Orange Healthcare & Wellness Centre, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 920 West La Veta Street, Orange, California 92868
- CMS Provider Number
- 055252
- Inspections on file
- 40
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Orange Healthcare & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident with intact cognition repeatedly requested a copy of his entire medical record using the facility’s PHI access forms, but the records were not provided in accordance with the facility’s policy requiring release within two working days. The MRD forwarded the request to the corporate legal team, which later approved the release, yet the MRD did not provide the records even after approval. The DON confirmed the request and acknowledged that access was not granted until prompted by a surveyor, while the resident’s family member reported not being informed of any fees or signing any refusal, in contrast to the Administrator’s undocumented claim of verbal notification. These events led to a failure to provide timely access to the resident’s medical records.
A resident's pressure ulcer progressed from Stage 3 to Stage 4 with muscle exposure, and the physician was not notified of this significant change in condition as required by facility policy. The DON confirmed that the health record lacked documentation of physician notification regarding the change in the pressure ulcer's stage.
Two residents' call lights were not answered in a timely manner despite being audible at the nurses station and observed by staff, resulting in delays of up to 20 minutes before assistance was provided. Staff interviews confirmed awareness of the call lights and the expectation for prompt response, but the facility's policy was not followed.
Licensed nurses did not document their initials on the TARs after providing prescribed skin treatments to two residents, resulting in incomplete and inaccurate medical records as required by facility policy. The DON confirmed that documentation was missing for several dates on the evening shift.
Staff failed to follow infection control protocols, including an LVN not wearing a gown during wound care for a resident with a stage four pressure injury under Enhanced Barrier Precautions, and another LVN wearing PPE in the hallway after preparing to enter a COVID-19 isolation room. These actions were not in accordance with facility policy and were confirmed by facility leadership.
A resident reported physical abuse by a CNA, but instead of being suspended as required by facility policy, the CNA was reassigned to a different duty during the investigation. Staff interviews confirmed the CNA remained on duty, and the Administrator acknowledged the failure to follow protocol.
The facility failed to maintain infection control practices, as staff neglected hand hygiene during wound care. A nurse did not wash hands before treating a resident's wound, and another nurse and CNA failed to perform hand hygiene before applying barrier cream and accessing clean linens. Both staff members acknowledged their lapses, and the facility's IP and DON confirmed the importance of hand hygiene to prevent disease transmission.
A resident with dysphagia did not receive oral care every shift as ordered, with care only provided during day and evening shifts on specific dates. Observations confirmed the resident's mouth was dirty, and the lips were dry with white patches. The facility's LVN, RN, and DON acknowledged the failure to adhere to the three-shift oral care requirement.
The facility failed to prevent UTIs for two residents with urinary catheters by improperly positioning drainage bags on their beds, visible from public areas, and not covering them with dignity bags. Additionally, staff did not monitor one resident's urine color, which was dark yellow-brown, contrary to facility policy requiring regular assessment of urinary output. The DON and a treatment nurse confirmed these deficiencies.
Two residents' medical records were found incomplete due to missing documentation in the TAR for assessments and care related to urinary drainage and Foley catheter maintenance. These omissions occurred on multiple dates and were confirmed by a treatment nurse and the DON.
A facility failed to report the results of an investigation into possible financial abuse of a resident by a family member within the required five working days. Despite the facility's policy, the investigation remained incomplete beyond the mandated timeline, posing a risk of unaddressed abuse. The resident involved had severe cognitive impairment, and the delay in reporting was confirmed by the DON and Administrator.
A facility failed to develop a care plan for a resident at risk of financial abuse by a family member, despite being informed of an investigation. The resident had severe cognitive impairment and lacked decision-making capacity, yet no care plan was documented to address this risk. The DON confirmed the absence of a care plan during a review.
Two residents' rooms in the facility were found to have peeling paint above the headboards, compromising the homelike environment. Observations confirmed by an LVN and a CNA revealed the deficiency, which was acknowledged by the DON, who noted that maintenance should be notified to fix the issue.
The facility failed to follow its policy and procedures for bed rail use, affecting five residents. Staff did not attempt alternative measures, obtain informed consent, or complete necessary assessments and care plans. This oversight was confirmed through staff interviews and medical record reviews.
The facility failed to ensure proper medication storage and temperature control in three medication rooms. Syringes for a discharged resident were not discarded, and oral medications were improperly stored with external patches. Refrigerator temperatures were significantly above the required range, risking medication efficacy. Staff confirmed the issues, and temperature checks were not consistently logged.
The facility failed to follow food safety and sanitation guidelines, including a lack of backflow prevention in a food prep sink, unclean drying racks, and improper storage of perishable food in a resident's room. These issues were confirmed by staff and posed a risk of contamination for 83 residents consuming food from the kitchen.
The facility failed to maintain an accurate infection control surveillance program, only including residents prescribed antimicrobial medications. In the laundry room, personal items were found on a clean table, violating infection control practices. Additionally, an RN entered a COVID-19 isolation room without wearing an N95 mask, despite knowing the requirement. These deficiencies were acknowledged by staff.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection. The Infection Preventionist did not document whether the criteria were met or notify physicians to reassess the need for antibiotics. Monthly reports showed cases of unnecessary antibiotic prescriptions, and the Director of Nursing acknowledged incomplete documentation.
