Northvine Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 446 Arrowood Dr, Santa Rosa, California 95407
- CMS Provider Number
- 056259
- Inspections on file
- 40
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Northvine Postacute Care during CMS and state inspections, most recent first.
A resident with respiratory failure, recent pulmonary emboli, muscle weakness, and impaired mobility had MD orders and a care plan for skilled PT five times per week for four weeks, including therapeutic exercises, activities, neuro re-ed, gait training, and training. During a transition from a contracted rehab provider to in-house rehab, the facility ended its external contract and had only an OT available, with no PT on staff and a PTA not yet started. The OT confirmed that only OT services could be provided and that the resident did not receive the ordered PT. The DON verified the active PT order, and RNA staff reported the resident was not on the restorative list. The resident reported not having PT appointments despite expressing a need to walk, while facility policy required therapy to be scheduled per the treatment plan.
Multiple residents and staff reported and observed flies in common areas and resident rooms, with torn window screens found in several rooms. Flies were seen on fly paper, windowsills, and buzzing around, and residents expressed annoyance at their presence. The maintenance worker had no record of screen repairs or proactive pest prevention, and the administrator was unaware of the issue until informed.
Three pleather chairs in a hallway were found to be cracked, worn, and unable to be properly disinfected, with one used by a resident and another moved by a guest. The IP confirmed the chairs' poor condition and infection control concerns, stating the issue had been reported to the previous Administrator without action.
A resident with Alzheimer's disease and behavioral disturbances exhibited physical aggression toward two other residents when staff were unable to consistently implement or verbalize the care plan interventions designed to manage her aggression. Staff interviews revealed a lack of familiarity with the resident's triggers and care plan, and the resident was not removed from congested areas as required, resulting in multiple incidents of aggression.
Three residents with muscle weakness and personal care needs were observed to have long, jagged, and dirty fingernails, with some nails containing brown debris. Staff confirmed that nail care was inconsistent and not prioritized, despite facility policy requiring regular cleaning and trimming. One resident had scratches from self-inflicted nail injuries, and staff acknowledged the deficiency in providing necessary grooming assistance.
A resident with severe cognitive impairment and multiple diagnoses developed a UTI and experienced constipation, but nursing staff did not initiate or implement care plans for these conditions. Despite being prescribed antibiotics and having bowel care protocols in place, interventions were not documented or carried out, and staff acknowledged these omissions were not in line with facility policy.
The facility failed to follow professional standards for food safety, including serving sandwiches at unsafe temperatures, not monitoring food and storage temperatures, improper dishwashing and sanitation practices, and staff not wearing required protective clothing. These actions placed most residents at risk for foodborne illness.
Facility administration did not complete required kitchen repairs after a health inspection report identified a grease trap in disrepair and non-compliance with food safety codes. This inaction led to the suspension of the facility's food permit and interruption of food services for nearly all residents when wastewater overflowed in the kitchen.
The facility did not address a CDHS inspection report identifying a disrepair in the kitchen's grease trap, failing to include the issue in QAPI activities or initiate repairs. This inaction resulted in wastewater overflowing onto the kitchen floor and the suspension of the facility's Retail Food Permit, interrupting food services for nearly all residents.
The facility did not ensure an effective pest control program, resulting in rodent and fly infestations in both the offsite commissary kitchen and a temporary dietetic service space. Observations included chewed food packaging, rodent droppings, nesting materials, and flies present in food service areas, with improper storage and sanitation practices noted. These deficiencies had the potential to cause foodborne illness for nearly all residents receiving food from the kitchen.
A resident's abuse allegation was not reported to the appropriate agencies within the required 2-hour timeframe. The incident involved a staff member using vulgar language towards the resident, which was reported by the resident's brother-in-law. Despite the facility's policy, the report was delayed, and staff interviews confirmed the failure to adhere to reporting protocols.
A facility failed to suspend an unlicensed staff member accused of verbal abuse against a resident with muscle weakness and anxiety disorder. Despite the facility's policy requiring immediate suspension during abuse investigations, the staff member continued working, only being reassigned to another room. This action compromised the investigation and resident safety.
The facility failed to maintain an effective pest control program, leading to a fly infestation affecting residents' comfort and food safety. Flies were observed in residents' rooms and the kitchen, causing disturbances during meals and rest. Despite a pest control policy, the facility did not adequately address the fly issue, focusing instead on ants and rodents.
The facility failed to provide four residents with their Baseline Care Plans and medication lists upon admission, as required. This deficiency was confirmed through interviews with the residents and facility staff, revealing that the usual process was not followed due to the absence of social service staff.
A facility failed to follow the Restorative Nursing Assistant (RNA) process for a resident with hand contractures. The resident, dependent on staff for care, had a physician's order for splint application for 2 to 4 hours daily, but the RNA only applied it for 30 minutes. The Director of Rehabilitation confirmed the minimum effective time was 2 hours, and the RNA process, including documentation and meetings, was not followed, potentially risking further contracture.
A resident with depression and persistent mood disorder was not provided necessary behavioral health care services, despite exhibiting behaviors such as crying, self-isolation, and hallucinations. Staff were unable to determine the cause of her distress, and the facility lacked behavioral health services, leaving the resident's needs unmet.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, increasing the risk of MDRO transmission. Residents requiring wound care or with devices like Foley catheters and G-tubes were not placed on EBP, and staff were not trained. Additionally, a service technician entered the kitchen without a hairnet or beard cover, violating hygiene protocols.
