Premier Care Center For Palm Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Springs, California.
- Location
- 2990 East Ramon Road, Palm Springs, California 92264
- CMS Provider Number
- 056328
- Inspections on file
- 46
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at Premier Care Center For Palm Springs during CMS and state inspections, most recent first.
A resident with multiple constipation-risk medications had no BM for several days, but staff did not act on PCC alerts, did not give ordered PRN bowel meds, and did not notify the MD. The resident later developed abdominal pain, fecal impaction, and imaging findings concerning for bowel ischemia before dying. The report also cites similar missed constipation interventions for several other residents, plus failures involving elevated BS, wounds, and edema.
Food items were found improperly labeled and stored in the kitchen, including multiple opened herbs and spices without open dates, opened ranch dressing and mayonnaise in a refrigerator without open dates, an opened bottle of sesame oil without an open date, and a package of roast beef kept past its use-by date. The ADS confirmed the labeling problems and stated the roast beef should have already been discarded; the RD later agreed the items should have been dated appropriately.
Incomplete Care Plans for Behavioral, Dental, and Oxygen Needs: The facility failed to develop individualized care plans for a resident with hallucinations, depression, and anxiety; three residents with dental concerns and denture problems; and three residents receiving oxygen. Records and staff interviews showed missing or untimely care plans despite diagnoses, physician orders, and observed conditions such as severe cognitive impairment, loose or absent dentures, chipped and blackened teeth, and continuous oxygen use.
Oxygen cannulas were not managed according to policy for three residents receiving O2 via nasal cannula. Two residents had tubing labeled with the same date and staff stated it had not been changed weekly, while another resident’s tubing was not dated when observed. Staff and the IP stated the cannulas should be changed every 7 days and dated in an identifiable fashion.
Pharmacy services were not carried out according to policy when a Shingrix vial labeled for a resident was left in the med refrigerator even though the resident had already completed the vaccine series. The facility also failed to document PRN controlled meds on the MAR for multiple residents, including hydrocodone-acetaminophen and lorazepam doses signed out on the count sheets but not recorded as administered. The DON stated these narcotic doses should be documented on the MAR to prevent drug diversion.
Medication storage practices were not followed when an IV med was stored with oral meds on a med cart, eye drops were stored with oral meds in another cart drawer, and several discontinued or completed treatment meds remained in treatment carts. An opened box of expired iodine prep pads was also found in a treatment cart. Staff stated the IV med should have been kept in the IV cart, eye drops should be stored separately from oral meds, and discontinued meds should have been removed from active supply.
Failure to Provide Dental Follow-Up and Denture Care: A resident had denture impressions completed but no documented dental follow-up, another resident had missing, broken, and decayed teeth with no dental consult despite staff observing the condition, and a third resident reported loose-fitting dentures with no documented oral/dental follow-up. Assessments and records did not reflect the oral concerns, and staff interviews confirmed the issues were observed but not escalated for dental services.
A facility's Administrator and governing body failed to ensure a QAPI plan addressed systemic issues with the bowel management program. Surveyors found the facility was not implementing the bowel management program or following the physician's order to address constipation, and an IJ was called after review of a resident's record showed the facility failed to carry out constipation interventions per policy and orders. The Administrator stated the QAPI committee met quarterly but had not identified bowel management issues until the survey team discovered the concern.
A hospice RN failed to follow EBP precautions while providing care to a resident with a suprapubic catheter, entering the room without gown and gloves, placing his bag on the bed, using shared equipment without disinfecting it, touching catheter tubing without gloves, and leaving without hand hygiene. In separate observations, two LPNs wiped a shared BP cuff with disinfectant wipes but did not keep the cuff wet for the required two-minute contact time, despite the facility’s expectation and the manufacturer’s instructions.
A resident with dementia, psychosis, depression, anxiety, and severe cognitive impairment received PRN lorazepam multiple times without documentation of the reason for use or any non-pharmacologic interventions before administration. The record also lacked documented informed consent for mirtazapine when it was first ordered, and the DON confirmed the missing documentation.
A resident who was cognitively intact did not receive a timely written transfer/discharge notice with appeal rights and Ombudsman contact information before discharge home, even though a NOMNC was issued. Another resident transferred to a GACH had an incomplete personal effects inventory, with no signed discharge section or documented evidence that belongings were turned over to the resident representative. The facility’s policy required timely written notice before transfer/discharge and a signed inventory confirming receipt of personal property.
A resident with the capacity to make decisions was found with cigarettes and a lighter stored in a bag at his bedside, despite a care plan directing that all smoking items be kept secured at the nursing station. An LVN confirmed the items were at bedside and said the resident could keep them there because he was independent, while the DON later stated smoking paraphernalia was supposed to be stored in the locked box at the nursing station.
Two residents were observed with water pitchers out of reach during multiple checks. One resident had heart failure, acute pulmonary edema, severe cognitive impairment, and care plan directions to encourage fluids and keep water in reach; the other had hemiplegia/hemiparesis after CVA, nutritional deficiency, severe cognitive impairment, and care plan directions to encourage hydration and keep needed items in reach. Staff stated water pitchers should always be in reach, and one CNA said the resident required assistance with hydration and meals.
Pain medication was administered outside the ordered pain scale for two residents. One resident with heart failure and left leg pain risk had hydrocodone-acetaminophen given for pain ratings that did not match the active PRN order, and another resident with polyneuropathy received hydrocodone-acetaminophen for pain ratings below the severe-pain threshold ordered by the MD. The IP and DON confirmed the medication should have been given according to the physician’s pain parameters.
Missed Required Physician Visits: A resident with hemiplegia/hemiparesis after cerebral infarction and nutritional deficiency, with severe cognitive impairment (BIMS 3), had no documented physician visits or total program of care assessments throughout the year. The DON confirmed the resident did not receive the required ongoing MD oversight, and the facility policy required physician review at least every 90 days and quarterly review of the resident’s total program of care.
Failure to Report Abnormal Lab Result: A resident with a muscle disorder had a BMP ordered, and the lab showed a low potassium level of 3.2 mmol/L. The record had no evidence the abnormal result was reported to the physician, and the DON acknowledged it was not referred. The facility policy stated nursing is to notify the physician of lab results and wait for further orders.
Fortified Diet Not Provided as Ordered: A resident with palliative care, malignant lung cancer, and nutritional deficiency had a physician-ordered fortified diet, regular level 7 texture, thin liquids. During lunch observation, the resident’s tray did not include the expected fortified salad marking, and the salad and Salisbury steak were served without the menu-specified extra dressing and extra gravy. The RD confirmed these fortified meal components should have been provided.
Food Served at Improper Temperatures: Two residents reported that meals were lukewarm or consistently cold. During lunch meal service, a test tray showed hot items at 120 F, but milk was 47 F and salad was 46.6 F, both above the facility’s stated cold-food temperature limits. The RD stated food should be served within recommended temperatures to prevent food borne illness and ensure a palatable meal experience.
Failure to monitor multiple antibiotics under the antibiotic stewardship program: A resident with cellulitis, a right foot wound, and later osteomyelitis received several oral and IV antibiotics over time, but the IP did not review the antibiotic regimen for compatibility, adverse interactions, or ongoing need. The record lacked documented ongoing monitoring of infection signs, antibiotic tolerance, or an updated IDT review, and the DON confirmed the resident was not documented as being assessed while receiving multiple antibiotic treatments.
Influenza vaccine was not administered to a resident after consent was obtained and a physician order was entered. During a med refrigerator check, a vial labeled for the resident was found, and record review showed the resident was cognitively intact, had capacity to make decisions, and still had not received the ordered flu vaccine. The IP stated the vaccine should have been given.
A resident with cognitive communication deficit, syncope, collapse, and a history of falls experienced multiple unwitnessed falls over several months while the facility failed to consistently evaluate and modify fall-prevention interventions. IDT notes described the resident as confused, lacking safety awareness, and exhibiting behavior-related falls, yet recommended measures such as bilateral bed bolsters and a psych consult were not clearly implemented, and no new interventions were added after some subsequent falls. Care plan interventions included a low bed, fall mats, non-skid footwear, and neuro checks, but post-fall neurological assessments were repeatedly incomplete or missing required vital signs and neuro parameters over the mandated 72-hour periods. Although orders allowed use of alarms and placement near the nurses’ station, there was no sitter care plan, and the DON confirmed that post-fall neuro assessments were not completed as required, resulting in a deficiency for failing to maintain an accident-hazard-free environment and provide adequate supervision to prevent accidents.
Surveyors found that the facility failed to integrate ventilation and HVAC practices into its infection prevention and control program during a COVID-19 outbreak. COVID-positive residents were cohorted on one wing without consideration of how multiple rooms were connected by shared HVAC units, and the IP reported there was no ventilation mitigation strategy or policy for airborne infections. The DM explained that vents and returns in rooms of COVID-positive residents should be covered and portable AC units used, but there was no evidence this was consistently applied, and the facility used MERV 12 filters despite higher-efficiency recommendations in national guidance. The DM also stated that HVAC filters were last changed several months earlier and could not provide documentation of required 90-day filter changes or maintenance logs, contrary to the facility’s own maintenance and infection control policies and national ventilation guidelines.
Surveyors found that an emergency exit door on one wing and an adjacent maintenance shop door were left open and unattended, despite the DON and DM stating these doors should remain closed, alarmed, and locked unless staff are physically present. The investigation also revealed that required monthly generator tests were not documented for the past year, contrary to facility policy. In addition, the DM could not locate water temperature logs since mid-year, and on-site checks showed hot water temperatures in resident rooms and a conference room sink above the facility’s policy limit of 120°F, indicating that environmental monitoring and controls were not being consistently maintained.