The facility failed to conduct accurate entrapment assessments for residents using bed rails, as required by FDA guidelines. Six residents were observed with grab bars installed without proper documentation of entrapment assessments, potentially leading to serious injury or death. The Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars, and the DON was informed of these findings.
A resident with an indwelling urinary catheter was observed with the collection bag not placed inside a privacy bag, compromising dignity. A CNA confirmed the oversight, and the DON acknowledged the expectation for privacy bags to be used for all catheter collection bags.
The facility failed to ensure call lights were within reach for five residents, as required by their policy. Observations showed call lights were inaccessible for several residents, with staff confirming these findings. The DON acknowledged the issue, but no corrective actions were mentioned.
The facility failed to provide and maintain documentation of advance directives for several residents, as required by policy. This included not obtaining copies of existing directives and not offering information on formulating directives to residents or their representatives. These deficiencies were identified through interviews and medical record reviews, highlighting a lack of systematic follow-up and documentation.
The facility failed to maintain proper IV access and medication labeling for two residents. One resident's PICC line measurement was not documented upon admission, and another resident's IV antibiotic bag was unlabeled. These oversights were confirmed by staff and violated the facility's policies.
The facility failed to provide appropriate respiratory care for several residents, including undated and improperly stored oxygen and nebulizer equipment. Observations revealed that oxygen tubing was left on the floor, nebulizer masks were not stored in setup bags, and CPAP equipment was improperly handled. These actions were contrary to the facility's policy, which requires proper labeling and storage of respiratory equipment. The Director of Nursing confirmed these expectations, highlighting deficiencies in respiratory care practices.
A resident receiving Norco for pain management was not monitored for side effects, and non-pharmacological interventions were not consistently provided. Despite the facility's policy, these interventions ceased after a reassessment, and no side effect monitoring was ordered or conducted.
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record for Medication Carts 1 and 3. This deficiency was confirmed by the DON and indicates non-compliance with the facility's protocols for medication accountability.
A facility failed to monitor a resident's orthostatic blood pressure as ordered by the physician for a resident on risperidone, an antipsychotic medication. The medical records showed inconsistent documentation of blood pressure readings, with some marked as 'NA' without explanation. Interviews with the LVN and DON confirmed that the readings should have been obtained and compared to prevent potential adverse complications.
A resident was served Brussels sprouts and low-fat milk despite documented preferences for nonfat milk and a dislike for Brussels sprouts. The discrepancy was confirmed by an MDS Coordinator, who took steps to rectify the situation. The DON acknowledged the failure to honor the resident's preferences.
The facility failed to educate staff and visitors on safe food handling practices for food brought from outside, risking residents' exposure to foodborne illnesses. Interviews revealed that staff, including an RN and the DON, were unaware of or had not received training on these practices, and the DSD confirmed no training had been conducted.
The facility failed to maintain essential kitchen equipment and a low air loss mattress in proper working condition. The ice machine was unclean, with a damaged rubber strip and residue, and the walk-in freezer floor was not cleanable. A resident's low air loss mattress pump malfunctioned with a muted alarm, unnoticed by staff. These issues highlight lapses in equipment maintenance and monitoring.
A facility failed to document a medication reconciliation for a resident upon discharge, as required by its policies. The resident's medical records lacked evidence of a completed reconciliation, which was confirmed by the MDS Coordinator during a review. This oversight risked discrepancies in medication orders, potentially impacting the resident's well-being.
The facility failed to maintain accurate and complete POLST forms for two residents. One resident's POLST was incomplete, lacking information on an advance directive or health care agent. Another resident's POLST was outdated, not reflecting an executed advance directive. The SSD acknowledged these issues, and the DON confirmed the need for immediate updates.
The facility failed to provide written notification of room changes to two residents, violating their rights. Despite the facility's policy requiring written notice, staff only informed residents verbally. One resident lacked the capacity to make decisions, and the other was not given written notice, highlighting a failure in adhering to established procedures.
A resident with moderate cognitive impairment and multiple chronic conditions experienced an unwitnessed fall. Despite recommendations from the IDT to update the care plan with specific interventions, the facility failed to revise the care plan accordingly, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents, leading to potential risks. One resident's elopement evaluation was inconsistent with their history, while another resident's fall risk evaluation was inaccurately documented. The DON confirmed that nurses did not verify medical histories before completing assessments, resulting in incorrect evaluations.
A facility failed to provide visual privacy for a resident during care, compromising the resident's dignity. The resident's door was left halfway open, and no curtain was drawn while a CNA assisted the resident with their diaper, exposing the resident's left buttock. The resident was cognitively intact, and the Infection Preventionist acknowledged the need for privacy measures.