A facility failed to notify the Ombudsman and provide an appropriate discharge notice when a resident with Alzheimer's and severe cognitive impairment was transferred to the ED. The Interim DON confirmed the oversight, and interviews revealed staff were unaware of the policy requiring Ombudsman notification. The facility's policy mandates notification within 24 to 48 hours, but this was not adhered to.
A facility failed to complete the MDS Discharge Assessment for a resident with Dementia and Alzheimer's Disease, who was mostly dependent on staff. The missing assessment was confirmed by the Interim Director of Nursing, and the MDS Coordinator acknowledged delays in MDS assessments, which could lead to inaccurate data. The facility's policy requires comprehensive assessments, which was not followed in this instance.
A resident experienced severe weight loss due to the facility's failure to notify the physician of the RD's recommendation for a nutritional supplement. Despite the RD's recommendation for Med Pass to aid in wound healing, the facility delayed implementation for nearly two months, resulting in continued weight loss. Communication breakdowns among staff contributed to the deficiency.
A facility failed to report an alleged abuse incident involving a resident with intact cognition and multiple diagnoses within the required 2-hour timeframe to CDPH, the Ombudsman, and the local PD. The incident occurred in the morning, but the local PD was notified later that afternoon, and the Ombudsman was informed days later. The facility's policy mandates immediate reporting of such incidents, which was not adhered to, as confirmed by the Administrator and Interim DON.
A resident with a complex medical history, including quadriplegia and bipolar disorder, was verbally abused by a staff member in an LTC facility. The staff member was recorded making derogatory remarks and threats, causing emotional distress to the resident. The facility's abuse prevention policy was not upheld, leading to this deficiency.
A facility failed to manage its phone system, leading to unanswered calls and communication breakdowns. This resulted in a resident not receiving Paxlovid for COVID-19 treatment for five days and a complainant unable to reach staff. The receptionist was unaware of the phone system's mailbox setup, and the facility's policy on phone answering was not effectively implemented.
Two residents experienced significant medication errors at the facility. One resident did not receive Paxlovid for COVID-19 due to a failure in pharmacy communication, while another received an incorrect dose of Duloxetine HCI, leading to distress and refusal of the correct dose. These incidents highlight a failure to adhere to medication administration policies.
A long-term care facility failed to provide a functioning call light system for two residents, one with muscle weakness and spinal cord disease, and another dependent on staff for personal care. Despite requests for a touch pad due to difficulty using the call button, no action was taken, leaving residents without a reliable means to call for assistance. Staff were unaware of the issues, and maintenance logs were not checked, leading to significant safety and communication concerns.
A resident with muscle weakness and spinal cord disease was allowed to vape in his room without supervision, contrary to the facility's smoking policy. Staff, including the SSD, ADM, CNAs, and LN, were aware of the resident's actions but did not enforce the policy, citing difficulty in getting the resident out of bed. The facility's policy prohibited smoking, including vaping, inside, yet the resident continued to vape indoors, exposing roommates to secondhand aerosol.
Two residents in an LTC facility had their attending physician changed without their consent, violating their right to choose. Despite being self-responsible, the residents were transferred to the care of the facility's Medical Director without documentation of their request or consent. Staff interviews confirmed the oversight, and facility policies were not followed.
A resident received an incorrect dosage of Duloxetine HCI Delayed Release from an RN, who administered 60 mg instead of the physician-ordered 30 mg. This error was discovered during a Care Conference when the resident expressed dissatisfaction with the physician's refusal to increase the dosage. The resident, admitted with conditions like sciatica and depression, refused the correct dosage after the error. Facility policies on medication administration were not followed.
A resident with a full code status unexpectedly expired, and the facility failed to follow its death protocol. An LVN pronounced the death instead of a registered nurse or physician, and staff did not perform CPR or call 911. Additionally, the mortuary was not informed about the need for an autopsy, contrary to the facility's policy for unexpected deaths.
Failure to Provide Ordered Physical Therapy During Rehab Service Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services, specifically PT, to a resident in accordance with physician orders and the care plan. Resident 1 was admitted with acute and chronic respiratory failure, recent pulmonary emboli, muscle weakness, and a need for assistance with personal care. The MDS dated 1/6/26 indicated no memory impairment. Physician orders dated 12/30/25 directed skilled PT services five times per week for four weeks, including therapeutic exercises, therapeutic activities, neuro re-education, gait training, and patient/caregiver training. The resident’s care plan, initiated the same day, identified generalized weakness, impaired functional mobility, balance deficits, and increased need for caregiver assistance, with interventions that included the same ordered PT services. During interviews and record review, surveyors found that these PT services were not provided. The Administrator reported that the facility ended its contract with the outside rehab provider at the start of the year and was transitioning to in-house rehab staff, with only one OT hired from the former contractor and a PTA scheduled to start later. The OT confirmed that since the contract ended, no PT, OT, or SLT staff from the outside provider had come to the facility and that, at the time of the survey, the facility could only provide OT services. The OT stated the facility did not have a PT, so the resident did not receive the ordered PT. The DON acknowledged the PT order in the electronic record and stated most of the resident’s PT was due during the transition period. The RNA staff reported the resident was not on the restorative list and had not been discharged from PT to restorative services. The resident reported needing PT to be able to walk, stated she had not had any PT appointments, and recalled only possibly seeing a therapist once with a promise that therapy would start soon. The facility’s policy on scheduling therapy services required that therapy be scheduled in accordance with the resident’s treatment plan, which did not occur for PT in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in common hallways and multiple resident rooms, as well as torn window screens in four resident rooms. Observations included a strip of fly paper with dead and live flies in one resident's room, flies seen flying in other rooms, and dead flies on windowsills. Several residents reported frequent fly activity in their rooms, expressing annoyance and concern. In one instance, a resident's bedside table contained an open urinal and partially eaten food, which could attract pests, and the window screen in that room was torn. The maintenance worker was unable to locate any work orders for window screen repairs and confirmed that pest prevention was not proactively addressed. The administrator was unaware of the fly problem until interviewed and acknowledged that flies in the facility posed a significant issue. The facility's policy stated that an ongoing pest control program should be maintained to keep the building free of insects, but observations and interviews indicated this was not effectively implemented.
