start time in the order. Both nursing staff and the DON verified that the order was incomplete and should have included this critical detail. Another resident's medical record contained inaccurate RNA documentation. The active and passive range of motion interventions, as well as the application of a hand splint, were documented with a code indicating 'Not Applicable' instead of the correct code for resident refusal. The RNA staff member explained that this miscoding was due to CNA documentation practices, which could not be overridden by RNA staff, and acknowledged this was an ongoing issue. This resulted in the resident's therapy interventions not being accurately reflected in the medical record. A third resident's medication administration record (MAR) was found to be inaccurate regarding the administration of oxycodone. The controlled drug record showed the removal of a 15 mg dose at specific times, but the MAR indicated that a 10 mg dose was administered at one of those times, and the 15 mg dose was documented as given before it was actually removed from storage. The DON confirmed that the process required documentation on both the controlled drug record and the MAR, and acknowledged the discrepancies found in the records.
Failure to Implement Ordered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as ordered for one resident with a history of multiple falls and moderately impaired cognition. Despite physician orders and care plan interventions specifying that floor mats should be placed on both sides of the resident's bed, observations on multiple occasions revealed that only one floor mat was in use, with the other mat found against the wall and not positioned as required. Staff interviews confirmed awareness of the resident's fall risk and the need for bilateral floor mats, yet the intervention was not consistently implemented. Medical record reviews showed that the resident had experienced multiple falls, leading to specific recommendations and orders for the use of floor mats on both sides of the bed. The facility's policy required staff to identify and implement individualized fall prevention measures, but these were not followed in this case. Both nursing and administrative staff acknowledged that the floor mats should have been in place as ordered, confirming the deficiency in adhering to the prescribed fall prevention interventions.
Failure to Assess and Manage Pain According to Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services for a resident requiring pain management by not conducting a complete pain assessment prior to administering pain medication and by not following the physician's orders for pain management. According to the facility's pain management policy, staff are required to reassess pain at regular intervals and document pain characteristics such as frequency, duration, intensity, location, and factors that aggravate or alleviate the pain. However, medical record review revealed that for multiple instances when the resident reported moderate to severe pain (pain levels 5-8), acetaminophen was administered instead of the prescribed hydrocodone-acetaminophen for pain levels above 3, and there was no documentation of pain characteristics or assessment prior to medication administration. Interviews with LVNs and review of the medical record confirmed the absence of required documentation regarding the resident's pain, including its location, characteristics, and related factors. Staff were unable to locate this documentation and acknowledged that the correct medication was not administered according to the physician's orders for higher pain levels. The DON was informed of these findings and acknowledged the deficiencies in pain assessment and medication administration for the resident.
Inaccurate and Incomplete Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies related to documentation of falls, change in condition, and treatment administration. For one resident, after experiencing a fall, the licensed nurse completed a Change in Condition Evaluation but documented vital signs that were taken hours or days before the incident, rather than obtaining and recording new vital signs as required. Additionally, the same resident's fall risk assessment was completed inaccurately, omitting relevant medical history and medication use, and incorrectly indicating no risk for falls. The neurological assessment documentation was also inconsistent, with entries recorded after the resident had already been transferred to an acute care hospital. The facility's policies and procedures require that all incidents, accidents, and changes in condition be thoroughly documented, including the date, time, and assessment data. However, the review found that the required observations and assessments were either incomplete or inaccurately recorded. The Director of Nursing confirmed that the documentation did not meet facility standards and that the necessary information, such as vital signs and fall risk factors, was missing or incorrect in the resident's records. For another resident, the Treatment Administration Record (TAR) was found to be incomplete, with several days lacking documentation of a prescribed wound care treatment. The nurse responsible acknowledged that the treatment had been performed but was not documented at the time, as required by facility policy. This lapse in documentation resulted in an incomplete medical record for the resident.