The facility failed to maintain infection control practices, as staff did not perform hand hygiene during resident care, and a basin with medical items was left unlabeled in a resident's room. These actions were confirmed by the Infection Preventionist, indicating lapses in adherence to infection control policies.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to implement its policy to provide timely access to medical records for one of three sampled residents, resulting in a violation of the resident’s right to access his records. The facility’s policy, revised 11/1/15, required the HIPAA Privacy Officer to provide a copy of the medical record within two working days after receiving a written request. A cognitively intact resident, with a BIMS score of 13, submitted a written request on 1/29/26 for a copy of his entire chart, documented on a “Resident Request for Access to Protected Health Information” form as a second request. A corresponding “Resident Records Request Intake” form from the same date indicated that the resident’s family had raised concerns. The resident reported in interview that he had signed several request forms since 1/2026 and submitted them to the Medical Records Director (MRD), but had not received the requested records after several months. The MRD confirmed that the resident requested his whole chart on 1/29/26 and stated that facility practice was to provide requested records within 48 to 72 business hours. After receiving the 1/29/26 request, the MRD sent it to the corporate legal team for review, noting there was no defined timeframe for legal review. An email from the corporate legal team’s Health Information Specialist dated 3/31/26 showed the request was approved for release, but the MRD acknowledged that he still did not provide the records to the resident. The DON verified the resident’s request and stated that the facility could not deny residents access to their medical records, acknowledging that the records were not provided until the surveyor’s investigation. The resident’s family member reported not being informed of any required fees and not signing any form declining to pay such fees, while the Administrator stated she had verbally informed them of required fees but had no documentation of their refusal to pay. These actions and inactions resulted in the resident not receiving timely access to his requested medical records in accordance with facility policy.
Failure to Notify Physician of Pressure Ulcer Progression
Penalty
Summary
The facility failed to notify the attending physician of a significant change in a resident's condition, specifically when a pressure ulcer progressed from Stage 3 to Stage 4. According to the facility's policy, the physician must be notified of any significant change in a resident's condition, including changes in pressure ulcer staging that require medical assessment and potential changes in the treatment plan. Review of the resident's health record showed that the pressure ulcer on the right gluteus was documented as Stage 3 on one date and then as Stage 4 with muscle exposure on a subsequent date. The wound consultant performed debridement, and the ulcer was reclassified as Stage 4. Despite these changes, there was no documentation that the physician was notified of the progression from Stage 3 to Stage 4. During an interview and concurrent record review, the DON confirmed that the physician should have been notified of the change in the pressure ulcer's stage and verified that the health record did not show such notification. This failure to notify the physician was identified for one of five sampled residents.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of two out of thirteen sampled residents by not ensuring that their call lights were answered in a timely manner. Observations revealed that for one resident with severe cognitive impairment who required substantial to maximum assistance with activities of daily living, the call light was activated and audible at the nurses station, but two staff members passed by the room without responding. The resident began screaming and was not assisted until 20 minutes later, when a CNA responded and confirmed the resident needed to be changed. In a separate incident, another resident activated the call light, which was also audible at the nurses station where two LVNs were present. An RNA passed by the room without responding, and the call light remained unanswered for 20 minutes until a CNA responded to remove the resident's lunch tray. Interviews with the involved staff confirmed they heard the call light but did not respond promptly, despite acknowledging that call lights should be answered right away. The facility's policy required prompt response to call lights, but this was not followed in these instances.
Failure to Document Treatments on TARs for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not ensuring that licensed nurses documented their initials on the Treatment Administration Records (TARs) after providing prescribed treatments. For one resident, the TAR for July did not show documentation that the evening shift nurse performed the ordered sacrum cleansing and application of barrier cream on four specific dates. For another resident, the TAR lacked documentation for the cleansing and barrier cream application to the sacrococcyx and buttocks on two dates during the evening shift. These omissions were identified through medical record review and confirmed by the Director of Nursing (DON). The facility's policy and procedure required that medical records be completed and corrected in a standardized manner, with entries recorded promptly as events occur. The DON verified that after providing treatment, licensed nurses are expected to document the care provided in the resident's medical record. The absence of nurse initials on the TARs indicated that the required documentation was not completed as per facility policy, resulting in incomplete and potentially inaccurate medical records for the affected residents.
Failure to Follow Infection Control Practices During Wound Care and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were followed as outlined in its own policies and procedures. During wound care for a resident with a stage four pressure injury, an LVN did not wear a gown as required under Enhanced Barrier Precautions (EBP), despite signage and supplies being available at the resident's door. The LVN confirmed awareness that the resident was on EBP for a wound but still did not don the appropriate personal protective equipment (PPE) during the procedure. In a separate incident, another LVN was observed wearing PPE in the hallway after preparing to enter a resident's room under COVID-19 isolation but did not enter the room, instead proceeding to the medication room while still wearing PPE. Facility policy specifies that gowns and gloves should not be routinely worn in the hallway and should only be donned immediately before high-contact care tasks. Both the Infection Preventionist and the Administrator confirmed these observations and acknowledged that the correct infection control practices were not followed.
Failure to Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse protocol during the investigation of an alleged physical abuse incident involving a resident and a CNA. According to the facility's policy, any staff member accused of abuse must be suspended and removed from the premises during the investigation. However, after a resident reported an allegation of physical abuse by a CNA to an LVN during the night shift, the CNA was not suspended but was instead reassigned to a different assignment for the remainder of the shift. The facility's investigation documents did not show evidence that the CNA was suspended immediately after the allegation was made. Interviews with staff confirmed that the CNA continued to work in the facility after the allegation, although not directly with the resident who made the report. The LVN and RN involved in the incident acknowledged that the CNA was not suspended and that the Administrator was not informed immediately after the allegation. The resident involved had the capacity to make their own medical decisions, and an assessment following the report showed no injury. The Administrator later acknowledged the findings of the investigation.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff neglecting to perform hand hygiene during wound care procedures. Treatment Nurse 1 was observed initiating wound care on a resident's left shin without washing hands before donning gloves. After cleaning the wound, the nurse removed the soiled gloves but did not perform hand hygiene before putting on a new pair of gloves to continue the treatment. This lapse in protocol was acknowledged by the nurse during an interview, who admitted the importance of hand hygiene in preventing infection spread. Similarly, Treatment Nurse 2 and a CNA were involved in another incident where hand hygiene was not performed before wound care. Treatment Nurse 2 applied barrier cream to a resident's buttock area without washing hands first. The CNA, after cleaning the resident's buttock area, attempted to access the clean linen cart with soiled gloves, only stopping when reminded to change gloves and perform hand hygiene. Both staff members acknowledged their failure to adhere to hand hygiene protocols during interviews. The facility's Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene before and between tasks to prevent disease transmission.