Worn and Unsanitary Chairs Compromise Clean, Homelike Environment
Penalty
Summary
Three wooden chairs with pleather seats and armrests located in the Garden Hall were observed to be cracked, flaky, and worn-out, exposing discolored and coarse fabric fibers. These chairs were available for use by residents and guests, with one chair being moved into a resident room by a guest and another being used by a resident. The condition of the chairs was confirmed during an interview and observation with the Infection Preventionist (IP), who stated that the chairs were torn and had worn-out cushions. The IP identified the chairs as an infection control concern, noting that their condition prevented proper disinfection. The IP explained that if a resident who was wet sat in the chair, moisture could seep through the cushion, making it impossible to clean and disinfect. The IP also stated that she had reported the issue to the previous facility Administrator, but no action had been taken. Facility policies reviewed indicated that environmental surfaces should be disinfected regularly and that infection prevention measures should be instituted, but the condition of the chairs did not meet these standards.
Failure to Protect Residents from Aggressive Behavior Due to Inadequate Implementation of Care Plan
Penalty
Summary
The facility failed to protect residents from aggressive behavior exhibited by a resident with Alzheimer's disease and dementia with behavioral disturbance. This resident had a documented history of striking, spitting, grabbing, refusing care, and throwing objects, with behaviors escalating in areas of increased stimulation or congestion. Despite these known behaviors and a care plan intervention to remove the resident from overstimulating environments, staff were unable to consistently articulate or implement the care plan strategies to manage the resident's aggression. On two separate occasions, the resident became physically aggressive with other residents. In one incident, the resident hit another resident when their wheelchairs became stuck together in a hallway. In another, the resident struck a different resident with a piece of paper while being moved through a congested area. Staff present during these incidents attempted to manage the situation but were unable to prevent the aggressive acts. Interviews with staff revealed a lack of familiarity with the resident's specific triggers and care plan interventions, with several staff members stating they simply tried to keep a close eye on the resident or distract her when agitated. Record review and staff interviews confirmed that the care plan included removing the resident from areas of increased stimulation to minimize agitation, but this intervention was not consistently followed. The facility's abuse and neglect policy required staff to be knowledgeable about residents' care needs and appropriate interventions for aggressive behaviors, but staff assignments changed daily and not all staff were aware of or able to verbalize the care plan. Leadership discussed the resident's behavior after the incidents, but there was no clear plan communicated to manage the aggression toward other residents.
Failure to Provide Adequate Nail Care and Grooming
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living, specifically in maintaining good grooming and nail care, for three residents who required help due to generalized muscle weakness and the need for personal care. Observations revealed that all three residents had long, jagged, and dirty fingernails, with some nails having brown debris underneath. One resident was noted to have multiple scratches on her forearm caused by scratching herself, and staff confirmed that nail care had not been provided as needed. Interviews with staff, including a CNA and the DON, confirmed that nail care was not consistently performed and was often deprioritized when staff were busy. The facility's own policy required regular cleaning and trimming of nails to prevent skin problems and injuries, but this was not followed. The lack of proper nail care was directly observed and acknowledged by staff, and records confirmed the residents' need for assistance with personal care.
Failure to Initiate and Implement Resident-Centered Care Plans for UTI and Constipation
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate and implement resident-centered care plans for a resident who developed a urinary tract infection (UTI) and experienced constipation. The resident, who had a history of hemiplegia, hemiparesis, vascular dementia, anxiety, and muscle weakness, was admitted with significant cognitive impairment. After leaving the facility with her sister, the resident was hospitalized for stomach pain and diagnosed with an acute UTI, receiving treatment before returning to the facility. Despite being prescribed antibiotics for the UTI, nursing staff did not initiate a care plan specific to the UTI or antibiotic treatment, as confirmed by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). Both acknowledged that a care plan was not created, which was not in line with facility policy, and that typical interventions such as increased hydration and monitoring for systemic infection were not formally directed. Additionally, the resident experienced three days without a bowel movement, but no bowel care medications were administered as per the facility's bowel protocol. The care plan for constipation included interventions such as administering Milk of Magnesia and Dulcolax suppository if needed, but these were not implemented or documented. The DON was unable to confirm whether the resident received bowel care management or if it was simply not documented. The LVN stated that bowel care interventions are triggered in the electronic health record after three days without a bowel movement, but there was no evidence that these interventions were carried out. Facility policies required that care plans be reviewed and updated when there is a significant change in a resident's condition, and that nursing staff adjust treatment based on ongoing assessment. In these instances, the lack of initiation and implementation of care plans for both the UTI and constipation represented a failure to provide resident-centered care as outlined in facility protocols.