Incomplete Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented, which could potentially impact the resident's care needs. The medical record review revealed missing documentation on the Treatment Administration Record (TAR) for various physician's orders related to wound care and other treatments. Specifically, there were gaps in documentation for wound care on multiple dates for the resident's right buttock, right dorsal foot, right heel, and right lateral malleolus. Additionally, there was missing documentation for orders to apply a left knee immobilizer, monitor left lower extremity pitting edema, and offload the right heel using pillows. During an interview, RN 4 confirmed the missing documentation and stated that the TAR should have been completed by the licensed nurses. The Director of Nursing (DON) was informed and acknowledged the findings. The lack of documentation on the TAR for the specified dates and shifts indicates a failure in maintaining complete and accurate medical records for the resident, as required by professional standards.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident, specifically by not ensuring the resident's call light was within reach. This deficiency was identified during an observation where the resident was seen screaming and asking for assistance. The resident expressed frustration during an interview, stating that it was difficult to get help because the call light was not accessible, forcing them to yell for assistance, which often went unanswered. The resident's medical record indicated that they were usually able to make themselves understood and understand others. However, during the observation, the call light was found clipped to the head of the bed, out of the resident's reach. A Licensed Vocational Nurse (LVN) confirmed the call light's inaccessibility and subsequently placed it within the resident's reach, instructing them on its use. This oversight had the potential to impact the resident's psychosocial well-being and delay the provision of care.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure (P&P) for reporting suspected abuse in a timely manner, as required by section 1150B of the Act. An incident involving alleged staff-to-resident abuse occurred on 11/22/24, with Resident 4 as the alleged victim and LVN 3 as the alleged abuser. Despite the incident being reported internally to the Administrator, Director of Nursing (DON), and RN 1 on the same day, the facility did not report the allegation to the California Department of Public Health (CDPH) until 11/27/24, five days after the incident. This delay was contrary to the facility's P&P, which mandates immediate reporting, or within two hours if the alleged violation involves abuse. Interviews conducted with Resident 4, LVN 3, RN 1, and DON 1 confirmed the timeline of the incident and the delay in reporting. Resident 4 reported the incident to RN 1 on the day it occurred, and both LVN 3 and RN 1 confirmed they informed the DON and Administrator on the same day. However, the DON did not fax the SOC 341 form to the CDPH until 11/27/24. This failure to report the incident in a timely manner posed a risk of continued abuse and highlighted a significant lapse in the facility's adherence to its own policies and regulatory requirements.
Failure to Notify Physician of Resident's Weight Loss
Penalty
Summary
The facility failed to notify the physician of a resident's significant weight loss, which was a critical component of the resident's care plan. Resident 8, who had fluctuating capacity to understand and make decisions, experienced a three-pound weight loss in one week. This weight loss was documented in the resident's Weight and Vitals summary, showing a decrease from 143 lbs to 140 lbs between 12/23/24 and 12/30/24. The care plan for Resident 8, dated 12/24/24, included interventions to monitor, record, and report significant weight loss to the physician, which was not adhered to. Interviews with facility staff, including an LVN and an RN, confirmed that the physician was not notified of the weight loss as required by the care plan. The RN acknowledged that the resident had episodes of poor oral intake and confirmed the weight loss. The Director of Nursing was informed of these findings and acknowledged the oversight. This failure to notify the physician as per the care plan had the potential to negatively affect the resident's health and well-being.
Infection Control Deficiency Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate infection control practices were implemented, as evidenced by an incident involving CNA 3. During an observation, CNA 3 was seen removing soiled sheets and towels from a resident's room, disposing of his gloves, and then leaving the room without performing hand hygiene. This action was contrary to the facility's policy and procedure (P&P) on hand hygiene, which mandates hand hygiene immediately after glove removal to prevent the spread of healthcare-associated infections. The incident involved Resident 7, who was capable of understanding and making medical decisions. CNA 3 admitted to changing the resident's soiled brief and cleaning him up but failed to perform hand hygiene due to being in a hurry. The facility's P&P, revised in October 2023, emphasizes hand hygiene as the primary means to prevent infection spread, highlighting the importance of this practice. The deficiency was acknowledged by the Administrator, Director of Staff Development (DSD), and Infection Preventionist (IP) upon being informed of the findings.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not administering scheduled morning medications within the required timeframe. According to the facility's policy and procedure, medications should be administered within one hour of their prescribed time. However, on the morning of the survey, a resident reported that their blood pressure was taken at 0738 hours, showing a high reading, but their morning medications had not yet been administered. The resident expressed frustration and had to call the nurse to receive their medications. Observations and interviews conducted later in the morning confirmed that the resident's medications, including losartan for hypertension, aspirin for CVA prophylaxis, and Voltaren gel for pain, were not administered until 1044 hours, well beyond the one-hour window. The LVN responsible for administering the medications acknowledged the delay, attributing it to distractions. The Director of Nursing also verified and acknowledged the findings, confirming the failure to adhere to the facility's medication administration policy.