A resident with hemiplegia and intact cognition developed a pruritic rash and was twice evaluated by dermatology, which diagnosed scabies and ordered Permethrin 5% cream treatment with a repeat dose and recommended contact precautions and management of close contacts. Facility staff did not transcribe or carry out the initial Permethrin order, later entered and then discontinued a Permethrin order on the same day without administering any doses, and discontinued an order for a skin scraping for scabies without performing the test or documenting a reason. The resident was not placed on contact isolation, roommates were not prophylactically treated, and no close contact list was initiated, despite facility policy and expectations described by the IP and DON.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
A resident with a recent UTI and catheter removal reported significant pain, and while PRN Tylenol was administered, nursing staff failed to document the location of the pain in both progress notes and condition monitoring, contrary to facility policy and care plan requirements. Interviews confirmed that staff were expected to include pain location in documentation, but this was not done, resulting in an incomplete pain assessment.
A resident with a history of stroke and encephalopathy experienced two unwitnessed falls, after which required neurological assessments were not fully completed or documented according to facility policy. Multiple scheduled neuro checks were missed or incomplete, and key assessment forms lacked signatures or were not filled out, as confirmed by interviews with nursing staff and the DON.
Five residents did not receive their scheduled 9 a.m. medications within the required timeframe, with doses administered several hours late due to an LPN becoming busy and not seeking assistance. The medications included treatments for chronic conditions such as hypertension, seizures, and depression. Facility policy requires medications to be given within one hour of the scheduled time, which was not met.
The facility failed to schedule a registered nurse (RN) for eight consecutive hours on multiple dates, relying instead on licensed vocational nurses (LVNs) to manage in the RN's absence. This deficiency was identified during an unannounced visit, with interviews revealing that the Director of Staff Development was unaware of the requirement, and the Director of Nursing acknowledged insufficient RN hours. Documentation confirmed the RN's reduced hours, raising concerns about potential delays in care and risks to resident safety.
A resident with a suprapubic catheter was observed with an uncovered urinary drainage bag, contrary to the facility's policy to maintain dignity. The resident expressed discomfort, and the LVN acknowledged the oversight. The DON confirmed the potential psychosocial impact of this failure.
A facility failed to provide a functional call light system for a resident with quadriplegia, leaving him unable to call for assistance. The resident was given a portable call bell, which he could not use due to his paralysis, and had to resort to yelling for help. The call light system was broken, and the facility's maintenance and accommodation policies were not followed, resulting in this deficiency.
A resident with hemiplegia and hemiparesis experienced verbal abuse from a CNAS who used inappropriate language and gestures during care. The incident was witnessed by a CNA and reported to the LVN, who confirmed the behavior as verbal abuse. The facility's Administrator acknowledged the failure to prevent the altercation, which violated the facility's policy on abuse prevention.
A facility failed to report an allegation of verbal abuse by a CNAS towards a resident to CDPH within the required timeframe. The incident involved a verbal altercation where the CNAS used inappropriate language and gestures, leading the resident to feel disrespected and verbally abused. The incident was reported to an LVN by a CNA, but the DON did not investigate further or report it to CDPH. The facility's policy requires immediate reporting within two hours, which was not followed.
A facility failed to report a verbal abuse allegation by a CNAS towards a resident to CDPH within the required 2-hour timeframe. The resident, who had hemiplegia and hemiparesis, reported feeling disrespected after a verbal altercation with the CNAS. The incident was initially reported by a CNA to an LVN, but the DON did not investigate or report it promptly. The SSD confirmed the delay in reporting, which was against the facility's policy.
A resident experienced significant weight loss due to the facility's failure to follow the Registered Dietitian's recommendations for weekly weight monitoring. Despite being identified as at risk for weight loss, the resident's weight was not consistently recorded, and there was no documentation explaining the oversight. Interviews with facility staff confirmed the lack of adherence to the interdisciplinary team's recommendations.
The facility failed to update care plans for residents experiencing gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. One resident with nutritional deficiency and anemia did not have their care plan updated to include Zofran and IV hydration. Another resident with heart failure and detected Norovirus had no care plan for diarrhea. A third resident with diabetes had a delayed care plan update for diarrhea treatment. Lastly, a resident with spinal stenosis had a care plan that was not updated to include Zofran and lab tests. The DON acknowledged the delay in updating care plans.
The facility failed to implement effective infection control practices during a GI outbreak, leading to the spread of infection among residents and staff. Staff did not perform hand hygiene after contact with high-touch areas, and appropriate PPE was not used while providing care to residents requiring Enhanced Barrier Precautions. Additionally, the facility did not monitor residents with GI symptoms or conduct timely surveillance tracking, resulting in a delayed identification of the outbreak and late notification to health authorities.
Three residents were found with medications on their overbed tables without proper assessments for self-administration. One resident had eye drops, another had a respiratory inhaler, and the third had muscle balm ointment. Despite being mentally capable, there were no documented assessments or physician's orders for self-administration, leading to potential risks of improper medication use.
A facility failed to administer medications according to physician orders for a resident with hypertension, did not monitor or document skin discolorations for another resident, and neglected to notify a physician of a change in condition before transporting a third resident to an appointment. These deficiencies involved improper medication administration, lack of documentation, and failure to follow change of condition protocols.
A LTC facility failed to administer medications as prescribed, including incorrect dosing of fluticasone nasal spray, missed doses of IV antibiotics, improper documentation for withheld blood pressure medication, and incorrect oxycodone dosing for severe pain. These errors were confirmed by the DON.
The facility failed to meet the special dietary needs of three residents during a lunch meal. Two residents on a fortified diet were initially served regular pureed chili instead of fortified chili, which was later corrected. Another resident on a dysphagia mechanical soft diet was served a meal without a starch component, which was acknowledged as an oversight and corrected with mashed potatoes. The facility's policy requires menus to meet residents' nutritional needs.
The facility failed to store residents' food items in accordance with professional standards, as observed during an inspection of the nurses' station refrigerator. Several food items, including yogurt, creamer, apple juice, and leftovers, were found undated or past their storage dates, contrary to the facility's policy requiring labeling and discarding after 72 hours. The DON acknowledged these lapses, which could potentially lead to foodborne illnesses among residents.
The facility failed to maintain infection control practices when a resident was observed with a urinal hanging from their wheelchair, and staff were not wearing fit-tested N95 masks while caring for COVID-19 positive residents. The facility's policies require proper waste containment and fit-tested respirator use to prevent infection spread.
A resident experienced a delay in assistance after activating the call light, waiting 30 minutes for a juice refill. Despite two nurses being present at the station, they did not respond, and a CNA eventually assisted after 15 minutes. Staff interviews confirmed the expectation for prompt response, ideally within five seconds, as per facility policy.
A facility failed to ensure a resident's Advance Directive (AD) was available in their medical record, risking non-compliance with the resident's treatment wishes if they became unable to decide. Despite the resident having an AD and the family member visiting regularly, the AD was not in the record. The Social Service Director acknowledged the oversight, and the facility's policy required ADs to be communicated to the care team and physician.
A resident experienced discomfort and potential risk due to a detached chair rail molding above their bed, which was not reported or repaired by the facility staff. Interviews with staff confirmed the issue, and facility policies indicated the need for routine maintenance to ensure safety and comfort.
A resident with diabetes was observed with long, thick toenails after his requests for nail care were ignored. A CNA responsible for his care did not notice the issue due to being hurried and failed to inform the charge nurse. The facility's policy required licensed nurses to perform nail care for diabetic residents, but this was not followed, leading to a deficiency in maintaining the resident's personal hygiene.
The facility failed to properly store medications, resulting in expired and discontinued medications being found in storage areas. An RN found expired daptomycin IVPB bags in the medication refrigerator, and an LVN discovered a discontinued medication in the medication cart. Additionally, an insulin pen without an open or expiration date was found, contrary to guidelines. These issues could lead to residents receiving ineffective medications.
A resident experienced discomfort due to a persistent water leak from a pipe under the sink in their room, which was not addressed despite being reported to staff. The Maintenance Supervisor was unaware of the issue, and the Administrator acknowledged the need for repair. The facility's policies on equipment maintenance and providing a homelike environment were not followed, leading to an unsafe and uncomfortable living condition for the resident.
Failure to monitor and treat constipation and other ordered care needs
Penalty
Summary
The facility failed to provide appropriate bowel monitoring and constipation treatment for Resident 113, who had orders for routine bowel management medications and PRN laxatives if there was no bowel movement for three days. The resident also had multiple medications that could contribute to constipation, including hydrocodone-acetaminophen, ferrous sulfate, quetiapine, citalopram, Cymbalta, and trazodone. The bowel record showed no bowel movement from February 4 through February 10, yet there was no documented administration of MOM, bisacodyl suppository, or Fleet enema during that period, and no documented physician notification for the seven-day absence of bowel movement. The record also showed daily PCC alerts from February 6 through February 11 indicating no bowel movement for more than three days, but staff did not act on those alerts. Resident 113 later reported abdominal discomfort during physical therapy, and the NP documented abdominal pain with orders for STAT KUB, UA, and CBC. The KUB showed dilated loops of bowel, colonic fecal residual, and gastric distention, with ileus favored and obstruction not excluded. The resident was sent to an IC facility for CT imaging, where the exam noted severe fecal impaction, abdominal distention, absent bowel sounds, and elevated WBC. The CT report described large amounts of stool throughout the colon, portal venous air raising concern for bowel ischemia, and surgical consultation was advised. The resident later returned to the facility in a confused and restless condition with shallow respirations and a weak pulse, and 911 was called. The resident’s record and interviews with the DON, LVN, MD, and NP confirmed that the resident had not had a bowel movement for seven days and that PRN constipation medications had not been given despite the no-BM alerts. The MD and NP also stated the resident was high risk for constipation because of routine narcotic pain medication. Resident 113 died on February 13, 2026, and the death certificate listed mesenteric ischemia due to atherosclerotic vascular disease as the immediate cause of death. The report also identified similar failures for other residents when no bowel movement for three days or more was not assessed or treated, and additional deficiencies involving elevated blood sugar, open lower-extremity areas, and edema/wound monitoring.