Multiple Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that tuna and chicken salad sandwiches did not reach safe internal serving temperatures, with measurements showing temperatures well above the required 41°F for cold foods. The sandwiches were prepared hours before serving and attempts to cool them down were unsuccessful, as internal temperatures remained above safe levels. Additionally, the kitchen environment was excessively warm, with thermometer readings as high as 90°F, and food items such as bread were stored in these conditions. Staff were observed not following proper hygiene and food safety protocols. Food preparers and dishwashers were not wearing required aprons, and there was no touch-free garbage can by the handwashing sink, leading to potential hand contamination. Internal food temperatures were not consistently monitored prior to transporting meals to residents, and logs for cold storage and kitchen temperatures were not completed as required. Wet pots and pans were stacked without air drying, and the three-compartment sink manual dishwashing process was not performed correctly, with items not being fully submerged in sanitizer for the required time. Further deficiencies included improper use of the food production sink, where a dietary aide rinsed dirty pans instead of using the designated three-compartment sink. The facility's policies and procedures outlined correct practices for food cooling, dishwashing, sanitation, and storage, but these were not followed. These failures placed the majority of residents who received facility-prepared foods at risk for foodborne illness, as stated in the report.
Failure to Address Kitchen Repairs Leads to Food Service Interruption
Penalty
Summary
The facility administration failed to use its resources effectively and efficiently when it did not complete corrective actions following the County's Department of Health Services (CDHS) Site Review Inspection Report issued in October 2024. The report identified that the kitchen's grease trap was in disrepair and that the facility was not in compliance with the California Retail Food Code. Despite receiving the report, the necessary repairs were not made, and there was no communication about the outstanding issues during the transition between administrators. The Dietary Manager and Maintenance Manager were also aware of the report and the required repairs, but no follow-up actions were taken by the previous Administrator. As a result of these inactions, the CDHS suspended the facility's Retail Food Permit after discovering wastewater overflowing onto the kitchen floor from the unrepaired grease trap. This suspension required the facility to cease all food production operations, interrupting food services for 57 out of 59 residents who relied on the facility's kitchen. The deficiency was directly linked to the failure of the administration to address the cited kitchen repairs and ensure compliance with regulatory requirements.
Failure to Address Kitchen Code Violations in QAPI Led to Food Service Interruption
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not addressing code compliance corrective actions related to the physical environment of dietetic services, as required by the County Department of Health Services (CDHS). Despite receiving a Site Review Inspection Report from CDHS indicating that the kitchen's grease trap was in disrepair and not in compliance with the California Retail Food Code, the facility did not take action to repair the issue. The report was received by the previous Administrator, the Dietary Manager, and the Maintenance Manager, but was not discussed in QAPI meetings or addressed in any QAPI documentation. The previous Administrator did not communicate the findings or initiate repairs, and the issue was not handed over to the interim Administrator. As a result of the facility's inaction, wastewater overflowed onto the kitchen floor from the grease trap, leading to a CDHS inspection and the immediate suspension of the facility's Retail Food Permit. This action required the facility to cease all food production operations, interrupting food services for 57 out of 59 residents who relied on the facility's kitchen. Review of facility policy confirmed that the QAPI committee is responsible for addressing such issues, but there was no evidence that the CDHS inspection report or required kitchen repairs were ever incorporated into the QAPI process.
Failure to Maintain Effective Pest Control in Food Preparation Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in evidence of rodent and fly infestations in areas where resident food was prepared and stored. All resident food was being prepared in an offsite commissary kitchen due to remodeling of the onsite kitchen. During inspections and interviews, staff and county health inspectors observed chewed food packaging, rodent droppings, and a hole in the ceiling of the commissary kitchen, indicating active rodent activity. Multiple dirty rodent traps and nesting materials were also found, and pest control reports confirmed significant rodent feces and nesting on top of refrigeration units. Additionally, a fly infestation was observed in the temporary dietetic service space, which was formerly the staff breakroom. Flies were seen on light fixtures, walls, and windowsills, and food items were improperly stored on the windowsill. The area lacked a lidded garbage can, and the screen on the window was damaged, allowing insect entry. The kitchen door was also found propped open due to heat, and there was no screen door, further facilitating the entry of pests. Facility policies required ongoing pest control, proper screening of doors and windows, and routine sanitation, but these were not consistently followed. Staff were not aware if the offsite commissary had a pest mitigation program, and there was a lack of communication with the kitchen owner regarding pest control. These failures had the potential to cause foodborne illness for nearly all residents receiving food from the facility's kitchen.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to the appropriate agencies within the required 2-hour timeframe after the allegation was made. This involved a resident who was dependent on staff for most of his care, except for eating and oral hygiene, and had intact cognition. The incident occurred when the resident's brother-in-law reported to a licensed staff member that an unlicensed staff member used vulgar language towards the resident. Despite the facility's policy requiring immediate reporting of such allegations, the report was not made to the state, ombudsman, and local police department within the stipulated time. Interviews with staff, including unlicensed staff, a licensed nurse, the administrator, and the director of nursing, confirmed that the use of vulgar language constituted verbal abuse and should have been reported promptly. The administrator and director of nursing acknowledged that the facility's policy on abuse reporting was not followed, which could potentially put the resident's safety at risk. The facility's policy, updated in February 2024, mandates that alleged violations of abuse, neglect, exploitation, or mistreatment be reported to the proper agencies as per regulations.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident when an unlicensed staff member, accused of verbal abuse, was allowed to continue working during the investigation of the abuse allegation. The incident involved a resident who was admitted with diagnoses of muscle weakness and anxiety disorder, and who had intact cognition but required substantial assistance with care. The alleged verbal abuse occurred on 11/12/24, but the staff member was not suspended immediately as per the facility's policy. Instead, the staff member was only reassigned to another room, which did not align with the facility's procedures for handling such allegations. The facility's policy, updated in February 2024, clearly states that any employee accused of resident abuse should be suspended immediately pending the outcome of the investigation. Both the Administrator and the Director of Nursing confirmed that the staff member was not suspended immediately, acknowledging that this could compromise the investigation and put resident safety at risk. The failure to adhere to the policy reduced the facility's ability to protect the resident from further potential abuse while the investigation was ongoing.