Failure to Provide Consistent Oral Care for Resident
Penalty
Summary
The facility failed to provide oral care every shift for a resident diagnosed with dysphagia, as per the medical orders. The resident was admitted with an order dated 10/17/24, specifying that oral care should be provided every shift using a swab/suction as appropriate. However, a review of the resident's oral hygiene interventions for January 2025 revealed that oral care was only provided during the day and evening shifts on specific dates, and not consistently every shift as ordered. Observations and interviews conducted with the facility's LVN and RN confirmed that the resident's oral care was not provided every shift. During an observation on 1/8/25, the LVN noted that the resident's mouth was dirty, and the lips were dry with white patches, indicating a lack of oral care. The RN acknowledged the importance of oral care in preventing mouth infections and sores, and the DON confirmed that the facility's three-shift system was not adhered to in providing the required oral care for the resident.
Failure in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling urinary catheters. Observations revealed that the urinary drainage bags for both residents were improperly positioned on top of their beds, visible from the hallway and patio, and not covered with dignity bags. This improper positioning risked urine flowing back into the bladder, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Additionally, the facility's policy required that catheter bags be kept below the bladder level and away from entrance doors, which was not adhered to in these cases. Furthermore, the staff failed to monitor and assess the urinary output of one resident, whose urine was observed to be dark yellow-brown, indicating a potential issue. The facility's policy mandated that nursing staff assess urinary drainage for signs of infection, including color, cloudiness, and other factors, every shift. However, this was not done, as evidenced by the lack of monitoring of the resident's urine color. The Director of Nursing (DON) and a treatment nurse acknowledged these deficiencies during interviews, confirming the failure to follow the facility's policies and procedures for catheter care.
Incomplete Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Treatment Administration Records (TAR) for two residents. For the first resident, there were missing entries regarding the assessment of urinary drainage for signs of infection and the provision of Foley catheter care on multiple dates in November 2024. These assessments and care were required every shift as per the physician's order dated October 4, 2024. The specific dates of missing documentation included November 3rd, 4th, 15th, and 28th, during various shifts. Similarly, for the second resident, the TAR lacked documentation for the assessment of urinary drainage, Foley catheter care, and monitoring for signs and symptoms of a urinary tract infection (UTI) on November 7th and 15th, 2024. These tasks were mandated by physician orders dated May 8, 2024, and July 23, 2024, to be performed every shift. The absence of these records was confirmed during interviews with Treatment Nurse 2 and the Director of Nursing (DON), who acknowledged the deficiencies in the residents' medical records.
Failure to Timely Report Financial Abuse Investigation
Penalty
Summary
The facility failed to provide a thorough investigation and report the results of an investigation regarding an allegation of possible financial abuse involving a resident's family member. The facility's policy and procedure on abuse reporting and investigations, revised in March 2018, requires that the results of all abuse investigations be reported to the California Department of Public Health (CDPH) Licensing and Certification Program within five working days of the reported allegation. However, the facility did not comply with this requirement for one of the two sampled residents, identified as Resident 2, who was involved in an allegation of financial abuse. Resident 2, who was admitted to the facility with severe cognitive impairment, was the subject of an open investigation for possible financial abuse by a family member, as informed by a Court Investigator. Despite the facility's Social Services Director completing a Report of Suspected Dependent Adult/Elder Abuse form on the date of the incident, the Director of Nursing (DON) confirmed during an interview that the facility's internal investigation was still ongoing beyond the five-day reporting requirement. The Administrator verified that the investigation had not been completed, indicating a failure to meet the mandated timeline for reporting the investigation results to the CDPH, thus posing a risk for potential abuse to remain unidentified and for the resident to go unprotected.
Failure to Address Financial Abuse Risk in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was at risk of financial abuse by a family member. Despite being informed by a Court Investigator about an open investigation into possible financial abuse, the facility did not create a care plan to address this risk. The facility's policy requires that care plans be updated to reflect new problems or changes in a resident's condition, but this was not done in this case. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1, and lacked the capacity to understand and make decisions. Despite these vulnerabilities, the facility did not document any care plan addressing the risk of financial abuse. The Director of Nursing confirmed the absence of such a care plan during a record review and interview, acknowledging the oversight.
Failure to Maintain Homelike Environment Due to Peeling Paint
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, as observed during a survey. Resident 3's room was found to have chipped paint on the wall above the headboard during an observation conducted on October 2, 2024. This observation was verified by LVN 2, who confirmed the presence of chipped paint in Resident 3's room. The facility's policy and procedure on Resident Rights Personal Property, revised in January 2012, emphasizes ensuring the quality of life for all residents by allowing them to create a homelike environment. Similarly, Resident B's room was observed to have peeling paint above the headboard. This was confirmed through interviews and observations with CNA 2 and LVN 3. The Director of Nursing (DON) was informed of these findings and acknowledged that peeling paint does not constitute a homelike environment. The DON stated that the process would involve notifying the maintenance department to address the issue.