Food Items Found Without Required Dating and One Item Kept Past Use-By Date
Penalty
Summary
Food was not stored and labeled in accordance with the facility’s food safety procedures during an initial kitchen tour with the Assistant Dietary Supervisor (ADS). Several opened bottles of herbs and spices on the spice rack were not labeled with open dates, including Mediterranean style ground oregano, ground cumin, dill weed, ground ginger, rubbed sage, ground cayenne pepper, and ground rosemary. In Refrigerator #1, an opened one-gallon container of buttermilk ranch dressing and an opened one-gallon container of whole egg mayonnaise were also found without open dates. The ADS confirmed these items lacked open dates and stated the ranch dressing and mayonnaise should be good for one month after opening, but staff would not know when to discard them without an open date. Additional food storage issues were identified in the walk-in refrigerator and dry storage room. A package of roast beef was found labeled with an open date of 2/24/26 and a use-by date of 2/28/26, and the ADS stated it was past its use-by date and should have already been discarded. An opened one-gallon bottle of sesame oil in dry storage was labeled with a received date only and no open date. The ADS stated the bottle should have been labeled with an open date. The Registered Dietitian later stated the herbs and spices, ranch dressing, mayonnaise, and sesame oil should have had open dates, and the roast beef should have been discarded.
Incomplete Care Plans for Behavioral, Dental, and Oxygen Needs
Penalty
Summary
The facility failed to develop individualized comprehensive care plans for multiple residents with identified needs. For Resident 8, the record showed diagnoses of dementia, psychosis, depression, and anxiety, with a BIMS score of 6 and no capacity to make decisions. Physician orders addressed anxiety, depression, and psychosis with medications for verbalization of anxiousness, sadness, and auditory and visual hallucinations, but the record did not contain an individualized care plan for those targeted behaviors. During interview, the DON stated there was no individualized care plan developed to address the resident’s behaviors. The facility also did not develop care plans for dental concerns for Residents 25, 109, and 119. Resident 25 was observed without teeth or dentures, reported prior denture impressions, and stated she had not received follow-up information and had to moisten food with her tongue and gums before swallowing. Resident 109 was observed with missing, chipped, and blackened teeth throughout the oral cavity, and staff stated these findings had been present since admission. Resident 119 was observed without teeth or dentures in place and reported loose-fitting dentures that she did not feel comfortable wearing. For each of these residents, the record review showed no documented individualized care plan addressing dental issues or related chewing and swallowing concerns. The facility also failed to develop care plans for oxygen use for Residents 32, 89, and 116. Resident 32 was observed receiving oxygen via nasal cannula at 2 L/min and stated she used oxygen continuously; the record contained an oxygen order but no care plan. Resident 89 was observed receiving oxygen at 2 L/min, had an oxygen order, and had a care plan focused on shortness of breath with oxygen listed as an intervention, but staff stated the oxygen care plan was not entered timely. Resident 116 was also observed receiving oxygen at 2 L/min, had an oxygen order, and the record contained no care plan for oxygen management and use. The facility policy stated the interdisciplinary team shall develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes, and that a comprehensive care plan is developed within seven days of completion of the MDS.
Oxygen Cannulas Not Changed or Dated per Policy
Penalty
Summary
The facility failed to follow its oxygen use policy for three residents receiving oxygen via nasal cannula. For Resident 32, who used oxygen continuously and had diagnoses including shortness of breath, the nasal cannula was observed labeled with a date of 2/22/26, and staff stated it had not been changed weekly as required. For Resident 89, who also received oxygen at 2 L/min and had diagnoses including atherosclerotic heart disease, the nasal cannula was likewise labeled with 2/22/26, and staff stated it had not been changed weekly in accordance with facility policy. For Resident 116, who was observed receiving oxygen at 2 L/min and stated she used oxygen continuously, the nasal cannula was not labeled with a date when observed. Staff stated the tubing should have been dated in accordance with facility policy and procedure. The facility policy titled, Oxygen, Use of, stated that oxygen cannulas or masks would be changed at least every 7 days and tubing would be dated in an identifiable fashion.
Pharmacy Services and Controlled Medication Documentation Deficiencies
Penalty
Summary
Pharmacy services were not implemented according to facility policy when a vial of Shingrix labeled for Resident 19 was found stored in the medication refrigerator on March 5, 2026, even though the resident had already received the second dose of shingles vaccine on February 16, 2026. Resident 19’s record showed a physician order dated February 16, 2026 for Shingrix 50 mcg intramuscularly, and the immunization report and CAIR history both indicated the shingles vaccine had already been administered. The Infection Preventionist stated the vial should have been discarded and not kept in the refrigerator readily available for use. The facility also failed to document PRN controlled medications on the MAR for Resident 12 and Resident 24 in accordance with physician orders and facility policy. Resident 12 had an order for Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for pain, but the controlled medication count sheet showed doses signed out on January 9, 2026 at 9:15 a.m. and January 12, 2026 at 11:26 a.m. that were not documented on the MAR. Resident 24 had an order for Ativan 1 mg every 8 hours as needed, but a dose signed out on February 28, 2026 at 9:53 p.m. was not documented on the MAR. A similar documentation issue was identified for Resident 23. Resident 23 had orders for Lorazepam 0.5 mg every 6 hours as needed and Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed, but the controlled medication count sheet showed Lorazepam signed out on February 16, 2026 at 2:10 a.m. and Hydrocodone signed out on February 19, 2026 at 9:19 a.m. without corresponding MAR documentation. The DON stated that narcotic medications signed out from the count sheet should be documented as administered in the residents’ MAR to prevent drug diversion.
Improper Medication and Treatment Cart Storage
Penalty
Summary
Medication storage practices were not followed when one vial of IV ondansetron labeled for a resident was observed stored together with oral medications on Medication Cart A. The vial was found in the same container as three bottles of nitroglycerin tablets for different residents, one opened bottle of stool softener, and one opened bottle of Tylenol. During the observation, the Infection Preventionist stated the IV ondansetron should have been kept in the IV cart and not stored with oral medications. On Medication Cart C, multiple oral medications labeled for different residents were stored together with multiple eye drop medications labeled for different residents in the first drawer of the cart. During the observation, an LVN stated that oral medications and eye drops should be stored separately. The facility policy titled Storage of Medications stated that medications and biologicals are stored safely, securely, and properly, orally administered medications are kept separate from externally used medications and treatments, and eye medications are stored separately per facility policy. Treatment Carts 1 and 2 contained several discontinued or completed treatment medications that remained readily available for use. These included an open box of Lidocaine solution 4% for Resident 7 after the 21-day order had ended, discontinued Bethamethasone Dipropionate cream for Resident 11 after the order was changed to Bethamethasone Valerate, completed Calcipotrien cream for Resident 99, completed Nystatin cream for Resident 67, and completed Ciclopirox solution for Resident 71. An opened box of iodine prep pads with an expiration date of February 2025 was also found in the treatment cart. The Treatment Nurse stated these discontinued or completed medications should have been removed from the cart and not left readily available for use, and the facility policy on Discontinued Medications stated medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue.
Failure to Provide Dental Follow-Up and Denture Care
Penalty
Summary
The facility failed to provide routine and emergency dental care and follow-up treatment for three residents reviewed for dental services. The report states that Resident 25 had denture impressions obtained on October 5, 2025, but there was no documented follow-up dental consult or status update after that appointment. Resident 25 was observed without teeth or dentures, stated she had not received updates about her dentures, and reported that staff cut up her food because she did not have dentures. Her record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction and dysphagia, and the dental record dated October 2, 2025, indicated a request to submit authorization for new full upper and lower dentures. Resident 109 was observed with missing, chipped, and blackened teeth throughout the oral cavity, and he stated his teeth had been that way for years and that he had not had a dentist appointment since admission. His admission record documented natural teeth present with no missing, broken, or carious teeth, but later assessments did not identify dental issues and there was no physician order for a dental consult. Staff interviews confirmed that the CNA and LVN had observed the broken, missing, and decayed-appearing teeth, and the LVN stated the oral cavity status should have been documented on admission and the physician notified for a dental consult order. Resident 119 was observed without teeth or dentures in place and stated she had dentures but did not feel comfortable wearing them because they were loose. She reported telling the Social Services Director about the loose-fitting dentures and said she was not asked if she wanted dental follow-up. Her admission and skilled evaluation records did not document an oral/dental status check or denture concern, and the MDS did not identify broken or loosely fitting dentures or edentulous status. The SSD confirmed that the initial social services assessment did not include oral cavity status or denture concerns and stated the resident was at risk for choking and losing weight due to not eating properly.