Fly Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation throughout the premises. Observations and interviews revealed that flies were present in multiple residents' rooms, causing discomfort and disturbance during meals and rest. Resident 30, who had a right foot ulcer, reported a persistent fly issue and had resorted to using a plug-in bug trap and sticky fly paper, both of which were filled with dead flies. Other residents, such as Resident 13 and Resident 108, also experienced fly problems, with flies landing on clothing and food, prompting them to use personal fly swatters. The presence of flies was not limited to resident rooms but extended to the kitchen, where flies were observed on food carts and near the dishwasher, raising concerns about potential food contamination. Interviews with staff, including the Administrator and various nursing staff, confirmed the ongoing fly issue, particularly in the [NAME] Hall and kitchen areas. The Administrator acknowledged the problem and mentioned that the pest control company attributed the fly increase to nearby compost but had not taken measures to address flies specifically, focusing instead on ants and rodents. A pest control report recommended keeping a back door closed to prevent fly entry, but the facility's pest control policy, dated 4/2018, was not effectively implemented to ensure the premises were free of pests, compromising the health, safety, and comfort of residents and staff.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide four residents with a summary of their Baseline Plan of Care upon admission, which is a requirement to ensure effective communication and care management. Resident 45, who was admitted with multiple serious health conditions including respiratory failure and a tracheostomy, did not receive a copy of his Baseline Care Plan or a list of his medications. The resident confirmed during an interview that he had not received any paperwork or signed his Baseline Care Plan. Similarly, Resident 48, who had a history of cerebrovascular disease and other significant health issues, did not receive a copy of his Baseline Care Plan or medication list. The resident's representative, who was involved in care discussions, also did not sign or receive the necessary documentation. This lack of documentation was confirmed during interviews with the resident and facility staff. Residents 54 and 108 also did not receive their Baseline Care Plans or medication lists. Resident 54, who had been in a motorcycle accident resulting in multiple fractures, and Resident 108, who had a concussion and other injuries, both confirmed they had not received the required documentation. Interviews with facility staff revealed that the absence of social service staff contributed to the failure to provide these documents, as the usual process of having residents sign and receive copies was not followed.
Failure to Follow Restorative Nursing Assistant Process
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) process was followed for a resident, identified as Resident 6, who did not have a weekly summary completed by the RNA, and there were no monthly summary meetings documented in the resident's electronic medical chart. This oversight was discovered during interviews and record reviews. Resident 6, who was admitted with diagnoses including muscle weakness, chronic pain syndrome, and spinal cord disease, was dependent on staff for all care. The resident had a physician's order for the RNA to apply a splint to both hands for 2 to 4 hours daily, or as tolerated, to manage hand flexion contractures. During an observation and interview, Resident 6 reported that the RNA only applied the splint for about 30 minutes daily, contrary to the physician's order. The resident expressed concern that this limited time was ineffective and felt that his contracture was worsening. The Director of Rehabilitation (DOR) confirmed that the minimum effective time for the splint was 2 hours and that any inability to tolerate the prescribed time should have been reported for potential adjustment. However, there was no documentation of such reports or adjustments, and the RNA process, including monthly meetings and weekly summaries, was not followed. The Interim Director of Nursing (IDON) and RNA B both acknowledged that the physician's order was not followed, with RNA B admitting that Resident 6 had only been tolerating 40 minutes of splint use for about a month. Despite recognizing this change in the resident's status, RNA B did not focus on reporting it to the DOR. The facility's policy required daily and weekly documentation of the RNA process, including any changes in a resident's status, but these were not completed for Resident 6, potentially placing the resident at risk for further contracture and decreased quality of life.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for Resident 27, who was admitted with active diagnoses of depression and persistent mood disorder. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition, and she was dependent on staff for all care. Despite being on antipsychotic and antidepressant medications, Resident 27 exhibited behaviors such as self-isolation, withdrawal, and hallucinations, as documented in her electronic medication administration record (EMAR) for August, September, and October 2024. Observations and interviews revealed that Resident 27 frequently cried, and staff were unable to determine the cause of her distress. Certified Nursing Assistant (CNA) K and Licensed Nurse (LN) D noted that the resident cried regardless of the situation, and attempts to comfort her were only sometimes effective. The Minimum Data Set Coordinator (MDSC) and other staff confirmed that Resident 27 was not receiving behavioral health care services, despite her ongoing behaviors and the potential benefits of such services. Interviews with staff, including the Interim Director of Nursing (IDON), highlighted that Resident 27's lack of access to behavioral health care services was due to the absence of such services in the facility. The IDON and MDSC acknowledged that the resident's behaviors could be addressed with appropriate behavioral health care, which was not being provided. The facility's policy on behavioral health services emphasized the importance of prevention and treatment of mental disorders, yet Resident 27's needs were unmet, placing her at risk for emotional distress and unmet needs.