Failure to Maintain Clean AC Units in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean air conditioning (AC) unit for one sampled resident and one non-sampled resident, which could potentially affect the residents' health and well-being. During an observation and interview with the Housekeeping Supervisor, it was revealed that the outside casing of the AC unit in every room was cleaned daily. However, a black ash residue was found on the air outlet blade of the AC unit in Room A, indicating it was dirty. The facility's Deep Clean Calendar for August 2024 showed that Room A was cleaned on August 5, 2024, and the Deep Clean Check Off List required the room to be sanitized, dusted, and dirt-free. Despite this, the Maintenance Director confirmed that the inside of the AC unit in Room A was not clean, with thick dust and calcified particles present, even though the AC filters were reportedly cleaned in January and June 2024. Additionally, during another observation and interview with the Maintenance Director, thick dust, stone-like dirt, and a rusty grill were found inside the AC unit for Room B. The Maintenance Director confirmed that the inside of the AC unit for Room B was not clean, despite records showing that the AC filters were cleaned in June 2024. The Administrator was informed of these findings and acknowledged the issues. These observations indicate a failure to adhere to the facility's policy and procedure for maintaining a clean and homelike environment, as outlined in their policy revised in February 2021.
Improper Discharge Process for a Resident
Penalty
Summary
The facility failed to ensure a proper discharge process for one of the sampled residents, identified as Resident 5. The facility's policy and procedure for transfer or discharge, dated October 2022, required that a member of the interdisciplinary team review the final post-discharge plan with the resident and family at least 24 hours before discharge. However, the review of Resident 5's records showed that the discharge process was not adequately documented. Although Resident 5 was discharged home with a plan for home health services, there was no information provided about the agency, contact, or phone number for these services. Additionally, the discharge instruction form was incomplete, lacking the resident or representative's signature, and there was no documentation of the discharge instructions being provided to Resident 5 or their representative. Interviews with the Assistant Director of Nursing (ADON) and RN 2 revealed that the facility's protocol for discharge was not followed. The ADON confirmed that there was no documentation of the discharge process for Resident 5, including the lack of a signed copy of the discharge instructions. The ADON also stated that if instructions were given over the telephone, the discharge instruction paper should be signed by at least two nurses to confirm it was given to the resident. The Administrator was informed of these findings, acknowledging the lack of proper documentation and adherence to the facility's discharge protocol.
Improper Administration of Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of oxycodone-acetaminophen. Resident 5 was prescribed this narcotic pain medication to be administered only for severe pain levels of 8-10 on a 0-10 pain scale. However, the medication was administered on multiple occasions when the resident's pain level was below the prescribed threshold. For instance, the medication was given when the resident reported pain levels of 2, 5, and 3, which were below the ordered parameters. The facility's policy and procedure for medication administration required that medications be administered in a safe and effective manner, including reading the medication label before administration. During an interview and medical record review, the Assistant Director of Nursing (ADON) and a registered nurse (RN) confirmed that the medication was administered contrary to the physician's order, which specified administration only for pain levels of 8-10. This oversight had the potential to expose the resident to unnecessary medication and its associated adverse effects, such as sedation, confusion, and constipation, as noted in the clinical drug information reference Lexicomp.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations during a survey. Food stored in the walk-in refrigerator was not labeled or dated, and there was a lack of monitoring for cool down temperatures of potentially hazardous foods, such as cooked ground beef. Additionally, various food items, including sliced meat and tomatoes, were found without proper labeling or covering, and personal staff items were improperly stored in the refrigerator. These lapses in food storage and labeling practices were confirmed by the Dietary Services Supervisor (DSS) during interviews. The facility also failed to maintain cleanliness and sanitation in the kitchen. Food contact surfaces were observed to be unclean, with crumbs, dirty knives, and soiled utensils present in food preparation areas. Juice dispenser nozzles were improperly stored, and cutting boards were heavily marred, making them difficult to clean effectively. The DSS acknowledged these issues and agreed that the cutting boards needed replacement. Furthermore, hair restraints were not worn by some kitchen staff and non-kitchen staff entering the kitchen, posing a risk of contamination. Additional deficiencies were noted in the manual ware washing process, where the water temperature was below the required level, and the proper two-compartment sink method was not followed. Maintenance tools, such as mops, were stored in unsanitary conditions, and nonfood contact surfaces, including fans and dishwashing carts, were found with residue and rust. The DSS and Maintenance Director confirmed these findings, with the latter admitting to a lack of maintenance logs for cleaning the fans.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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