QAPI Plan Not Addressing Bowel Management Program Issues
Penalty
Summary
The facility's Administrator and governing body failed to ensure a QAPI plan was in place to address systemic process issues related to the bowel management program and constipation. During the recertification survey, surveyors identified that the facility was not implementing the bowel management program and was not following the physician's order to address constipation, which was cited as a systemic issue and cross-referenced to F684. The survey also resulted in an Immediate Jeopardy determination on [DATE] at 5:58 p.m. after further investigation and approval from the State Agency Supervisor, with the Administrator and DON present when the IJ was declared. Resident 113's record was reviewed on [DATE] at 10:12 a.m. The record showed the facility failed to implement interventions to address constipation according to the facility's policy and procedure and the physician's orders, and this failure was associated with Resident 113's death on February 13, 2026, secondary to mesenteric ischemia. During an interview on [DATE] at 7:21 p.m., the Administrator stated the QAPI committee met quarterly and included multiple disciplines, but he was unaware of any bowel management program issues until the survey team identified the concern, and the QAPI committee had not identified issues related to constipation.
Infection Control Practices Not Followed During Resident Care and Equipment Disinfection
Penalty
Summary
The facility failed to follow infection control practices during care provided to a resident on Enhanced Barrier Precautions (EBP). The resident had diagnoses including neuromuscular dysfunction of the bladder and a suprapubic catheter, and the medical record showed an infection control order for EBP due to the catheter. During observation, a hospice RN entered the resident’s room without putting on a gown and gloves, placed his nursing bag on the resident’s bed, removed a stethoscope, blood pressure cuff, and pulse oximeter from the bag without disinfecting them, and used the equipment to obtain vital signs. The RN then returned the equipment to the bag without disinfecting it, touched the resident’s Foley catheter tubing and drainage bag without gloves, and exited the room without sanitizing his hands. The hospice RN stated he was not sure why the resident was on EBP precautions and said he was not required to wear a gown or gloves because he was only checking vital signs and did not move the resident. The resident’s EBP signage outside the room indicated that providers and staff must wear gloves and a gown for high-contact care activities. Staff interviews stated that EBP required gowns and gloves for patient care activities such as checking vitals, turning a resident, emptying a catheter drainage bag, and personal care, and that PPE should be removed and hand hygiene performed before exiting the room. The infection preventionist also stated that third-party contractors should wear a gown and gloves when performing skilled assessments such as vital signs, lung auscultation, and any contact with the Foley catheter, and that a disposable barrier pad should be placed under a nursing bag in the room. The facility also failed to ensure shared resident-care equipment was disinfected according to manufacturer instructions during medication pass observations. A licensed nurse wiped a shared blood pressure cuff with a Sani Cloth after removing it from one resident’s arm, but the cuff was not observed remaining visibly wet for the required two-minute contact time. The same issue occurred later with another resident when a different licensed nurse wiped the shared blood pressure cuff but did not keep it wet for two minutes. Both nurses stated after review of the manufacturer’s instructions that the cuff should have remained wet for two minutes. The infection preventionist stated the expectation was to clean shared resident equipment before and after each use and to follow the manufacturer’s instructions so the item remained wet for the full recommended contact time. The facility policy required disinfection of equipment, hand hygiene for direct resident contact, and following manufacturer recommendations for cleaning equipment.
Unnecessary Psychotropic Medication Use and Missing Informed Consent
Penalty
Summary
The facility failed to ensure Resident 8 was free from unnecessary use of psychotropic medications. Resident 8 was admitted with diagnoses including dementia, psychosis, depression, and anxiety, and the history and physical stated the resident did not have capacity to make decisions. The MDS dated January 14, 2026, indicated a BIMS score of 6, showing severe cognitive impairment. Resident 8 had orders for PRN lorazepam 0.5 mg every 6 hours as needed for anxiety manifested by verbalization of anxiousness, with an additional order to document non-pharmacological interventions every shift. Review of the MAR for January and February 2026 showed lorazepam was administered on five occasions, but there was no documented reason for the administrations and no documented evidence that non-pharmacological interventions were provided before the medication was given. The DON stated there was no documentation of the reason for administering PRN lorazepam, including non-pharmacologic interventions prior to administration, and stated the licensed nurse should assess the resident, determine the cause of anxiety, and provide non-pharmacologic interventions before giving PRN lorazepam if ineffective. Resident 8 also had an order for mirtazapine 15 mg at bedtime for depression manifested by verbalization of sadness. The record did not contain documented evidence that informed consent for the use of mirtazapine was obtained by the prescribing physician prior to administration. The DON stated mirtazapine was administered starting January 7, 2026, and that a new consent form was completed on February 3, 2026, but could not find documentation that informed consent had been obtained when the medication was first ordered.
Late discharge notice and incomplete personal effects inventory
Penalty
Summary
The facility failed to provide a timely written Notice of Proposed Transfer/Discharge for a resident who was cognitively intact and had capacity to understand and make decisions. The resident’s record showed a BIMS score of 14, and the interdisciplinary team discussed discharge planning with the resident and his son. A NOMNC was issued, but the Notice of Proposed Transfer/Discharge was completed after the resident had already been discharged home and was mailed to the resident’s family member rather than being provided before discharge. The facility’s policy required written notice of a proposed transfer/discharge at least 48 hours before the effective date, unless it was an emergency transfer, and the notice was to include the reason, effective date, location, and appeal rights information, including contact information for the Long-Term Ombudsman and Disability Rights California. The facility also failed to complete the inventory of personal effects for a resident who was transferred to a general acute care hospital due to chest pain. The resident had diagnoses including pneumonia, pulmonary fibrosis, and sepsis. The Inventory of Personal Effects form was dated before the transfer, but the discharge portion was not signed by the resident or the resident’s representative after the transfer to the hospital. There was no documented evidence that the resident’s personal belongings were turned over to the resident representative upon transfer or after the resident was later discharged from the facility following a prolonged hospital stay beyond seven days. During interview, Social Services staff stated that nurses usually had the resident or representative sign out belongings upon transfer or discharge, but on weekends housekeeping kept a list of belongings turned over to the representative. The Social Services Assistant stated she would follow up with housekeeping to obtain that list, and the Administrator stated staff were still trying to locate it. The facility policy required the resident or responsible party to date and sign the discharge section of the inventory form with a staff nurse to certify receipt of personal effects, and a photocopy of the completed original form to be given to the resident or responsible party.
Smoking paraphernalia left unsecured at bedside
Penalty
Summary
The facility failed to ensure cigarettes and smoking paraphernalia were kept secured in a locked container in the nursing station for one resident who was reviewed for smoking. On March 3, 2026, the resident stated his cigarettes and lighter were stored in his bag at the bedside, and staff observed one box of cigarettes and one lighter inside the gray bag on the bed beside him. The resident’s face sheet showed he was admitted with diagnoses including need for assistance with personal care, and his history and physical, dated February 26, 2026, indicated he had the capacity to understand and make decisions. The resident’s care plan, dated March 1, 2026, identified that he exhibited non-compliance with the facility smoking schedule and included an intervention to keep all lighters, matches, and cigarettes secured at the nursing station. On March 4, 2026, an LVN verified the resident had two and a half cigarettes and one lighter in his bag at bedside and stated he could keep them there because he was independent. On March 5, 2026, the DON stated all smoking paraphernalia was to be stored in the locked box at the nursing station and that the resident’s smoking paraphernalia should not have been kept at his bedside.
Water Pitchers Left Out of Reach for Two Residents
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met when two residents were observed with water pitchers out of reach. Resident 12 was seen in bed with the head of the bed elevated, awake and alert, with dry forearms and a water pitcher on the nightstand beside the upper part of the bed that was out of reach. Resident 12 had diagnoses including heart failure and acute pulmonary edema, a BIMS score of 06 indicating severe cognitive impairment, and care plan directions to encourage fluids during the day, keep needed items and water in reach, and monitor for dehydration. Staff interviews showed CNA 5 stated water pitchers should always be in reach and that signs of dehydration such as dry lips, dry mouth, dry skin, or low urine output should be reported immediately. CNA 6 stated the water drop signage outside Resident 12's room indicated fluid restriction, and that the resident's water bottle should always be in reach. Resident 12's record also showed a physician order for furosemide twice daily for fluid retention and a care plan entry for potential fluid deficit related to diuretic use and poor oral intake. Resident 17 was also observed multiple times with the water pitcher out of reach while in bed, including when asleep with the bed flat and when awake with the head of bed elevated. CNA 6 stated Resident 17 required assistance with hydration and all meals, liked to drink water when offered, and that the water pitcher should always be in reach. Resident 17's record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction and nutritional deficiency, a BIMS score of 03 indicating severe cognitive impairment, and care plan directions to encourage good nutrition and hydration and keep needed items, including water, in reach.
Pain Medication Given Outside Ordered Pain Scale
Penalty
Summary
Safe, appropriate pain management was not provided for two residents when hydrocodone-acetaminophen was administered outside of the physician’s ordered pain parameters. Resident 12, who was admitted with diagnoses including heart failure and had a care plan noting risk for discomfort due to pain in the left leg, had orders for hydrocodone-acetaminophen 5/325 mg every 6 hours as needed for mild to moderate pain rated 1-3/10, then later for severe pain rated 7-10/10. Review of the MAR and controlled medication count sheet showed the medication was given on January 9 and January 10 for pain rated 7, and later on January 17 and January 23 for pain rated 6 and 4, which did not match the active order at those times. Resident 62, who was admitted with diagnoses including polyneuropathy, had an order for hydrocodone-acetaminophen 5/325 mg every 4 hours as needed for severe pain rated 7-10/10. Review of the MAR and controlled medication count sheet showed the medication was administered on February 6 for pain rated 6, on February 15 for pain rated 5, and on February 16 for pain rated 3, which was not consistent with the physician’s order. During interview, the IP stated the medication should be administered according to the pain rating scale as ordered, and the DON stated the licensed nurse should assess pain and administer the medication according to the physician’s order.