Failure to Implement EBP and Ensure Kitchen Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, which are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Specifically, two sampled residents and five unsampled residents who required dressing changes or had indwelling devices such as Foley catheters or G-tubes were not placed on EBP. The Interim Infection Preventionist (IIP) acknowledged that EBP had not been implemented due to the previous Infection Preventionist's departure, and staff had not been trained on EBP. Observations confirmed the absence of EBP signage and PPE carts outside residents' rooms. Resident 30, who had a diabetic pressure ulcer on his right heel, was not placed on EBP despite being seen by a wound nurse weekly. Similarly, Resident 212, with a stage four pressure ulcer and an indwelling catheter, and Resident 213, with a G-tube for enteral feeding, were not on EBP. The facility's policy, dated June 2022, outlined the need for EBP for residents with wounds or indwelling devices, regardless of MDRO colonization status, but this was not followed. Additionally, the facility failed to ensure proper attire for a service technician entering the kitchen, which could lead to food contamination. The technician entered the kitchen without a hairnet or beard cover, contrary to the facility's dress code policy. Observations noted hair in the kitchen handwashing sink and refrigerator, indicating lapses in hygiene practices. The Certified Dietary Manager confirmed the technician's attire was inappropriate and instructed him to wear the necessary protective gear.
Failure to Notify Ombudsman and Provide Discharge Notice
Penalty
Summary
The facility failed to provide an appropriate notice of discharge to a resident and their representative, and did not notify the Ombudsman when a resident was transferred to the emergency department. This deficiency was identified in the case of a resident with Alzheimer's Disease, Muscle Weakness, and Bipolar Disorder, who had severely impaired cognition. The Interim Director of Nursing confirmed that the Ombudsman was not notified when the resident was sent to the emergency department, and no notice of transfer was completed. The facility policy requires that a notice of transfer or discharge be provided to the resident or their representative, and the Ombudsman must be notified within 24 to 48 hours. Interviews with licensed staff revealed a lack of awareness regarding the facility's policy on notifying the Ombudsman during transfers and discharges. One licensed nurse stated she had never sent a copy of the notice of transfer to the Ombudsman, and another nurse was unaware of any policy requiring such notification. The facility's policy and procedure document, dated December 2016, specifies that an appropriate notice of discharge should be provided, including the contact information for the state long-term care Ombudsman. However, this policy was not followed in the case of the resident transferred to the emergency department.
Failure to Complete MDS Discharge Assessment for a Resident
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Discharge Assessment (DCA) for one of the sampled residents, identified as Resident 28. This oversight was discovered during a review of Resident 28's records, which showed that the MDS DCA was missing upon her discharge. Resident 28 was admitted with diagnoses of Dementia and Alzheimer's Disease, and her Brief Interview for Mental Status (BIMS) indicated severely impaired cognition, making her mostly dependent on staff for care. The Interim Director of Nursing confirmed the absence of the MDS DCA and emphasized the importance of timely MDS assessments to ensure accurate representation of residents' status. The Minimum Data Set Coordinator acknowledged that some MDS assessments were delayed, which could lead to inaccurate data and errors in reports. The MDSC highlighted the significance of completing the DCA, as it provides essential information for residents reintegrating into the community and for home health services to understand the resident's current status and needs. The facility's policy on MDS Accuracy, updated in 2023, mandates comprehensive assessments per the guidelines set by the Resident Assessment Instrument manual, which was not adhered to in this case.