Failure to Follow Bed Rail Policy and Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of bed rails, which are intended to be used as mobility enablers. The policy requires that before bed rails are used, staff must attempt appropriate alternatives, assess the resident for safety risks, obtain a physician's order, and secure informed consent from the resident or their representative. Additionally, a care plan should be initiated to address the use of bed rails. However, the facility did not complete these steps for five of the six residents reviewed for side rail use, potentially putting them at risk for serious injuries. For Resident 64, the facility did not document any attempts to use alternative measures before installing bilateral grab bars. There was no physician's order, informed consent, or care plan addressing the use of these grab bars, despite the resident using them for repositioning and turning. Similarly, Resident 45 had a physician's order and a care plan for the use of grab bars, but the facility failed to obtain informed consent. Resident 47 had a physician's order for grab bars, but the assessment did not indicate a need for them, and there was no care plan or informed consent documented. Resident 78 had a physician's order and a care plan for a left-side grab bar, but informed consent was not obtained. Lastly, Resident 601 had a physician's order for bilateral grab bars, but the assessment did not support their use, and there was no care plan or informed consent documented. These deficiencies were verified through interviews and medical record reviews with various staff members, including LVNs and the DON, who acknowledged the findings.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage in three medication storage rooms, leading to potential risks for residents. During an inspection, it was observed that syringes with needles labeled for a discharged resident were not discarded and remained on the medication room shelf. Additionally, oral lactulose solution was improperly stored next to lidocaine patches, violating the facility's policy of separating orally administered medications from externally used ones. The inspection also revealed that the temperatures of the medication refrigerators in all three medication rooms were out of the required range. In one room, the refrigerator temperature was recorded at 64 degrees Fahrenheit, while in another, it was 55 degrees Fahrenheit, and in the third, it was 50 degrees Fahrenheit. These temperatures were significantly higher than the required range of 36 to 46 degrees Fahrenheit for most medications stored, including insulin, antibiotics, and other injectable medications. The discrepancies in temperature logs and actual readings indicated a failure in monitoring and maintaining appropriate storage conditions. Interviews with staff, including the Infection Preventionist, Registered Nurses, and Licensed Vocational Nurses, confirmed the findings. The staff acknowledged the improper storage and temperature issues but were unable to provide explanations for the discrepancies. The facility's policy required regular checks and logging of refrigerator temperatures, but it was noted that the Pharmacy Nurse Consultant's checks were not logged, contributing to the oversight.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by three specific deficiencies. Firstly, a food preparation sink located near the DSS's office was found to lack backflow prevention, which is a requirement according to the USDA Food Code 2022. The Maintenance Assistant confirmed that the backflow prevention device had been removed, posing a risk of contamination. Secondly, a rack used for drying plate covers was observed to have a greasy residue and food debris, which violates the USDA Food Code's requirement for nonfood contact surfaces to be free of dirt and debris. The DSS acknowledged this finding during the inspection. Additionally, the facility did not comply with its own policy regarding perishable food brought in by visitors. A resident's room was found to contain perishable food items, such as a block of cheese, that were not stored in a refrigerator as required. The resident confirmed that the cheese needed refrigeration, and both LVN 1 and MDS Coordinator 2 acknowledged the oversight. These deficiencies posed a risk of cross-contamination and potential food poisoning for the 83 residents who consumed food from the facility's kitchen.
Infection Control Deficiencies in Surveillance, Laundry, and PPE Use
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program from January 2024 through August 2024. The surveillance was only conducted on residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. Residents who showed signs and symptoms of infection but were not prescribed antimicrobial medications were not included in the facility's infection control surveillance log. The Surveillance Data Collection Form was incomplete and inaccurate, failing to determine whether the resident's infection met the McGeer's criteria for true infection. The facility also failed to implement proper infection control practices in the laundry room. During an inspection, personal items such as eyeglasses and an employee phone were found on the clean table area where clean clothes or linens were folded. This was verified by Laundry Services Personnel 1, who acknowledged that these items should not be on the table used for folding clean laundry. Additionally, the facility did not ensure that RN 2 wore the appropriate PPE when entering a COVID-19 isolation room for a resident. RN 2 entered the room without wearing an N95 mask, despite knowing the requirement to do so. The resident was on COVID-19 isolation, and the required PPE included an N95 mask, face shield, goggles, gown, and gloves. This oversight was acknowledged by RN 2 and confirmed by IP 1.