Missed Required Physician Visits
Penalty
Summary
The facility failed to ensure required physician visits and ongoing medical oversight were completed for one resident reviewed, Resident 17. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and nutritional deficiency. A review of the resident’s MDS dated February 4, 2026, showed a BIMS score of 3, indicating severe cognitive impairment. During a concurrent interview and record review with the DON, it was confirmed that Resident 17 did not receive documented physician visits, including total program of care assessments, throughout 2025. The DON stated that long-term care residents were to be seen by the physician at least once a month and verified that the facility did not follow the physician visit requirements for this resident. The facility policy titled Physician Services-Physician Visits, dated January 15, 2026, stated residents must be seen by their attending physician at least every 90 days and that the attending physician must review the resident’s total program of care, including medications and treatments, at least quarterly.
Failure to Report Abnormal Lab Result
Penalty
Summary
The facility failed to ensure that an abnormal laboratory result was referred to the physician for one resident reviewed. Resident 11 was admitted with diagnoses that included a muscle disorder. A physician order dated January 7, 2026, directed a BMP for January 8, 2026, and the lab result showed a potassium level of 3.2 mmol/L, below the normal range of 3.5 to 5.1. The record contained no documented evidence that the low potassium result was reported to the physician. During a March 6, 2026 interview and record review, the DON stated that physicians were to be notified of abnormal laboratory values at least within the day or sooner depending on urgency, and acknowledged that Resident 11's potassium level of 3.2 was not referred to the physician. The facility policy stated that nursing is notified of lab results and will notify the physician of the results and wait for further orders.
Fortified Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that a fortified diet was provided as ordered for Resident 44. During lunch tray line observation, some salad bowls were marked with an F on the plastic covers to indicate fortified items, but Resident 44’s tray contained a covered tossed green salad with no F marking. The tray also included mushroom soup, Salisbury steak with 1 oz of gravy, beets, noodles, coffee, a chocolate shake, grape juice, and a lemon cookie. When the resident’s tray was later observed in the room, the salad remained unopened and still had no F marking, and the Salisbury steak had only approximately 1 oz of gravy. Record review showed Resident 44 had a physician’s order for a fortified diet, regular level 7 texture, thin liquids consistency. The meal ticket identified the diet as regular-level 7, fortified, and the facility’s Spring 2026 Week 1 menu listed fortified lunch components of 1 oz extra gravy for Salisbury steak and 2 tsp extra dressing for salad. During interview and record review, the RD stated the fortified lunch components of extra gravy for the Salisbury steak and fortified dressing for the salad should have been provided on Resident 44’s tray. Resident 44 was admitted with diagnoses including palliative care, malignant lung cancer, and nutritional deficiency.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide food at appropriate temperatures when served to residents according to its policy and procedure for two residents, Resident 32 and Resident 5. On March 2, 2026, Resident 32 in B Wing stated during interview that meals were lukewarm. On March 3, 2026, Resident 5 in A Wing stated during interview that food was consistently cold. During lunch meal service on March 5, 2026, a test tray was requested to determine serving temperatures of food served to residents. The tray was placed in the last meal cart at 12:53 p.m., left the kitchen at 12:55 p.m., and arrived at A Wing at 12:58 p.m. At 1:10 p.m., the temperatures measured were regular beets at 120 F, beets at 120 F, pureed pasta at 120 F, milk at 47 F, and salad at 46.6 F. On March 6, 2026, the Registered Dietitian stated that food items should be served within recommended serving temperatures to prevent food borne illness and ensure a palatable meal experience. The facility policy titled MEAL SERVICE, dated 2023, stated that the goal is to serve cold food cold and hot food hot, with salads at or below 45 F and milk/cold beverages at 45 F.
Failure to Monitor Multiple Antibiotics Under Stewardship Program
Penalty
Summary
The facility failed to ensure the Infection Preventionist implemented the antibiotic stewardship program for one resident who had multiple antibiotic orders for cellulitis and a right foot wound. The resident was admitted with diagnoses including cellulitis and type 2 diabetes mellitus, and the MDS dated January 30, 2026, showed a BIMS score of 13, indicating the resident was cognitively intact. The medical record showed a series of antibiotic orders over several months, including cephalexin, cefpodoxime proxetil, doxycycline hyclate, mupirocin, cefepime, and vancomycin for cellulitis, wound infection, and osteomyelitis. The record also included an Infection Screening Evaluation dated January 8, 2026, documenting redness, tenderness, warmth, swelling, pus, and suspected skin and soft tissue infection, with McGeer's Criteria met for cellulitis, soft tissue, or wound infection. An Infectious Disease Progress Note/Antimicrobial Stewardship Note dated January 13, 2026, stated the resident tolerated antimicrobial therapy and to continue oral antibiotics. The care plan dated December 23, 2025, identified an open area to the right foot with drainage and swelling and noted the need for a care plan specific to antibiotics and antibiotic stewardship. Further review found no documented evidence of ongoing monitoring for cellulitis, signs and symptoms of infection, or tolerance of the oral or IV antibiotics. There was also no updated IDT meeting to address the resident’s ongoing use of multiple antibiotics and infection status. During interviews, the IP stated she did not follow the facility antibiotic stewardship or infection surveillance policy and did not review the resident’s antibiotics to confirm compatibility or check for adverse interactions or contradictions. The DON confirmed there was no documented evidence of ongoing assessment and monitoring while the resident received multiple antibiotic treatments.
Influenza Vaccine Not Administered After Consent and Order
Penalty
Summary
The facility failed to ensure that an influenza vaccine was administered to Resident 88 after consent was obtained on January 26, 2026, and after a physician order was entered on January 27, 2026. During a March 5, 2026 inspection of the medication refrigerator with the Infection Preventionist, one vial of influenza vaccine was found stored and labeled for Resident 88, with a pharmacy dispensed date of January 27, 2026. Record review showed Resident 88 was admitted to the facility on [DATE], had a Resident Consent for Influenza indicating a wish to receive the vaccine on an annual basis, and had a physician order for FLU (Influenza) VACCINE WHEN AVAILABLE (CONSENTED). The resident’s MDS dated February 6, 2026 showed a BIMS score of 12, and the History and Physical Examination dated March 5, 2026 indicated the resident had capacity to understand and make decisions. The Immunization Report indicated Resident 88 did not receive the influenza vaccine as ordered by the physician on January 27, 2026. In a concurrent interview, the Infection Preventionist stated the influenza should have been administered to Resident 88.
Failure to Evaluate and Modify Fall-Prevention Interventions and Complete Post-Fall Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall-prevention interventions for a resident with multiple falls were evaluated for effectiveness and modified appropriately. The resident was admitted with diagnoses including cognitive communication deficit, syncope, and collapse, and had a known history of falls prior to admission. Progress notes document repeated unwitnessed falls beginning in June and July 2025, often with the resident found on the floor next to the bed, sometimes stating he was reaching for something or trying to get up. The resident was described as alert with confusion, lacking safety awareness, and not following fall precautions, and the IDT identified the falls as likely related to behaviors, spontaneous movements, and limited cognitive ability for safety. Across multiple IDT meetings, various fall-related issues were discussed, but interventions were not consistently implemented or updated in response to repeated falls. In July 2025, the IDT discussed several unwitnessed falls and noted the resident’s confusion and behavioral component, planning bilateral fall mats, a psych referral, and encouraging time in a wheelchair at the nurses’ station. In September 2025, after another fall, the IDT noted the resident slid off the bed while trying to get up and documented existing interventions such as a geri chair, fall mats, and possible bed alarm. Later in September, after another fall, the team considered bilateral bolsters in bed to mitigate rolling off the bed, but subsequent progress notes in October 2025 did not indicate that these bolsters were in place, and there were no new interventions implemented after the September 22 fall despite additional falls on October 17 and October 25, 2025. The resident continued to report rolling out of bed or acting on confused perceptions, such as chasing animals he believed were in the room. The facility also failed to complete required post-fall neurological assessments for this resident following unwitnessed falls. Review of Post Fall-Neurological Check documents showed multiple missing entries for vital signs and neurological parameters over several dates. On various dates in July, August, and September 2025, documentation lacked pulse, respirations, assessments of pupils and extremities, and evaluations for seizure, headache, nausea, or vomiting. Several shifts had no entries for respirations, level of consciousness, response, or speech, and some entries lacked times or dates. The DON confirmed that neurological assessments are required for 72 hours after unwitnessed falls or possible head injury and acknowledged that these assessments were not completed as required for this resident. The facility’s fall management policies required individualized care plans with measurable objectives, post-fall risk evaluations, 72-hour follow-up documentation, neurological assessments after unwitnessed falls, investigation of causal factors, and care plan updates, but the documented record for this resident showed repeated falls without consistent modification of interventions and incomplete post-fall neurological monitoring. Additional documentation showed that orders for alarms and supervision were present but not clearly tied to effective modification of the care plan in response to ongoing falls. Physician orders in November 2025 allowed the resident to be up in a geri chair when not in bed and permitted use of tab alarms and alarm pads in bed and chair to remind the resident to call for assistance and alert staff to unsupervised transfers or ambulation. The DON stated that the resident had been moved closer to the nurses’ station for better supervision and that when up in a geri chair he was to be near the nurses’ station, but there was no care plan or order for a sitter. The DON also stated that a psychology consult was ordered in July 2025 but could not find documentation that it was completed. Overall, the record shows that despite multiple falls and identified behavioral and cognitive risk factors, the facility did not consistently evaluate the effectiveness of fall interventions, did not reliably implement or document planned interventions such as bed bolsters and psych evaluation, and did not complete required 72-hour neurological assessments after unwitnessed falls, leading to the cited deficiency. The resident’s care plan documented actual falls on October 17 and October 25, 2025, with interventions including a fall mat, low bed, keeping items within reach, neuro checks, non-skid footwear, and monitoring and documentation for 72 hours. However, the pattern of repeated falls and the gaps in neurological check documentation demonstrate that these interventions and monitoring requirements were not fully carried out or adjusted in response to ongoing incidents. The facility’s own fall management policies required reassessment of fall risk with significant changes in condition and updating of the care plan after each incident, but the clinical record for this resident shows that after certain falls, such as the October 17 event, no new interventions were added beyond those previously considered, and recommended measures like bilateral bolsters were not clearly implemented. These documented inactions and incomplete assessments form the basis of the deficiency related to accident hazards and inadequate supervision to prevent accidents for this resident.