Failure to Implement Nutritional Supplement Recommendation
Penalty
Summary
The facility failed to notify a resident's physician of the Registered Dietitian's (RD) recommendation for a nutritional supplement, Med Pass, for a resident who experienced severe weight loss. The resident, identified as Resident 30, lost 16 pounds in one month, which is an 8.65% unplanned weight loss. This weight loss was significant enough to potentially impact the healing of the resident's right heel ulcer and overall physical wellbeing. Despite the RD's recommendation for protein supplementation to aid in wound healing, the facility did not act promptly to implement these recommendations. Resident 30 was admitted with multiple diagnoses, including cellulitis, muscle weakness, and type two diabetes, and experienced a pattern of severe weight loss over several months. The RD's notes indicated a need for increased protein intake and recommended the use of Med Pass to provide additional calories and protein. However, the recommendation made on August 23 was not acted upon until October 17, resulting in a delay of nearly two months before the nutritional supplement was administered. Interviews with facility staff revealed a breakdown in communication and follow-through on the RD's recommendations. The Interim Director of Nursing (IDON) received the RD's recommendations but failed to ensure they were communicated effectively to the nursing staff responsible for contacting the resident's physician. The Licensed Nurse (LN) assigned to follow up on the recommendation did not do so, leading to the delay in implementing the necessary nutritional intervention for Resident 30.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required 2-hour timeframe to the California Department of Public Health (CDPH), the Ombudsman, and the local Police Department (PD). The incident involved a resident with intact cognition, who was dependent on staff for all care, and had been diagnosed with muscle weakness, chronic pain syndrome, and spinal cord disease. The alleged abuse by a licensed nurse occurred at approximately 10:00 a.m. on 8/31/24, but the facility only notified the local PD at 4:10 p.m. on the same day, missing the 2-hour reporting requirement. The Ombudsman was not informed until 9/5/24, and there was no indication that CDPH was notified at all. During interviews, both the Administrator and the Interim Director of Nursing confirmed the failure to meet the 2-hour reporting requirement as per the facility's policy. The facility's policy, titled 'Abuse and Neglect Prohibition Policy,' mandates that all alleged violations involving abuse or serious bodily injury be reported immediately, but not later than 2 hours. The Administrator acknowledged this as a weak report and emphasized the importance of timely reporting to ensure resident safety and prevent further abuse. The Interim Director of Nursing also verified the lack of timely reporting to the necessary agencies, highlighting the importance of such actions to ensure resident safety and prevent recurrence of abuse.
Resident Subjected to Verbal Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in emotional distress for the resident. The incident involved a staff member, Licensed Staff A, who was recorded berating, cursing, and demeaning the resident. This recording was brought to the attention of the facility's administrator by another staff member, Licensed Staff B, who described the tone as badgering and filled with derogatory comments. The administrator confirmed the content of the recording, which included Licensed Staff A making derogatory remarks about the resident's bipolar disorder and threatening that the only way the resident would leave the facility was with police intervention. The resident involved had a complex medical history, including quadriplegia, bipolar disorder, dysphagia, and blindness due to the absence of eyes, following a motor vehicle accident. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including verbal abuse, and outlines measures to prevent such incidents. However, the failure to protect the resident from verbal abuse by Licensed Staff A indicates a breach of this policy, leading to the resident's emotional distress as evidenced by crying during the incident.
Communication Breakdown Due to Unanswered Phones
Penalty
Summary
The facility failed to ensure proper access to residents by not adequately managing their phone system, which resulted in significant communication breakdowns. The phones in the facility were left unanswered, preventing a pharmacy from contacting nursing staff to clarify a physician's medication order. This led to a resident not receiving Paxlovid, a medication for treating mild-to-moderate COVID-19, for five days. Additionally, a confidential complainant was unable to reach staff to discuss an urgent matter due to the facility's phone system issues. The deficiency was observed when the facility's phone rang multiple times without being answered, eventually rolling over to a message system. The receptionist, who was responsible for answering calls during business hours, was unaware of the phone system's mailbox setup. The facility's phone system was new and rang throughout the facility, but neither the Administrator nor the Maintenance Director was aware that calls rolled over to a mailbox after a certain number of rings. The facility's policy indicated that phones should be answered from the business office or nurses' station, but this was not effectively implemented, leading to the communication failures.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two of the three sampled residents. Resident 5, who was diagnosed with conditions including autistic disorder, catatonic schizophrenia, and dementia, tested positive for COVID-19. Despite a physician's order for Paxlovid to treat COVID-19 symptoms, Resident 5 did not receive the medication from 9/17/24 through 9/21/24. The Interim Director of Nursing (DON) acknowledged that the previous DON was aware of the issue with the pharmacy not delivering the medication but did not follow through, resulting in Resident 5 not receiving the prescribed treatment. Resident 6, who had diagnoses including sciatica, chronic pain, migraines, and major depression, was prescribed Duloxetine HCI Delayed Release 30 mg daily. However, a licensed nurse administered 60 mg of the medication upon Resident 6's request, without a physician's order. This deviation from the prescribed dosage led to Resident 6 becoming upset and refusing to take the correct dose, potentially leading to withdrawal symptoms. The Interim DON discovered this error during Resident 6's Care Conference, where Resident 6 expressed dissatisfaction with the physician's refusal to increase the dosage. The facility's policies on medication administration and error prevention were not adhered to, as evidenced by these incidents. The policies require medications to be administered as prescribed, with verification of the right resident, medication, dosage, time, and method. The facility's job descriptions for nursing staff emphasize the importance of following physician orders and ensuring positive clinical outcomes, which were not achieved in these cases.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a functioning call light system was available for two residents, leading to significant concerns about their ability to communicate with staff in emergencies. Resident 1, who was admitted with diagnoses including muscle weakness, chronic pain syndrome, and spinal cord disease, had a call light that was not functioning properly. Despite having intact cognition, Resident 1 was dependent on staff for care and expressed frustration and anxiety over the inability to call for help, resorting to yelling to get staff attention. The call light had been malfunctioning for about a week and a half, and despite requests for a touch pad due to difficulty using the call button, no action had been taken. Resident 7, also dependent on staff for personal care, was found without a call light in his vicinity. Observations confirmed the absence of a call light near Resident 7's bed, table, or drawer, and staff interviews revealed that his call light might have been taken to replace Resident 1's broken one. This left Resident 7 without a means to call for assistance, posing a risk to his safety and care needs. Staff acknowledged the importance of a functioning call light system for resident safety and communication but failed to ensure its availability for both residents. Interviews with staff, including CNAs and the interim DON, highlighted a lack of awareness and communication regarding the malfunctioning call lights. The maintenance director was unaware of the request for a touch pad for Resident 1 and had not checked the maintenance logbook recently. The facility's policy emphasized the importance of timely response to call lights and reporting defective systems, yet these procedures were not followed, resulting in the deficiencies observed.