Failure to Inform Physician of Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for one of the 19 final sampled residents and three non-sampled residents. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs and symptoms of an infection. However, the IP did not document whether the residents' conditions met McGeer's Criteria, and there was no evidence that the physician was notified to reassess the need for antibiotics. The facility's Monthly Antibiotic Stewardship Reports for June and July 2024 showed cases where residents were prescribed antibiotics without meeting the criteria for a true infection. Specifically, Residents 77, 87, and 603 were prescribed antibiotics without meeting the criteria, and there was no documentation of physician notification. Additionally, Resident 87's Surveillance Data Collection Form indicated that a urine culture was not obtained. The Director of Nursing (DON) acknowledged the findings and the incomplete and inaccurate documentation in the facility's Infection Control Surveillance Form.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, as required by the FDA's Hospital Bed System Dimensional and Assessment Guidance. The report highlights that six residents were observed with grab bars installed on their beds without proper documentation of entrapment assessments. This oversight could potentially lead to entrapment, serious injury, or death, especially for vulnerable populations such as the elderly or those with uncontrolled body movements. For Resident 64, the medical record review showed no physician's order for the use of bilateral bed grab bars, and the bed rail assessment indicated no siderail or assist bars were needed. However, observations confirmed the presence of grab bars, and the Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars. Similar issues were found with Residents 45, 47, 63, 78, and 601, where either the entrapment assessments were missing or the residents' preferences and needs were not accurately documented. The Maintenance Director acknowledged the lack of documentation for grab bar measurements, and the Director of Nursing (DON) was informed of these findings. The facility's policy requires annual bed measurement inspections to document entrapment areas, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure care was provided in a manner that promoted dignity and respect for a resident who was using an indwelling urinary catheter. During an initial tour of the facility, the resident was observed lying in bed with a urinary catheter draining into a collection bag that was not placed inside a privacy bag. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the collection bag should have been inside the privacy bag to maintain the resident's privacy. The resident, who was unable to make his own decisions, had a physician's order for a 16 Fr indwelling/suprapubic catheter due to benign prostatic hyperplasia. The Director of Nursing (DON) stated that it was expected for all catheter collection bags to be inside privacy bags to provide dignity to residents. The DON was informed of the findings and acknowledged the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for five residents, which could potentially impact their psychosocial well-being or delay the provision of care. The facility's policy and procedure (P&P) on the communication-call system, revised on January 1, 2012, mandates that call cords be placed within the resident's reach. However, observations and interviews revealed that the call lights for Residents 16, 38, 76, 39, and 61 were not accessible. Resident 16's call light was clipped on the edge of the head of the bed, out of reach. Resident 38's call light was found underneath the pillow, making it inaccessible. Resident 76's call light was placed on top of the bedside drawer, not within reach, despite the resident's need for dependent assistance for bed mobility. Further observations showed that Resident 39's call light button was on top of the bedside drawer, out of reach, and Resident 61's call light cord was clipped to the wall at the head of the bed, with the button hanging and inaccessible. Interviews with staff, including LVN 7, CNA 2, MDS Coordinator 3, and CNA 5, confirmed these findings. The Director of Nursing (DON) acknowledged the deficiencies, stating that call lights should be within residents' reach, but the report does not mention any corrective actions taken to address these issues.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to provide written information regarding advance directives and did not obtain or maintain copies of these directives in the medical records for five residents. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy required that upon admission, residents be informed of their rights to make medical decisions, including the formulation of advance directives. However, the facility did not adhere to this policy, resulting in incomplete documentation and follow-up regarding residents' advance directives. For Resident 17, the facility did not maintain a copy of the advance directive in the medical record, despite acknowledging its existence and requesting it. Similarly, Resident 76's records lacked documentation of whether the resident or their representative was offered information on formulating an advance directive. Resident 45's records showed an undated acknowledgment form indicating a request for more information on advance directives, but there was no evidence of follow-up or provision of the requested information. Resident 601's records indicated an advance directive was in place, but the facility failed to maintain a copy in the medical record. Additionally, Resident 351's records did not document whether an advance directive was offered to the resident's representative, despite the resident's severe cognitive impairment. These failures highlight the facility's lack of a systematic approach to ensuring residents' advance directives are documented and honored, potentially impacting the residents' healthcare decisions.
Deficiencies in IV Access and Medication Labeling
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous (IV) access for two residents. For Resident 600, the facility did not document the measurement of the peripherally inserted central catheter (PICC) line's external catheter length upon admission, as required by the facility's policy and procedure (P&P) for PICC dressing changes. This oversight was confirmed during an interview with RN 2, who acknowledged the absence of the required documentation in Resident 600's medical record. Resident 600 had orders for total parenteral nutrition (TPN) via the PICC line and weekly measurements of the arm circumference and external lumen catheter, but the initial measurement was not recorded. For Resident 89, the facility failed to properly label the IV antibiotic medication bag. During an observation, it was noted that Resident 89 was receiving an IV antibiotic at a specified rate, but the medication bag was neither labeled nor dated, contrary to the facility's P&P for administering intermittent infusions. RN 2 admitted to forgetting to label the medication bag. Resident 89 had a physician's order for cefoxitin sodium to be administered intravenously for an infection of the spine, but the lack of labeling was confirmed during a review with the Director of Nursing (DON).
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as observed during a survey. Resident 58's oxygen nasal cannula tubing was found undated, unlabeled, and not stored in a setup bag when not in use, contrary to the facility's policy. Additionally, the oxygen machine was left on while the resident was not in the room, with the nasal cannula left on the bed. Resident 351's nebulizer mask and tubing were also not stored in a setup bag, and there was no care plan in place for the use of nebulizer therapy, despite a physician's order for breathing treatment medication. Resident 352's oxygen tubing was observed touching the floor, which was verified by RN 2, who then replaced it with new tubing. Resident 75's nebulizer mask and tubing were undated and left on top of the nebulizer machine, with no physician's orders for medications requiring nebulizer use. Resident 69's CPAP mask was found touching the bedside table, and the tubing was undated, which was confirmed by the MDS Coordinator and the Director of Central Supply, who stated that the CPAP tubing should be dated and stored in a plastic bag. The facility's policy on oxygen therapy, revised in November 2017, requires that oxygen supplies be dated and stored safely. The Director of Nursing confirmed the expectation that all respiratory equipment should be labeled and stored properly when not in use. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident, identified as Resident 600, who was receiving narcotic pain medication. The facility did not monitor Resident 600 for side effects related to the use of Norco, a narcotic medication prescribed for moderate to severe pain. Additionally, the facility did not consistently implement non-pharmacological interventions for pain management, as required by their policy and procedure. These interventions were only provided until 9/3/24, despite the resident continuing to receive Norco on subsequent dates. During an interview and medical record review, RN 2 confirmed that non-pharmacological interventions should have been continued alongside the narcotic medication. However, these interventions were not reinstated after a 14-day reassessment of the resident's pain management. Furthermore, there was no physician's order to monitor for side effects of the Norco medication, nor was any monitoring completed. This oversight in pain management practices was identified as a deficiency by the surveyors.