Failure to Implement Ventilation-Based Infection Control and HVAC Filter Maintenance
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control standards related to its HVAC system and ventilation practices. During an unannounced complaint investigation focused on infection control, surveyors learned that the facility had experienced a COVID-19 outbreak in which approximately 20 residents and several staff members tested positive. COVID-positive residents were placed on isolation precautions and transferred to the B wing, but the Infection Preventionist (IP) stated she did not know how the HVAC units connected multiple rooms and that the ventilation system was not considered when placing COVID-positive residents. The IP also reported that the facility did not have a ventilation mitigation strategy or policy for airborne infections to minimize potential contamination between rooms sharing the same HVAC unit. Observations and interviews with the Director of Maintenance (DM) revealed that several HVAC units served multiple resident rooms and other areas, with each room having vents and returns that recirculated air back into the system. The DM stated that when a resident was COVID-positive, the vent and return in that room should be covered and a portable air conditioning unit used with the door closed to prevent recirculation of air to other rooms; however, there was no indication that this was systematically done during the outbreak. The DM also stated that the facility used MERV 12 filters in the ventilation system, and that the last filter changes occurred in September 2025, but he could not locate documentation to verify that the filters had been changed as required. Record review showed that national guidance from CDC/NIOSH, ASHRAE, the Occupational Health Branch, and CDC’s ventilation in healthcare settings emphasized the importance of ventilation, appropriate filtration (including recommendations for MERV 13–14 or higher where possible), and routine HVAC maintenance and documentation to reduce airborne infectious aerosol exposure and COVID-19 transmission risk. The facility’s own maintenance policy required visual inspection and replacement of HVAC filters at least every 90 days, with detailed documentation of all actions taken, and required the maintenance supervisor to participate in infection control education and follow guidelines for heating and ventilation systems. The facility’s infection prevention and control program and transmission-based precautions policies called for comprehensive infection detection, prevention, and control, individualized resident placement decisions, and adherence to national standards, but these policies did not translate into a ventilation-focused strategy or documented HVAC filter maintenance consistent with the facility’s stated requirements and referenced guidelines.
Failure to Secure Exits and Maintenance Area, and to Monitor Generator and Hot Water Temperatures
Penalty
Summary
Surveyors identified multiple failures in maintaining safe and functional environmental conditions for residents and staff. During an unannounced complaint investigation focused on the physical environment, an emergency exit door at the end of B wing was observed propped open with no staff present, and the adjacent maintenance shop door was also open and unattended. The DON confirmed that the emergency exit door, which is equipped with a wander guard and alarm, is required to remain closed with the alarm set unless someone is physically present, and that the maintenance shop door must be closed and locked when maintenance staff are not there. The DM similarly stated that both doors should remain closed and secured for resident safety and that maintenance staff should not leave these doors open when unattended. Surveyors also found that the facility was not following its own policies for generator testing and water temperature monitoring. The DM reported he could not locate documentation verifying that the emergency generator had been tested for the past year, despite a facility policy requiring the generator to be run monthly under load for 30 minutes with documentation of the checks. The DM further stated he could not find any logs confirming that water temperatures had been checked since May 2025, even though facility policy requires weekly checks and documentation. When surveyors measured water temperatures in various locations, they found readings of 124°F at a conference room sink and 120.4°F to 122°F in several resident rooms, exceeding the facility’s stated maximum of 120°F for resident care areas and the policy requirement that hot water in resident rooms and common areas be maintained between 105°F and 120°F.
Failure to Implement Scabies Treatment and Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered and recommended infection control interventions and treatment for a cognitively intact resident with suspected and later diagnosed scabies. The resident, admitted with hemiplegia following a stroke and scoring 13 on the BIMS, was noted on November 17, 2025, to have self-inflicted scratches and a rash on the chest and arms. On the same date, a dermatology visit documented an impression of scabies with linear burrows and a plan to treat with Permethrin 5% cream applied from neck to toes overnight and repeated in one week. The dermatology note also stated that scabies is very contagious and that household contacts should be treated, and contaminated clothing isolated and laundered appropriately. However, after this consultation, no physician order for Permethrin was entered, and the November 2025 TAR showed that Permethrin was not administered. On November 26, 2025, a physician order was written to “scrap” for scabies, but this order was discontinued later the same day without the procedure being completed and without any documentation explaining the discontinuation. The Infection Prevention Nurse (IP) confirmed that there were no skin scraping results for November 2025 and that she did not know why the order was discontinued, as it was not communicated to her and there was no nursing documentation. The DON similarly verified that no skin scraping was performed, that the order was discontinued without explanation, and that there were no results in the record, despite the facility policy stating that a diagnosis is made via physical exam and/or skin scrapings with microscopic exam. On December 1, 2025, the resident had a follow-up dermatology consultation again documenting an impression of scabies with linear burrows and the same plan for Permethrin 5% cream treatment and repeat in one week. A physician order for Permethrin was entered on December 1, 2025, but was discontinued twice on the same date, and the December 2025 MAR showed that the treatment was not administered or repeated one week later. There was no documentation in the progress notes explaining why the Permethrin treatment was discontinued or not given. Although a physician order for contact isolation for a diagnosis of scabies was written on December 17, 2025, the IP and DON confirmed that after both dermatology consultations, the facility did not implement contact isolation precautions, did not perform the ordered skin scraping, did not prophylactically treat the resident’s roommates, and did not initiate a close contact list, contrary to the facility’s communicable disease policy that required immediate containment, treatment, use of contact precautions, simultaneous treatment of roommates, and documentation of treatments and monitoring.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Incomplete Pain Assessment and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete pain assessment for a resident with a history of urinary tract infection (UTI) and acute pain. The resident, who had recently had a urinary catheter removed, reported ongoing burning sensation during urination and rated her pain as 6 or 7 on a scale of 1-10. Although Tylenol was administered as ordered for severe pain, documentation in the progress notes and condition monitoring failed to include the location of the pain, despite the resident indicating discomfort in the bladder area. The care plan required monitoring and documenting the probable cause of each pain episode, but this was not fully carried out. Interviews with nursing staff and review of facility policy confirmed that the expected process was to document the location of pain when administering PRN pain medications. However, both the progress notes and condition monitoring records lacked this information for the resident on the relevant dates. The Director of Nursing also stated that staff were expected to assess and document the location of pain prior to medication administration, but this was not done in this case, resulting in incomplete pain assessment and documentation.
Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure proper monitoring and completion of neurological assessments for a resident following two unwitnessed falls. The resident, who had a history of cerebral infarction and encephalopathy, experienced a change in condition and was noted to have fallen on two separate occasions. After the first fall, documentation showed that vital signs were taken and the resident was assessed, but the neurological assessment was incomplete, lacking documentation of pupil and extremity checks, and the falls checklist and CNA post-fall assessment were not completed or signed. Following the second fall, facility policy required neurological checks at specific intervals for unwitnessed falls or suspected head trauma. However, the resident's neurological status was not documented as completed at multiple required times over the subsequent days. Several scheduled neurological checks were either missing or incomplete, and there were gaps in documentation across multiple shifts. Interviews with nursing staff and the DON confirmed that the expected protocol was not followed, and that there were numerous blanks and uncompleted neurological monitoring entries for the resident after both unwitnessed falls. The facility's own policy required thorough assessment and documentation after such incidents, but these procedures were not consistently carried out or recorded in the resident's medical record.
Delayed Administration of Scheduled Medications
Penalty
Summary
The facility failed to ensure that five residents received their scheduled 9 a.m. medications within the required timeframe, as observed and confirmed through interviews and record reviews. On the day in question, medications for these residents were administered several hours late, with some not given until after 1 p.m. The medications included treatments for high blood pressure, nerve pain, depression, seizures, anemia, and other chronic conditions. Staff interviews revealed that the nurse responsible for administering the medications became busy and did not seek assistance, resulting in the delay. The Director of Nursing confirmed that the medications should have been administered within one hour of the scheduled time, in accordance with facility policy. Resident interviews indicated awareness of missed or delayed medications, with one resident specifically noting concern about a missed dose of Ritalin. The Medication Administration Records corroborated the late administration times for all five residents. The facility's policy requires accurate and timely preparation, administration, and documentation of oral medications, which was not followed in these instances.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period on multiple dates in November and December 2024. This deficiency was identified during an unannounced visit on January 27, 2025, following a complaint about nursing services. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the RN worked only six hours on the specified dates, and the facility relied on licensed vocational nurses (LVNs) to handle issues in the RN's absence. The DSD was unaware of the requirement for an RN to be present for eight consecutive hours, and the DON acknowledged the lack of sufficient RN hours, which could lead to delays in care. The facility's documentation, including the Daily Assignment and Census Sheet, staffing sign-in log sheet, and time card records, confirmed the RN's reduced hours. The DON and LVN both expressed concerns that the absence of an RN for the required hours could delay the identification and treatment of life-threatening conditions, compromising the health and safety of residents. The facility's policy on adequate staffing emphasized the need to meet residents' needs, but the failure to comply with the RN staffing requirement posed a risk to resident care.