Failure to Enforce Smoking Policy for Resident Vaping Indoors
Penalty
Summary
The facility failed to implement its smoking policy by allowing a resident to vape inside his room without supervision, despite the policy prohibiting smoking, including vaping, inside the facility. The resident, who was admitted with diagnoses of muscle weakness, chronic pain syndrome, and spinal cord disease, was assessed to be safe to smoke only with supervision due to contractures of his hands. However, the resident was observed with vaping devices in his room and admitted to vaping there for months without staff supervision. Interviews with facility staff, including the Social Services Director, Administrator, Certified Nursing Assistants, and a Licensed Nurse, revealed that they were aware of the resident's vaping activities in his room. The staff acknowledged that vaping was considered smoking and was not allowed inside the facility, yet they did not enforce the policy. The staff indicated that the resident was not supervised while vaping, and it was challenging to get him out of bed, which contributed to the lack of enforcement. The facility's smoking policy, released in January 2023, clearly stated that smoking was only permitted in designated areas outside the facility. Despite this, the resident continued to vape in his room, exposing his roommates to secondhand vape aerosol, which could pose health risks. The report highlights the facility's failure to adhere to its smoking policy and ensure the safety of all residents by preventing indoor vaping.
Violation of Residents' Right to Choose Physician
Penalty
Summary
The facility failed to honor the rights of two residents to choose their attending physician, as required by regulations. Resident 1, who was admitted with diagnoses including muscle weakness and spinal cord disease, had intact cognition and was self-responsible. Resident 2, readmitted with muscle weakness and dysphagia, had moderately impaired cognition but was also self-responsible. Both residents were transferred to the care of the facility's Medical Director without their consent or request, violating their right to choose their own physician. Interviews with staff, including a Licensed Nurse, the Minimum Data Set Coordinator, the interim Director of Nursing, and the Administrator, confirmed that the residents' rights were not honored, and there was no documentation indicating that the residents requested or were informed about the change in their attending physician. The facility's policy and procedure documents, titled 'Resident's Rights' and 'Choice of Attending Physician,' clearly state that residents have the right to choose their attending physician and must be informed in writing of any changes. Despite this, there was no evidence in the residents' medical records, including progress notes, interdisciplinary notes, change of condition notes, or care plans, to indicate that the residents were involved in the decision-making process or that their consent was obtained. The Administrator mistakenly believed that the residents had requested the change, but this was not documented in their charts.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality for one of the sampled residents, Resident 6, when a licensed nurse, RN K, did not adhere to the rights of medication administration. Specifically, RN K administered Duloxetine HCI Delayed Release 60 mg to Resident 6, instead of the physician-ordered dose of 30 mg, upon the resident's request. This deviation from the prescribed dosage occurred without a change in the physician's order, as confirmed by the Interim Director of Nursing (DON) during interviews. The incident was discovered during Resident 6's Care Conference, where the resident expressed anger over the physician's refusal to increase the dosage, revealing that RN K had been administering the higher dose. Resident 6 was admitted with diagnoses including sciatica, chronic pain, migraines, major depression, and muscle weakness, and had a BIMS score indicating intact cognition. The resident's medication administration record showed that Duloxetine 30 mg was prescribed to be taken once daily, starting from a specified date. However, after receiving the incorrect dosage, Resident 6 refused to take the prescribed 30 mg dose until discharge. The facility's policies on medication administration and error prevention emphasize adherence to physician orders and verification of the correct medication details before administration, which were not followed in this case.
Failure to Follow Death Protocols for a Resident
Penalty
Summary
The facility failed to adhere to its policy on handling the death of a resident, specifically in the case of Resident 2. Resident 2, who had a diagnosis of muscle weakness and dysphagia, was readmitted to the facility and had a POLST indicating full code status, meaning CPR and full treatment were to be attempted in the event of a medical emergency. Despite this, when Resident 2 suddenly expired, the death was pronounced by an LVN instead of a registered nurse or physician, as required by the facility's policy. Additionally, the staff did not call 911 or perform CPR, which was contrary to the directives outlined in the POLST and the facility's procedures for handling unexpected deaths. Furthermore, the facility did not inform the mortuary about the need for an autopsy, which was necessary due to the unexpected nature of Resident 2's death. Interviews with various staff members, including the interim DON, revealed that the facility's policy required notifying the local police department and requesting an autopsy in such cases. The failure to follow these procedures could have resulted in missed diagnostic errors and missed opportunities to improve medical treatment. The interim DON confirmed that the facility's policy was not followed, as the LVN did not call 911, did not perform CPR, and did not request an autopsy, which could have led to an investigation to determine the cause of death.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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