Failure to Ensure Proper Accounting of Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record. This deficiency was observed during a medication cart inspection of Medication Carts 1 and 3. Specifically, the controlled drugs count record for Medication Cart 3 had missing signatures on several dates, including 8/21, 8/22, 9/1, and 9/7. Similarly, Medication Cart 1 had missing signatures on 8/6, 8/18, 8/22, 8/24, 8/31, and 9/1. These findings were verified by the respective LVNs during the inspection. The facility's policy and procedure, as well as the Narcotic Book Guide, require that a physical inventory of all controlled medications be conducted by two licensed nurses at each shift change, with both nurses signing the controlled drugs count record. However, the failure to consistently follow this procedure was confirmed by the Director of Nursing (DON) during an interview and document review. The absence of signatures indicates a lack of compliance with the facility's established protocols for medication accountability, potentially leading to drug diversion.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs by not monitoring the resident's orthostatic blood pressure as ordered by the physician. The resident was prescribed risperidone, an antipsychotic medication, and the physician had ordered weekly monitoring of the resident's orthostatic blood pressure in lying, sitting, and standing positions. However, the medical records showed that the blood pressure readings were not consistently documented, with some readings marked as 'NA' without explanation. Interviews with the LVN and the DON confirmed that the blood pressure readings should not have been documented as 'NA' and should have been obtained and compared as per the physician's order. The facility's policy required monitoring for orthostatic hypotension, especially for residents on antipsychotic medications, to prevent adverse complications. The failure to monitor the resident's orthostatic blood pressure as ordered had the potential to result in adverse complications from the medication.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 30, which is a violation of their dietary policy. Resident 30, who has the capacity to understand and make decisions, was served Brussels sprouts and low-fat milk for lunch, despite having documented preferences for nonfat milk and a dislike for Brussels sprouts. This discrepancy was observed during a lunch observation in Resident 30's room, where the meal tray did not align with the resident's stated preferences as indicated on the meal ticket. The issue was confirmed by MDS Coordinator 2, who acknowledged that Resident 30 should have been provided with an alternative vegetable. The MDS Coordinator took immediate steps to rectify the situation by asking Resident 30 for her choice of an alternative vegetable and providing her with nonfat milk. The Director of Nursing (DON) was later informed of the findings and acknowledged that the resident's food preferences and dislikes should have been honored, as per the facility's policy.
Lack of Safe Food Handling Education for Staff and Visitors
Penalty
Summary
The facility failed to ensure that both employees and visitors bringing food from outside were educated on safe food handling practices, posing a risk of foodborne illness to residents. The facility's policy titled 'Food Brought by Visitors,' revised in June 2018, included guidelines for safe food handling, reheating, and storage. However, interviews with staff revealed a lack of awareness and training on these practices. RN 2 was unable to confirm receiving any education on safe food handling and was unsure if visitors were informed about these practices. The Director of Staff Development (DSD) confirmed that no training had been provided to staff during her two-month tenure. Further interviews with the Director of Nursing (DON) and the DSD highlighted the absence of a structured approach to ensure compliance with the facility's policy. The DON could only specify that food should be clean and in a sealed container but could not elaborate on how safe food handling was enforced. The DSD verified that no training records existed for educating staff on safe food handling practices. This lack of education and enforcement of the policy created a potential risk for residents consuming food brought in by visitors.
Deficiencies in Equipment Maintenance and Monitoring
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper working condition, as observed during a survey. The ice machine in the kitchen was found to be unclean, with a rubber strip on the harvester curtain not intact and covered in a white residue identified as dried glue. The ice machine chute also had a grayish, white residue. The Maintenance Assistant, who cleaned the ice machine monthly, admitted to not following the manufacturer's cleaning instructions due to a language barrier and used an incorrect cleaning solution. Consequently, the ice machine was taken out of service. Additionally, the walk-in freezer floor was not in a cleanable condition. The floor had black anti-slip tape that was not intact, exposing a metal floor with a hard, thick brown residue resembling rust. The linoleum floor beyond the ramp was cracked and not intact, with a brown residue. The Maintenance Director was unaware of the condition of the freezer floor, indicating a lack of communication or oversight in maintenance procedures. The facility also failed to ensure the proper functioning of a low air loss mattress for a resident. The mattress pump had a red light blinking, indicating a malfunction, and the alarm was muted. Despite daily checks by an LVN, the malfunction went unnoticed until it was observed by the MDS Coordinator. The LVN was unaware of any issues with the mattress pump or muted alarms, suggesting a gap in monitoring and reporting procedures for essential medical equipment.