Failure to Maintain Resident Dignity by Not Covering Urinary Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not covering the urinary catheter drainage bag with a dignity bag. During an observation and interview, the resident expressed discomfort about the visibility of the urine collection bag. The Licensed Vocational Nurse (LVN) acknowledged that the urinary bag was exposed and should have been covered, indicating a lapse in maintaining the resident's dignity. The resident, who was admitted with neuromuscular dysfunction of the bladder, was cognitively intact and had a care plan that included placing the catheter bag inside a basin. The Director of Nursing (DON) confirmed that the uncovered urinary bag could have a psychosocial impact on the resident. The facility's policies on resident rights and indwelling urinary catheter care emphasized the importance of covering the drainage bag to maintain dignity, which was not adhered to in this instance.
Failure to Provide Functional Call Light System for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a call light system was available and functional for a resident with quadriplegia, which resulted in the resident being unable to call for assistance. During an unannounced visit, it was observed that the resident had a portable call bell placed on his overbed table, but he was unable to use it due to his paralysis. The resident expressed frustration as he had to yell for help, which was not a reliable method for requesting assistance. The Licensed Vocational Nurse confirmed that the call light system was broken and that the resident could not use the bell due to his condition. The Maintenance Assistant acknowledged that the call light system was broken and should have been repaired. The facility's Administrator stated that maintenance issues should be addressed immediately and that the call light system should have been fixed to meet the resident's needs. The facility's policies on equipment maintenance and accommodation of needs emphasize the importance of ensuring equipment is in good working order and that residents' needs are accommodated, including the use of call lights. However, these policies were not followed, leading to the deficiency.
Verbal Abuse Incident Involving CNA Student
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a Certified Nurse Assistant Student (CNAS) used inappropriate language towards a resident. The incident involved a resident who was admitted with hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side. The resident was mentally capable of understanding and had a care plan indicating a potential for psychosocial well-being problems related to verbal altercations with staff. During an interaction, the CNAS told the resident to 'f____ off' and made an inappropriate gesture, which the resident found disrespectful. The incident was reported by a Certified Nursing Assistant (CNA) who witnessed the verbal altercation and was shocked by the CNAS's behavior. The Licensed Vocational Nurse (LVN) confirmed that the CNAS should not have engaged in a verbal altercation with the resident, identifying the behavior as verbal abuse. The facility's Administrator acknowledged that the verbal altercation should have been prevented and emphasized the expectation for all staff to maintain a facility free from any types of abuse. The facility's policy on abuse prevention clearly states that residents have the right to be free from verbal abuse, which includes the use of disparaging and derogatory terms.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident involved a verbal altercation between the CNAS and a resident who was mentally capable of understanding and had a history of hemiplegia and hemiparesis following a cerebral infarction. The resident reported feeling disrespected and verbally abused after the CNAS used inappropriate language and gestures during care. The incident was initially reported to a Licensed Vocational Nurse (LVN) by a Certified Nursing Assistant (CNA), who witnessed the altercation, but the Director of Nursing (DON) did not investigate further or report the incident to CDPH. The Social Service Director (SSD) confirmed that the incident was reported to the facility's administrator two days after the allegation was made, which was not in compliance with the facility's policy requiring immediate reporting within two hours. The facility's policy, dated October 2024, mandates that all alleged violations involving abuse be reported immediately to the administrator, the state Survey Agency, and Adult Protective Services. The failure to adhere to this policy had the potential to result in further abuse, affecting the resident's emotional and psychosocial well-being.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made. The incident involved a resident who was mentally capable of understanding and had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident reported feeling disrespected and verbally abused after a verbal altercation with the CNAS, during which inappropriate words were exchanged, and the CNAS made an offensive gesture. The incident was initially reported by a Certified Nursing Assistant (CNA) to a Licensed Vocational Nurse (LVN), who was expected to escalate the report. However, the Director of Nursing (DON) did not investigate further or report the incident to CDPH, despite being informed by the LVN. The Social Service Director (SSD) confirmed that the incident was reported to CDPH two days after the allegation was made, which was not in compliance with the facility's policy requiring immediate reporting within two hours. The facility's policy clearly outlined the need for prompt reporting of abuse allegations to ensure resident safety.
Failure to Follow Nutritional Recommendations for Resident
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident, identified as Resident 7, who experienced significant weight loss. The Registered Dietitian (RD) had recommended weekly weight monitoring for four weeks due to the resident's unexpected weight loss, but these recommendations were not followed. The resident's weight was not recorded on several occasions, and there was no documentation to explain the lack of monitoring. Resident 7 was admitted with a diagnosis of diabetes mellitus and was initially alert and oriented. The resident's weight decreased from 156 pounds at admission to 114 pounds over several months, indicating a significant weight loss. Despite the care plan identifying the resident as at risk for weight loss and dehydration, the facility did not consistently monitor the resident's weight as recommended by the interdisciplinary team (IDT). Interviews with the Director of Nursing (DON), Dietary Supervisor (DS), and RD confirmed the failure to follow the IDT's recommendations. The DON acknowledged the lack of documentation for the missed weigh-ins, and the RD emphasized the importance of following the IDT's recommendations to prevent further weight loss. The facility's policy required accurate and regular weight monitoring, especially for residents with significant weight changes, but this policy was not adhered to in Resident 7's case.
Failure to Update Care Plans for GI Symptoms
Penalty
Summary
The facility failed to update care plans with measurable goals and interventions for residents experiencing gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. This deficiency was identified during an unannounced visit for an infection control investigation. Resident 1, admitted with nutritional deficiency and anemia, experienced vomiting and nausea, leading to new orders for Zofran and IV hydration. However, the care plan did not include these interventions. Resident 2, admitted with heart failure, had diarrhea and was transferred to a hospital where Norovirus was detected. Despite this, there was no care plan addressing the diarrhea episodes. Resident 6, with nutritional deficiency and Type 2 diabetes, experienced diarrhea and was prescribed Immodium and IV hydration, but the care plan was not updated until ten days later. Resident 21, admitted with spinal stenosis and elevated white blood cell count, reported nausea and was given Zofran, but the care plan was not updated to include this medication or the ordered laboratory tests until two days later. The Director of Nursing acknowledged that several care plans were not updated in a timely manner, which was contrary to the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
Inadequate Infection Control During GI Outbreak
Penalty
Summary
The facility failed to implement effective infection control practices during a gastrointestinal (GI) outbreak, as evidenced by several deficiencies. Staff members did not perform hand hygiene after contact with high-touch areas, such as the electronic time clock, which is considered a high-touch area. This lack of adherence to hand hygiene protocols was observed by surveyors and acknowledged by the Director of Nursing (DON), who confirmed that staff should have used alcohol-based hand rub (ABHR) or washed their hands before and after using the time clock. Additionally, the facility staff did not wear appropriate personal protective equipment (PPE) while providing care to residents requiring Enhanced Barrier Precautions (EBP). A Certified Nursing Assistant (CNA) was observed assisting a resident without wearing gloves or a gown, despite the resident being on EBP due to an indwelling urinary catheter. The CNA admitted to not following proper infection control practices, which exposed both herself and the resident to potential infections. The facility also failed to monitor residents with GI symptoms and conduct surveillance tracking, resulting in a delayed identification of the GI outbreak. The Infection Preventionist (IP) reported that residents with GI symptoms were not placed on isolation precautions in a timely manner, and the outbreak was not reported to the California Department of Public Health (CDPH) promptly. This delay in implementing infection control measures and notifying relevant authorities contributed to the spread of the infection, affecting 30 out of 90 residents and seven staff members, with three residents testing positive for Norovirus.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for safe self-administration of medication for three residents, leading to potential risks of improper medication use. Resident 38 was found with an opened bottle of eye drops on his overbed table, which he used to relieve eye irritation. Despite being mentally capable, there was no documented self-administration assessment or physician's order for the eye drops. A registered nurse confirmed the absence of necessary documentation and orders. Resident 42 had an opened respiratory inhaler on his overbed table, which he used for shortness of breath without knowing the correct frequency of use. Although a physician's order existed for the inhaler, there was no self-administration assessment documented. Both a licensed vocational nurse and a registered nurse acknowledged the lack of assessment and physician's order for self-administration, highlighting potential adverse effects from unsupervised use. Resident 77 was found with an opened container of muscle balm ointment on his overbed table, which he applied for pain relief. Despite being mentally capable, there was no self-administration assessment or physician's order for the ointment. A licensed vocational nurse and the Director of Nursing confirmed the absence of required documentation and orders, emphasizing the risk of residents not receiving medications according to physician's orders and not being monitored for adverse effects.
Medication and Monitoring Deficiencies in Resident Care
Penalty
Summary
The facility failed to administer medications according to physician orders for Resident 28, who was diagnosed with hypertension and hemoptysis. Lisinopril and Metoprolol were given despite the resident's systolic blood pressure (SBP) being below the prescribed threshold on multiple occasions, and Midodrine was not administered when the SBP was below 90. Additionally, there was no documentation of blood pressure readings on several dates, and no follow-up assessments were conducted after the resident's readmissions from the hospital, potentially delaying necessary care and treatment. For Resident 33, the facility did not identify or monitor discolorations on the resident's forearms, despite the resident having a history of traumatic subdural hemorrhage and diabetes mellitus. The discolorations were not documented in the resident's skin evaluations or change of condition forms, and staff members, including an LVN and RN, acknowledged the lack of documentation and assessment regarding these changes in the resident's condition. Resident 88 experienced a change in condition characterized by lethargy, but the primary care physician was not notified before the resident was transported to a medical appointment. The resident's condition was not medically cleared for travel, and the family eventually took the resident to the hospital. The facility's policy required notification and assessment of significant changes in condition, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as prescribed by the physician, leading to several deficiencies. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered an incorrect dose of fluticasone nasal spray to a resident, giving two sprays in each nostril instead of the prescribed one spray per nostril. This error was acknowledged by the LVN during an interview. Another deficiency involved a resident who did not receive four doses of an intravenous antibiotic medication, cefazolin, as prescribed. The Medication Administration Record (MAR) showed missing documentation for two doses and a lack of nursing notes for the other two doses. The Director of Nursing (DON) confirmed the absence of documentation and acknowledged the error. Additionally, a resident's blood pressure medication, lisinopril, was held without proper documentation of the resident's systolic blood pressure and pulse, which were necessary to determine if the medication should be withheld. Furthermore, another resident received an incorrect dosage of oxycodone for severe pain, as the MAR indicated only one tablet was given when two were prescribed for severe pain levels. The DON confirmed these errors during interviews.
Failure to Provide Special Dietary Needs
Penalty
Summary
The facility failed to provide special dietary needs for three residents during a lunch meal preparation. Resident 46 and Resident 76, who were both on a puree - level 4, fortified diet, were initially served regular pureed chili instead of the fortified version. This discrepancy was identified during the meal preparation, and the dietary staff corrected the error by replacing the regular chili with fortified chili. The Registered Dietitian confirmed that the residents should have received fortified chili to meet their nutritional requirements. Resident 192, who was on a dysphagia mechanical soft diet and had specific dislikes for toast, bread, and rice, was served a meal without a starch component. The Dietary Supervisor initially justified the omission by stating that the resident usually finished the meal without the starch and had other food items like yogurt and milk to supplement intake. However, it was later acknowledged that an alternative starch component should have been provided, and mashed potatoes were prepared for the resident. The facility's policy indicated that menus should meet the nutritional needs of residents using established national guidelines.
Improper Food Storage in Nurses' Station Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly storing residents' food items in the nurses' station refrigerator. During an inspection, several food items were found undated or past their storage dates, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. Specific items included an opened tub of yogurt, a bottle of Coffeemate creamer, a bottle of Mott's apple juice, a takeout box with leftover food, another takeout box containing pancakes, and a half peanut butter and jelly sandwich. All these items were either undated or had exceeded the 72-hour storage guideline set by the facility. The Director of Nursing (DON) acknowledged during interviews that these food items should have been dated upon receipt and discarded after 72 hours if opened. The facility's policy, titled 'Foods Brought by Family or Visitor,' mandates that all resident food must be labeled with a resident identifier and date, and perishable prepared foods should be discarded after 72 hours. The DON confirmed that the nursing staff is responsible for labeling and dating food items upon receipt to ensure proper monitoring. The failure to comply with these guidelines resulted in the presence of outdated and undated food items in the refrigerator.
Infection Control Deficiencies in Waste Management and PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices in two observed instances. First, a resident was seen in the dining room with a urinal hanging from the back of his wheelchair. This was confirmed by both a Licensed Vocational Nurse and the Director of Nursing as an infection control issue, as the facility's policy requires proper containment of waste to minimize infection transmission. The resident had been admitted with a fracture and chronic kidney disease, which necessitates careful handling of waste to prevent infection. Secondly, staff members were observed not wearing the appropriate N95 respirator masks while providing care to COVID-19 positive residents. A Certified Nursing Assistant and a Licensed Vocational Nurse were both using Honeywell N95 masks, which they had not been fit tested for, instead of the BYD N95 masks they were fit tested to use. The Infection Preventionist confirmed that the staff should have followed the policy of wearing fit-tested respirators, as using the wrong mask increases the risk of spreading infection. The facility's policy mandates fit testing for respirators to ensure proper protection against communicable diseases.
Delayed Response to Call Light
Penalty
Summary
The facility failed to ensure that the call light system was answered promptly for one resident, leading to unmet care needs. On November 12, 2024, a resident was observed waiting for assistance for 30 minutes after activating the call light to request a refill of fruit juice. During this time, two licensed nurses were present at the nurse's station but did not respond to the call light. A Certified Nursing Assistant (CNA) eventually attended to the resident after a 15-minute wait, explaining that the delay was due to the assigned CNA being busy and emphasizing that any available staff, including the nurses at the station, should have responded. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expectation was for call lights to be answered promptly, ideally within five seconds or as soon as possible. The facility's policy indicated that call lights should be answered within a reasonable time and that staff should respond to residents' requests. The resident involved was mentally capable of understanding and had been admitted with diagnoses including muscle weakness and nutritional deficiency.
Failure to Ensure Advance Directive Availability in Resident's Record
Penalty
Summary
The facility failed to ensure that a copy of the Advance Directive (AD) was available in the medical record for a resident, which could potentially result in the resident's medical treatment wishes not being followed if they became unable to make decisions. The resident was admitted with diagnoses including sepsis and diabetes and had the capacity to understand and make decisions. The Social Services Assessment indicated that the resident had an AD, and a copy was requested from the resident and their family member. However, the AD was not found in the resident's record. Interviews with the Social Service Director (SSD) and Social Services Assistant (SSA) revealed that the family member visited the facility regularly, and a follow-up regarding the AD was planned but not executed. The SSD acknowledged that the AD should have been in the resident's chart. The facility's policy stated that a resident's choice about advance directives would be recognized and respected, and once received, the AD should be communicated to the care plan team and the physician. The Administrator expected the AD to be readily available in the chart if a resident had one.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment for a resident when the chair rail molding above the resident's bed was detached and damaged from the wall. This issue was identified during an observation and interview with the resident, who expressed discomfort and concern about the broken piece of wood hanging above his head, which affected his ability to sleep comfortably. The resident was worried about the potential risk of hitting his head on the broken molding. Interviews with facility staff, including a registered nurse and the maintenance supervisor, confirmed that the broken chair rail molding was not properly attached and should have been reported and repaired. The facility's policies on equipment maintenance and providing a homelike environment were reviewed, indicating that routine inspections and maintenance should be conducted to ensure resident safety and comfort. The administrator acknowledged that the maintenance staff should have addressed the issue to prevent accidents and maintain a homelike environment.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 9, who was unable to perform activities of daily living (ADL) independently. On November 12, 2024, Resident 9 was observed with long, yellowish, and thick toenails, which he described as resembling 'hawk nails.' The resident reported that his requests for nail trimming were ignored, and he had not been seen by a nail doctor. Certified Nurse Assistant (CNA) 1, responsible for Resident 9's care, admitted to not noticing the long toenails due to being in a hurry and stated that she would inform the charge nurse if a resident needed toenail trimming. However, she did not take action to address Resident 9's toenail care. Resident 9's medical records indicated he was admitted with a diagnosis of diabetes mellitus, which requires special attention to foot care. The facility's policy stated that only licensed nurses should perform nail care for diabetic residents. Despite this, CNA 1 mentioned that any staff could cut residents' toenails, contradicting the facility's policy. Registered Nurse (RN) 1 confirmed that Resident 9's toenails were excessively long and should have been trimmed to prevent infection and injury. The facility's failure to adhere to its policy and provide necessary nail care resulted in a deficiency in maintaining proper grooming and personal hygiene for Resident 9.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications, leading to the presence of expired and discontinued medications in the medication storage areas. During an inspection, two expired daptomycin IVPB bags were found in the medication refrigerator for a resident, despite being labeled with a discard date that had already passed. The registered nurse acknowledged the expiration and confirmed the medication had been discontinued by the physician, yet it had not been disposed of as per the facility's policy. Additionally, a discontinued medication for another resident was found in the medication cart alongside active medications. The licensed vocational nurse confirmed there was no current order for the medication, which should have been disposed of on the day it was discontinued. Furthermore, an insulin pen without an open or expiration date was found in the medication cart, contrary to guidelines that require such medications to be labeled with an open date and discarded after a specified period. These oversights had the potential to result in residents receiving expired and ineffective medications.
Failure to Address Water Leak in Resident's Room
Penalty
Summary
The facility failed to provide a comfortable environment for a resident due to a water leak from a pipe under the sink in the resident's room. This issue was observed during a visit, where a puddle of water was noted on the floor. The resident expressed discomfort and reported that the leak had been ongoing for some time, despite having informed the staff about it. The resident described the situation as unpleasant, especially when the sink was used, causing water to drip onto the floor. The Maintenance Supervisor was unaware of the leak and acknowledged the potential hazard it posed, such as accidents from stepping on the wet surface. The Administrator was aware of the need for repair but had not ensured the issue was addressed. The facility's policy on equipment maintenance requires routine inspections and prompt attention to maintenance needs, which was not adhered to in this case. Additionally, the facility's policy on providing a homelike environment was not upheld, as the resident's living conditions were disrupted by the unresolved leak.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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