Failure to Document Medication Reconciliation at Discharge
Penalty
Summary
The facility failed to ensure a thorough and documented medication reconciliation for Resident 99 upon discharge. Resident 99 was admitted to the facility and later discharged home. A review of the facility's policies and procedures indicated that the discharge summary should include a comprehensive medication reconciliation, detailing the resident's drug therapy and any changes from pre-discharge to post-discharge medication regimens. However, upon reviewing Resident 99's medical records, there was no documented evidence that such a reconciliation had been completed at the time of discharge. During an interview and concurrent medical record review with the MDS Coordinator, it was confirmed that the discharge nurse was responsible for completing and documenting the medication reconciliation. Despite this responsibility, the records for Resident 99 did not reflect any such documentation, indicating a lapse in following the facility's discharge procedures. This oversight posed a risk of not identifying discrepancies in medication orders, potentially affecting the resident's well-being.
Incomplete and Outdated POLST Forms for Two Residents
Penalty
Summary
The facility failed to ensure the medical records for two residents were accurate and complete, specifically regarding their Physician Orders for Life-Sustaining Treatment (POLST) forms. For Resident 64, the POLST form was incomplete as it did not indicate whether the resident had an advance directive or a health care agent. This was acknowledged by the Social Services Director (SSD) during an interview and concurrent medical record review. For Resident 63, the POLST form was outdated and did not reflect the resident's advance directive, which had been executed and documented in the resident's progress notes. The SSD admitted that the nursing staff completed the POLST form and that she failed to inform them of the advance directive update or update the POLST herself. The Director of Nursing (DON) confirmed that the facility should have updated the POLST immediately upon obtaining the advance directive.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes to two residents, violating their rights. According to the facility's policy, residents and their representatives should receive timely advance written notice of any room or roommate changes, including the reasons for such changes. However, for two residents, this procedure was not followed. Resident 7, who was nonverbal and lacked the mental capacity to make decisions, did not have documentation showing that their representative was notified of the room change. Similarly, Resident 8, who had the mental capacity to make decisions, was not provided with written notice of the room change. Interviews with facility staff, including the Social Services Director (SSD) and the Admissions Director, revealed that the facility's practice was to inform residents and their families of room changes verbally, without providing written documentation. The SSD confirmed that there was no room change form used to document these changes, and the Admissions Director acknowledged that written notifications were not provided. This lack of adherence to the facility's policy resulted in the failure to properly notify Residents 7 and 8 of their room changes in writing.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect current assessments, placing the resident at risk for unmet medical and physical needs. The facility's policies require that after a change in condition, such as a fall, the licensed nurse must assess the situation, document it, and update the care plan accordingly. However, in the case of Resident 3, who had an unwitnessed fall resulting in head discoloration and pain, the care plan was not updated with the necessary goals and interventions recommended by the Interdisciplinary Team (IDT). Resident 3, who has moderate cognitive impairment and multiple diagnoses including dementia and chronic conditions, experienced a fall while attempting to go to the restroom. Despite the IDT's recommendations to implement neuro-checks, pain management, and environmental adjustments to prevent further falls, these were not incorporated into the resident's care plan. The Director of Nursing confirmed that the care plan was not updated as required, highlighting a lapse in following the facility's procedures for managing changes in a resident's condition.
Inaccurate Medical Records for Elopement and Fall Risk
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, leading to potential risks of elopement and falls. For one resident, the elopement evaluation was inconsistent with their history. Despite having a documented history of elopement, the evaluation on a recent date incorrectly indicated no risk of elopement. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the nurse responsible for the evaluation did not verify the resident's medical history before completing the assessment. Another resident's fall risk evaluation was inaccurately documented. The resident, who had a history of falls and several medical conditions that increased their fall risk, was given a fall risk score that did not reflect their true condition. The DON confirmed that the nurse had incorrectly answered specific items related to the resident's medical history and medications, resulting in an inaccurate fall risk score. These inaccuracies in medical records could lead to inadequate preventive measures being implemented for the residents.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure visual privacy for a resident during care, which posed a risk to the resident's dignity. The facility's policy and procedure on Resident Rights, revised on January 1, 2012, mandates that employees treat all residents with kindness, respect, and dignity, including ensuring privacy and confidentiality. On June 11, 2024, an observation was made where a resident's door was halfway open, and no curtain was pulled for privacy while a CNA was assisting the resident with their diaper, resulting in the resident's left buttock being exposed. The resident was cognitively intact, as indicated by a BIMS Summary Score of 15. The Infection Preventionist confirmed that the CNA should have pulled the curtain to provide privacy for the resident.
Infection Control Deficiencies in Hand Hygiene and Equipment Labeling
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not performing hand hygiene during resident care. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene after assisting a resident with a breakfast meal tray and before retrieving a clean towel. Another CNA failed to perform hand hygiene after assisting a resident with adjusting their diaper and before handling a soiled linen bin. These actions were observed and confirmed by the Infection Preventionist, who acknowledged that hand hygiene should have been performed in these instances. Additionally, the facility did not label a basin found on a common dresser table in a resident's room. The basin contained an opened tissue box, a towel, and a kidney basin, which were not labeled, potentially leading to the transmission of infection. The Infection Preventionist verified that the items should have been labeled to prevent infection spread. These deficiencies highlight lapses in adherence to the facility's infection control policies and procedures.
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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